Every finding on record at Hillcrest Hospice, Inc

Observed in Record Review. In 1 of 6 Patient records reviewed, the clinician did not have accurate records without conflicting information. On HSHV/RR #1, POC order for Nystatin was for 14 days but in the case communication note it was noted that Nystatin was to be given for 3 weeks making a conflict of information for the communication note not matching the MD order. This finding was reviewed with the Director of nursing and administrator.

Observed in Record Review. In 5 of 6 patient records reviewed, Hospice surveyor noted some of the goals in patient records were not measurable. For example, on HSHV/RR #3, the goal was Pt will maintain optimum peripheral circulation, On review of HSRR #5, there was a goals of Pt will maintain optimum peripheral circulation and will have no complication, neither of these goals are measurable or specific to the patient. In addition, the plans of care for HSHV/RR #1, HSHV/RR #2, HSHV/RR #3, HSRR #4 and HSRR #5 did not have individualized care plans because goals were the same from chart to chart and not individualized to actual patient needs. Examples include: no oxygen related injury will occur to patient and pcg on a patients for patients not actively on oxygen, The patient's comfort will be promoted as skin integrity changes throughout disease and dying process throughout Hospice care. for patient with no documented skin issues and Patient/pcg will verbalize lesser to no episodes of nausea and vomiting until end of benefit period on patients with no documented nausea or vomiting. This was finding was reviewed with the Director of Nursing and Administrator.

Observed in Record Review. On 2 of 6 patients records reviewed, the organization did not plan care for the patient's needs. On review of HSHV/RR #2 the visit and IDG notes state patient is an aspiration risk but there is no treatment plan to address aspiration risk as evident by orders for a regular diet. Patient is also a risk for skin breakdown and using heel protectors and a dressing on her heel for prevention but there was nothing on the plan of care to address this issue. On review of HSRR #5, the admission assessment notes a coccyx wound with a dressing in place but there is no care ordered or follow-up for that wound care on the plan of care. This finding was reviewed with the Administrator and Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization’s infection prevention and control activities were not implemented. Agency policy states that equipment is to be cleaned with alcohol after each visit. During HSHV/RR#1 and HSHV/RR #2 the LVN was observed cleaning her vital signs equipment with Oxivir wipes. This was discussed and validated with the Director of Nursing who was present during the visit.

Observed in Record Review. In 1 of 1 patient record reviews that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of HSRR #4, there had not been an aide supervision done on the patient during the 16 days of aide services. This finding was reviewed and validated with the Clinical Director.

Observed in Record Review. In 2 of 6 patient records reviewed, entries in the patient record were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Agency policy (5-006.1) states documentation will be completed by end of day which is to include signature. On review of HSRR #4, the surveyor noted that the Chaplain admission assessment was not authenticated as evident by no electronic signature in the record and patient has been discharged for 5 months now. On review of HSRR #5, the surveyor noted the admission assessments for the Nurse and Chaplain and Nurse visits notes were not authenticated as evident by no electronic signature and this patient has been discharged for 5 months. This was reviewed and confirmed with the Administrator and Director of Nursing.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. In HSRR #4 and HSRR #5, the discharge summary indicated the patient revoked so the patient could seek treatment at hospital, a discharge summary was written but it was not sent to physician who will be providing care and a notification of it's availability was not competed either. This was reviewed with the Director of Nursing and Administrator.