Every finding on record at Hospice of Minnesota, LLC

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: The medical record contained an initial bereavement assessment completed 1/30/24 with a start of care 1/15/24.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: There was no evidence of coccyx wound measurements and assessments completed between 1/21/24 and 2/16/24. Agency policy states measurements and assessments are to be completed weekly.

Upon patient record review, 3 of 14 (Patients #7,#8,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 7: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site. Patient 10: The medical record contained an order for Bactrim to treat a UTI 2/2/24. There was no evidence of problems, goals, and interventions related to infection assessment and management. Corrected on site.

Upon patient record review, 3 of 14 (Patients #7,#8,#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a walker and nebulizer. There was no evidence of an order for the listed equipment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the nebulizer included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 4: The medical record contained a change in physician form indicating the patient declined having an attending physician and would like medical director to assist in care. The form contained a data entry error with the wrong physician listed as former attending.