Every finding on record at Hospice of the Southwest - West Valley LLC

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the patient received effective pain management and symptom control for conditions related to the terminal illness. For example: The record for HV#3 shows the patient complained of a pain level of 10 out of 10 in week 6 of benefit period 9 and was ordered Voltaren gel. There was no reassessment of pain until week 7 where pain level was again documented as 10/10 and using 8 PRN doses of pain medication in the past 24 hours. There was not indication that this pain was reported to the physician and there was no follow up again until week 8 where the patient again complained of a pain level of 10/10. Similar findings of consistent pain levels greater than the established tolerable level can be seen in RR#5, and RR#9. This observation was reviewed with the Executive Director.

Observed in Record Review. In 2 of 11 patient records reviewed, The organization failed to ensure that a patient-specific comprehensive assessment that included all areas of hospice care related to the palliation and management of the terminal illness and related conditions was documented. For example: in RR#9 the patient was admitted with a stage 4 pressure injury yet there was no documentation of a comprehensive wound assessment that included measurements as per organization policy 3.038 done on the admission visit. The wound was not formally addressed until a week after admission when the patient was found in crisis. In RR#4 there was documentation of a wound to the left heel yet a comprehensive wound assessment including measurements was not noted in the record. This observation was reviewed with the Executive Director.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure that each patient and the primary care giver receive education and training provided by the hospice as appropriate to their responsibilities. For example: in HV#3 record review it was noted that the patient was prescribed Voltaren gel for pain. There was no indication in the record that the patient and/or caregiver received any education or training on the medication and its administration. In HV#2 and RR#6 the record reflected that the patient was ordered comfort medications morphine and lorazepam, however there was no documentation that the patient/caregiver received any education or training on the medications and administration. In RR#6 there was documentation that the patient was imminent, yet there was no indication that the patient/family had any education on what to expect at the end of life. In RR#4 and RR#9 the patients had wounds yet there was no indication in the record that the caregiver received education and training on providing wound care, nor any indication of proficiency. These observations were reviewed with the Executive Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that the individualized plan of care contained goals and interventions based on problems identified in the comprehensive assessment. For example: in review of HV#1 and HV#2 there were multiple care plans open with interventions listed but no goals. In RR#6 the patient was noted to be imminent yet this status was not reflected in the plan of care. RR#4 had a wound, there was a skin integrity care plan open yet the wound care orders were not reflected in the plan. RR# 9 had a stage 4 wound yet no care plan for skin integrity was open to guide care. Further, throughout all records reviewed there was a noted disconnect in the care plans from the goals to the interventions. For example a goal for HV#1 was Pt able to identify physical and mental stressors and avoids them when possible the interventions were all directives to assess such as assess compliance with treatment regimen, and assess CV status for signs and symptoms of cardiac complications. The interventions provided no directives to help progress to achieve goals. These observations were reviewed with the Executive Director.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to include in the plan of care a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: During the home observation for HV#1 the patient mentioned the hospice aide comes weekly to help with household tasks, yet upon review of the current record there was no frequency orders for aide services. This observation was reviewed with the Executive Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that care was provided in accordance with the established plan of care. For example: review of RR#5 the patient's primary diagnosis was COPD and the plan of care for respiratory specifies interventions for assessing respiratory status, however multiple visits during March there was no documentation of the respiratory status to include breath sounds, dyspnea, cough, or breath patterns. Example 2: In review of RR#4 the patient was ordered dressing changes for wound care that included cleanse with wound cleanser, dry, apply calcium alginate, and cover with dry gauze. In the 2nd benefit period it was noted the care performed was documented as cleansed left heel wound and left open to air however no changes in the wound care orders were noted in the record. These observations was reviewed with the Executive Director.

Observed in Record Review. In 2 of 6 patient records reviewed, where hospice aide services were being provided, the organization failed to ensure that the registered nurse provided the hospice aide with specific written patient care instructions. For example: In HV#3 the hospice aide plan of care assigned a patient bath that stated Bath: complete, but failed to specify what type of bath to be given. In RR#4 the hospice aide plan of care only included 3 tasks of shower, elastic stockings, and change linens. There were no other tasks to address tasks such as mobility, or specific instructions about as how to handle the patient's wound dressing assigned This observation was reviewed with the Executive Director.

Observed in Record Review. In 6 of 11 patient records reviewed, The organization did not ensure the medical record contained pertinent clinical information reflecting the patient's care, treatment, and services. For example: in the nursing documentation for HV#1 during week 8 of the 6th benefit period, the nurse documented that the patient took Coricidin for allergy symptoms. The medication was not noted on the patient's medication profile. Further examples are In HV#2 and RR#6 the nursing documentation notes that morphine and Ativan ware placed in the home for comfort meds yet there was no indication of the medications on the patient's medication profile. In RR#5 the documentation notes the patient had increasing shortness of breath and needed PRN O2 yet there was no indication in the record the patient was on O2. Example 2: During the home observation for HV#1 the patient reported the hospice aide was coming weekly, however there was no hospice aide documentation nor an aide frequency noted for the aide in benefit period 6. Example 3: During review of the record for RR#9 there was a pressure injury noted on the initial assessment yet to date of survey there are no wound care orders noted in the record. The wound was not formally addressed until one week after start of care were the patient was found in crisis related to the wound and associated pain. A similar lack of wound assessment and wound care orders was noted in RR#4 where a wound to the left heel was noted in the record in December where wound care was being performed, there was no order for wound care in the record until February. Further, documentation states wound cleansed, dried, and new dressing applied lacking specific documentation of the dressing change that was performed. These observations were reviewed with the Executive Director. Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the medical record contained information reflecting the patient's care, treatment, or services. For example: upon review of RR#11 the patient died 7 days after admission and there was no medication profile noted in the clinical record. The initial nursing assessment noted the patient was taking morphine and lorazepam comfort medications. In RR#10 the patient was discharged for extended prognosis, there was no discharge order noted on the clinical record. This observation was reviewed with the Executive Director