Every finding on record at Hospital General Menonita, Inc.

Observed in Record Review. In 10 of 10 patient records reviewed, During document review and confirmed by the Nurse Services director and Quality Director. A fall risk safety assessment had not been completed on all patients at the initial assessment . For example: During review of HOSnhvrr#1, HOShvrr#1,HOShvrr#3 the initial assessment had stated that a falls risk assessment had not been completed.

Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Quality Manager and the Clinical Services Director. The initial patient assessment had not included patient safety risk assessment. Example: During review of HOSnhvrr#1 , HOSvrr#1, HOSvrr#2 a home safety risk assessment had not been completed per agency policy.

Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Nurse Services Director and Quality Director. The plan of care had not been updated to include progress toward outcomes as well as patients response to care. Example: During review of HOSnhvrr#1,#2,#3,#4 the patient goals and plan of care had not been updated . The plan of care had not changed in several months or years.

Observed in Record Review. In 3 of 10 patient records reviewed, Documentation had not been accurate to contain all documented data for each patient. Example: During the review of HOSnhvrr#2 he RN assessment had documented that a PT/INR had been part of the treatment, however during discussion it had not been identified on assessment as a need. During review of HOSnhvrr#5 and #6 as well as #7,#2,#3. The IDT notes had been transcribed on a paper log for all patients but had not been documented within the patient record to be utilized for care planning and coordination of services. This had been confirmed by the Director of Quality and the Clinical Services Director. Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Quality Director. The patient record had not contained timely submission of all the clinical data to assure individual patient care planning. Example: The IDT notes had been transcribed on a paper log for all patients but had not been documented within the patient record to be utilized for care planning and coordination of services. This had been confirmed by the Director of Quality and the Clinical Services Director.

Observed in Record Review. In 10 of 10 patient records reviewed, During document review and confirmed by the Clinical Services director and Quality Director . The plan of care had not been individualized to reflect the patient assessed needs. Example During review of HOSnhv#1, #2, #3, #4, #5 the plan of care goals and interventions had been standardized and had been documented the same for each patient and had not been documented based on the individualized assessed needs. Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Nurse Quality Director and Quality Director. Goals had not been measurable. Example: HOS nhvrr#1. #2, #3, #4 HOS hvrr#1, #2,#3 goals had documented Symptoms problematic to patients will be addressed to meet patient goal of quality of life. Patient will report pain below 3.

Observed in Record Review. In 4 of 10 patient records reviewed, During document review and confirmed by the Clinical Services Director and Quality Director. Medication orders had not been documented per organization policy to include PRN orders having an indication for use. Example: During review of of HOSnhvrr#1 medication order had documented Dologesic 1 tab po tid prn and Albuterol 0.83 CAD 8hr prn. HOSnhvrr#2 had documented Morfina 15mg 1 tab q12 hours prn. HOShvrr#1, HOShvrr#3 had documented Prunelex 1 tab prn and Sennosides 15mg 1 tab prn and HOShvrr#3

Observed in Patient Home. In 2 of 3 Hospice visits observed and confirmed by the Quality Director. Staff had not followed organization policy for standard practice for the use of protective equipment. Example: During HOShv#1 the SN had provided wound care to the scalp with moderate drainage. The SN had not followed organization policy with regard to use of gloves. The Sn had removed the old dressing with drainage and preceded to clean the are while wearing the same gloves. When gloves were removed to don a new pair the SN had not cleansed her hands per organization policy. During HHvrr#2 the SN had utilized the same gloves to clean equipment after caring for the patient.

Observed in Leadership Session. During the survey it had been noted that many areas related to documentation within the patient record that had risen to condition level. to include PC 01.02.01 EP36 , PC 01.02.01 EP 7, and RC 01.01.10.EP11

Observed in Record Review. In 10 of 10 patient records reviewed, Patients that had oxygen had not received education on the oxygen risk that had addressed all element to include fire hazard to other buildings and other risks such as open flames, use of petroleum. Example: During observation of HHv#1 the patient had been active with ordered oxygen utilizing it frequently. It had been observed that a jar of Vaseline had been used by the caregivers and patient. The caregiver , the patient and the SN had been unaware of the risk. This had been confirmed by the Quality Director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the plan of care did not specify the scope and frequency of services necessary. During record review of RR#9 there was no visit frequency for nursing services. This was verified by the Director of Clinical.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, related to the bereavement program, the surveyor noted that both bereaved records did not include the kind of bereavement services to be offered and frequency of service delivered. This was verified by the Director of Clinical.

Observed in Regulatory Review. The organization had not provided volunteers for six years, therefore, they were not able to demonstrate an amount of at least 5% level of activity and cost savings. This was verified by the Director of Clinical.

Observed in Leadership Session. During the initial opening conference the Director of Clinical stated that the organization did not currently provide aide services and that the organization was not admitting patients with that need. In addition, the Volunteer Coordinator, during the volunteer program interview, stated that there have been no volunteers for six years. Recruitment efforts have been made without success. This was verified by the Director of Clinical.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the surveyor was able to determine that the patient's medication lists were incomplete. During the second and third home visits the surveyor noted that the patients were on vitamins that were not included on the agency's medication lists. This was verified by the Director of Clinical.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the surveyor noted that the organization did not provide the attending physician with a copy of the discharge summary, and a copy of the clinical record if requested. There was no documentation that information had been sent to the physician following discharge of patient RR#10 and RR#11. This was verified by the Director of Clinical.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the surveyor noted that two patients, RR# 10 and RR#11, did not have discharge summaries which included any other documentation that would assist in post-discharge continuity of care or that was requested by the attending physician. This was verified by the Director of Clinical.

Observed in Document Review. In 2 of 6 contracts reviewed, the surveyor noted that the contracts for the DME company and the ambulance company did not stipulate that the entities obtain criminal backgrounds checks on all employees who have direct patient contact or access to patient records. This was verified by the Director of Clinical.