Every finding on record at John Fitzgibbon Memorial Hospital

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop an individualized plan of care (POC) that included all of the treatments in, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy, titled, "Plan of Care," revised 05/2021, showed, in part: - All hospice care and services furnished to patients and their families shall follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire; - The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including the following; * Interventions to manage pain and symptoms * Drugs and treatment necessary to meet the needs of the patient; and - The analysis of data obtained during assessments shall facilitate the ongoing identification and prioritization of patient problems, needs, goals and care, treatment and services. Review of the provider's policy, titled, "Telephone/Verbal Orders," revised 06/2018, showed, in part: - When services are furnished based on a physicians oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations; - The registered nurse will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed; - Orders for treatment include the following; * Type of treatment * Specific requirements, i.e. wet to dry dressings * Frequency and duration of treatment - Each telephone/verbal order is written down or entered into the computer and the read-back to the individual delivering the order, by an appropriate qualified agency staff member receiving the order; and - Hospice provides care, treatment and/or services to patients in accordance with current physician orders. RECORD/PATIENT #2: Review of the Plan of Care showed, in part: - The patient was admitted at home, on 01/18/2024, with a terminal diagnosis of pneumonitis due to inhalation of food and vomit; - Supplies included, 4x4 Dressing, wound cleanser, and foam dressing; - SN (skilled nurse) to assess for signs/symptoms of wound infection; - SN to assess measures in place to reduce risk and avoid wound infection; - SN to perform wound care/dressing change (Interventions failed to include specific wound care/dressing change orders); and - Patient/caregiver will verbalize/demonstrate proper wound care/dressing procedures. During home visit observation on 01/23/2024, beginning at 11:00 AM, showed, in part: - The hospice binder had written instructions for wound care to the left heal that included: Cleanse wound with wound cleanser, pat dry, apply TAO (triple antibiotic ointment), cover with foam and ace wrap. Change daily and PRN (as needed). Staff nurse to perform in the absence of hospice; and - The RN (registered nurse) performed wound care during the observation visit as written in the hospice binder. The clinical record failed to show orders for wound care. During an interview on 01/23/2024, at 2:45 PM, the director of nursing, stated that: - The clinical record failed to include the orders for wound care; - The nurse received the orders but forgot to enter them into the record; and - The nurse entered the verbal order into the record after realizing that the orders were missing.