Every finding on record at Kaiser Foundation Hospital Tri Central HHA

Observed in Record Review. In 1 of 23 patient records reviewed, During HOSRRHV# 5's patient record review it was noted the organization had not ensured the clinician reassessed the patient's pain per policy Pain Assessment 2.032.1 that included action to be taken in response to pain that is equal or greater than the identified pain level of four or greater than the patients identified threshold in the plan of care was a follow up assessment of the pain status within one calendar day either via phone or during a visit. For example: review of HOSRRVH# 5's patient record revealed a Skilled Nurse (SN) visit note with documented pain of 9/10. Review of the SN visit note revealed Norco was given during the visit. Further review of the SN visit note revealed no further documentation of a pain assessment or if the Norco was effective. Further review of HOSRRHV# 5's patient record revealed no documentation of a pain assessment within a calendar day. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 13 of 23 patient records reviewed, During HOSRRHV# 1, HOSRRHV# 5, HOSRRHV# 6, HOSRR# 5, HOSRR# 6, HOSRR# 7, HOSRR# 8, HOSRRD/C# 1, HOSRR# 9, HOSRR# 10, HOSRR# 11, HOSRR# 12's patient records review it was noted the organization had not ensured the written plan of care was based on the patient’s goals. For example: review of HOSRRHV# 1's RN start of care comprehensive assessment revealed documentation that HOSRRHV# 1 had a pain level of 2/10 with the worst the pain being 8/10, and the patient's acceptable level of pain as 0/10. Review of HOSRRHV# 1's plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRRHV# 5's patient record revealed documentation of pain of 5/10 with the worst pain 10/10 and an acceptable level of pain of 2. Review of HOSRRHV# 5’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRRHV# 6’s RN comprehensive assessment revealed documentation that HOSRRHV# 6’s pain level 5/10 with the worst pain being 10/10, and the patient’s acceptable level of pain as 3/10. Review of HOSRRHV# 6’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRR# 5’s patient record revealed documentation of a pain assessment that included an acceptable pain level of 3/10. Review of HOSRR# 5’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRR# 6’s patient record revealed documentation of an acceptable pain level of 4/10 with the worst pain level 6/10. However, review of HOSRR# 6’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRR# 7’s patient record revealed documentation of a pain assessment that included an acceptable pain level of 4/10 with the worst pain being 8/10. However, review of HOSRR# 7’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRR# 8’s patient record revealed documentation of a pain assessment that included an acceptable level of pain of 5/10 with the worst pain being 8/10. However, review of HOSRR# 8’s plan of care revealed no pain goal. Review of HOSRRD/C# 8’s patient record revealed of an acceptable pain level of 4/10 with the worst pain being 8/10. However, HOSRR# 8’s plan of care revealed a symptom management pain goal management of pain with no indication on how to measure management of pain. Review of HOSRR# 9, HOSRR# 10, HOSRR# 11, and HOSRR# 12’s patient records revealed documentation of pain. However, review of the patients’ plans of care revealed a symptom management pain goal “management of pain” with no indication on how to measure “management of pain”. This was reviewed with the Director of Patient Care Services and validated. Observed in Record Review. In 1 of 23 patient records reviewed, During HOSRRHV# 4 it was noted that the organization had not ensured the goals established on the plans of care included measurable outcomes as required by regulation. For example review of the patient's plan of care revealed a pain goal patient would have an acceptable level of pain. However, there was no indication what the acceptable level of pain was for HOSRRHV #4. . This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 5 of 23 patient records reviewed, During HOSRRHV# 2, HOSRRHV# 3, HOSRR# 1, HOSRR# 6, and HOSRR# 7's patient records review it was noted the organization had not ensured the registered nurse prepared the complete patient care written instructions for the hospice aide. For example: review of HOSRRHV# 3’s patient record revealed HOSRRHV# 3’s had a G-tube and on aspiration precautions. However, the patient written instructions did not provide directions regarding the G-tube or aspiration precautions. Review of HOSRRHV# 2's patient care plan revealed HOSRRHV# 2 had a wound to the right hip with a dressing. However, the patient written instructions did not provide directions regarding the dressing. Review of HOSRR# 1’s patient record revealed HOSRR# 1 had a Pleurix catheter. However, the patient written instructions did not provide directions regarding the Pleurix catheter. Review of HOSRR# 6’s patient record revealed HOSRR# 6 had a surgical wound with dressing to the right upper quadrant of the abdomen. However, the patient written instructions did not provide directions regarding the wound dressing. Review of HOSRR# 7’s patient record revealed HOSRR# 7 had a Pleurix catheter. However, the patient written instructions did not provide directions regarding the Pleurix catheter. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization had not ensured the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care in accordance with COP 418.24. For example, during record review 11 the surveyor identified the social work initial assessment was completed on day seven. This was confirmed by the Clinical Manager.

Observed in Individual Tracer. In 20 of 20 patient records reviewed, the organization had not ensured there were actions to take when medication orders are incomplete, illegible, or unclear. For example, in HOS HV3 and the associated medical record the patient had multiple pain medications listed. The order did not have values to help the family or LVN decide which medication to take or what to do if the medication was ineffective. This was confirmed by the Clinical Supervisor. During HOS HV5 and review of the associated medical record, the record had three vague medication orders. The patient was taking the promamatine twice a day instead of the prescribed three times a day . In one of the referred to medications the medication was written on the medication sheet identifying the discrepancy which was followed with not corrected since admission. This issue was addressed during the survey visit. This was confirmed with the Clinical Supervisor. This standard was noted widespread related to all patients receiving symptom management kits have multiple bowel management medications without indications when to use each option and many indicated multiple pain medications without pain severity ratings or medications that range from acetaminophen to morphine with some having a mid level pain management medication without indications of which to use first, second or next. This was confirmed with the Hospice Director.

Observed in Record Review. In 6 of 20 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to his or her individualized plan of care. During 20 record reviews 6 records revealed the patient had been provided services outside of the ordered frequency. The records involved are HV1, HV4, and their associated records as well as RR8, RR11, RR13, and RR19