Every finding on record at Kaiser Foundation Hospitals

Observed in Record Review. In 1 of 22 patient records reviewed, the organization failed to address patient decisions about care, treatment, or services received at the end of life according to their policy. During record review for HOSRRNHV#1, the Hospice Nurse Surveyor observed the EMR did not contain record of the POLST/ DNR form as required by policy. For example in HOSRRNHV#1, the patient was listed as DNR. The wife stated at SOC that the hospital had the DNR. The Epic system with the hospital stated Full Code. There was no uploaded document in the medical record for DNR. During the course of survey the organization was able to go out to the home and retrieve a copy of the DNR and enter it into the EMR. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In one of three bereavement records reviewed, the bereavement coordinator confirmed that the plan called for the MSW to contact the bereaved two weeks after the last phone call in November, but there was no documentation to indicate that the call occurred at the time of survey.

Observed in Record Review. In 1 of 13 patient records reviewed, the plan of care did not include all services needed to meet the patient/family needs. In HOHV#3 the MSW initial assessment identified that funeral arrangements were pending and indicated that the social worker would follow up. However the need for assistance with funeral arrangements was not included in the plan of care and there was no documented follow up on this need. This was validated with the Kaiser consultant.