Every finding on record at Lady of Joy Hospice, Inc.

Observed in Record Review. In 3 of 3 patient records reviewed, with wounds, the organization failed to maintain a complete and accurate patient record. During record review for RRNHV#2, RRBR#1, and RRNHV#7, the Hospice Nurse Surveyor observed the records did not contain assessment and measurement and description of wounds as required by policy. For example in RRBR#1, the Hospice had consulted with a wound clinic but no documentation from the hospice was occurring. For RRNHV#2, the patient had multiple wounds over the course of 4 months and no detailed documentation or measurement was found in the medical record, only narrative. The wound policy stated a detailed assessment would be done at every visit and measurements would occur at least every 14 days. In RRNHV#7, the patient had a fall with skin tears to right elbow, right eyebrow and right forearm, but there was no description of the wounds including size, drainage etc. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. the organization failed to complete a comprehensive assessment at least every 15 days related to no documentation of wounds. During record review for RRNHV#2, RRBR#1, and RRNHV#7, the Hospice Nurse Surveyor observed the records did not contain assessment and measurement and description of wounds as required by policy. For example in RRBR#1, the Hospice had consulted with a wound clinic but no documentation from the hospice was occurring. For RRNHV#2, the patient had multiple wounds over the course of 4 months and no detailed documentation or measurement was found in the medical record, only narrative. The wound policy stated a detailed assessment would be done at every visit and measurements would occur at least every 14 days. In RRNHV#7, the patient had a fall with skin tears to right elbow, right eyebrow and right forearm, but there was no description of the wounds including size, drainage etc. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for all records reviewed, the Hospice Nurse Surveyor observed the plan of care was not based on the patient's goals, time frames, and services required to meet those goals. For example in all records, the goals were the same as admission ( in many cases over a year earlier) and the timeframes were changed to the next certification date , episode after episode. Also in RRHV#1, the patient had a goal to acknowledge factors that may lead to unstable glucose with an intervention of maintain satisfactory glucose levels with no measurable expectation. During record review for RRHV#1, RRHV#2, and RRHV#3.the Hospice Nurse Surveyor observed the Plan of Care failed to address all services needed for the palliation and management of the terminal illness and related conditions. For example in RRHV#1, the patient had a goal of pt/family may receive needed spiritual and emotional support which is not a patient centered, measurable goal. For RRHV#2, the patient had a goal of pt/caregiver will receive support as needed to be able to cope with illness. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to plan the patient's care. During record review for all records .the Hospice Nurse Surveyor observed no documentation of progress towards goals and updates to the plan of care based on updated comprehensive assessments. For example in RRHV#1, the patient had been on service for almost a year and the cardiovascular goal had been implemented at SOC. It had never been updated only the target date was moved to reflect the current certification period. In RRHV#3, the patient had a respiratory goal of episodes of dyspnea will be alleviated with rest and oxygen administration for the next 14 days. This goal was placed at SOC 9 months prior to survey, when the patient had acute bronchitis . The only nursing documentation to support dyspnea was at one visit, 3 months prior to survey. For all records reviewed, they contained all of the same goals and interventions implemented at SOC with no updates. All patients were beyond their first certification period. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide care, treatment, or services in accordance with most current orders. During home visit for RRHV#1, the LVN did not follow most current wound orders and plan of care stated cleanse with normal saline, pat dry and cover with dry dressing. Instead the LVN cleansed with wound cleanser, patted dry, added triple antibiotic ointment and covered with a dry dressing. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During RRHV #1 and RRHV#3, the Hospice Nurse Surveyor noted that the organization did not implement the infection prevention and control activities it planned related to hand hygiene. During the visit, the LVN had multiple lapses in hand hygiene. The LVN did not do hand hygiene before taking her equipment out of her bag for set up. She did not do hand hygiene between glove changes. And she did not do hand hygiene between cleaning the wound and replacing the dressing. All these items were required by organizational policy and hand hygiene checklist. In RRHV#3, the aide did not perform hand hygiene between glove changes or when going from cleaning genitals to drying and placing lotion on the back. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 2 patient records reviewed, patients with wounds, the organization failed to provide for its planned scope and level of care. During record review for RRBR#1, the Hospice Nurse Surveyor observed the organization was routinely using a wound care contract for wound care and orders. During record review, the surveyor requested measurements and description of multiple wounds, including an unstageable to the right buttock and was told that the wound care consultants handle all of that and that their are pictures loaded from the wound care consultant but the organization failed to document description of the wounds every visit along with measurements at least every 14 days per organizational policy. This was discussed and reviewed with the Hospice Director.

Observed in Record Review. In 5 of 10 patient records reviewed, where aide services were ordered, the organization failed to plan the patient's care. During record review for RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, and RRNHV#3, the Hospice Nurse Surveyor observed the aide care plan did not contain all needed precautions. For example in RRHV#2, the patient was on Eliquis but there were no bleeding precautions on the aide plan of care. In RRHV#3, the patient had oxygen ordered but the plan of care did not address whether the patient could remove the oxygen during a bath. In RRNHV#1, the patient was on aspiring but the aide care plan did not address bleeding precautions. In RRNHV#2, the patient was on oxygen but it was not addressed on the aide care plan. In RRNHV#3, the patient was on continuous oxygen but it was not addressed on the plan of care. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. The organization failed to implement policies and procedures that guide and support patient care, treatment, or services. During tracer activities for Leadership, the Hospice Nurse Surveyor observed there was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level findings at 418.104, 418.56, and 418.70. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization's medical director failed to document a review of the clinical information related to terminal diagnosis. During record review for RRHV#1, the patient hospice diagnosis in malignant neoplasm of the prostate but there is no information in the medical record to support that diagnosis. The H&P loaded at admission does not include any information about a malignant neoplasm of the prostate. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. The patient has been on hospice for 10 months. In RRHV#3, the patient had a terminal diagnosis of benign neoplasm of the prostate with comorbidities being hypertension and gerd. The H& P from the referring physician stated per Sonia (daughter) patient was diagnosed with prostate cancer 2 years ago but does not want treatment. The clinical record does not contain clinical information related to prostate cancer. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. The patient has been on hospice for 9 months. In RRNHV#4, the patient had a terminal diagnosis of malignant neoplasm of the prostate. The H&P from admission and the SNF states history of prostate cancer. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. In RRNHV#5, the patient had a terminal diagnosis of chronic atrial fibrillation, unspecified The H&P from the previous hospice stated his diagnosis was sepsis, UTI with a history of atrial fibrillation. The CTI did not contain clinical information supporting a terminal diagnosis of chronic atrial fibrillation, what treatments or medications have been attempted or the medical management of the condition. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization's medical director failed to document a review of the clinical information related to terminal diagnosis. During record review for RRHV#1, the patient hospice diagnosis in malignant neoplasm of the prostate but there is no information in the medical record to support that diagnosis. The H&P loaded at admission does not include any information about a malignant neoplasm of the prostate. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. The patient has been on hospice for 10 months, with multiple recertifications. In RRHV#3, the patient had a terminal diagnosis of benign neoplasm of the prostate with comorbidities being hypertension and gerd. The H& P from the referring physician stated per Sonia (daughter) patient was diagnosed with prostate cancer 2 years ago but does not want treatment. The clinical record does not contain clinical information related to prostate cancer. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. The patient has been on hospice for 9 months, with multiple recertifications. In RRNHV#4, the patient had a terminal diagnosis of malignant neoplasm of the prostate. The H&P from admission and the SNF states history of prostate cancer. The CTI does not include information about the terminal diagnosis, what treatments or medications have been attempted or the medical management of the condition. The patient is in his second benefit period. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to maintain a complete and accurate record. For RRHV#3, RRBR#2, RRNHV#2, RRNHV#3, and RRNHV#6, the documentation contained conflicting information. For example RRHV#3, the patient's care plan states incontinent of urine. The nursing notes state continent of both bowel and bladder. And the patient's aide care plan states continent urine and the boxes continent and incontinent are both checked for bowel. In RRBR#2, the patient was documented to be bed bound 10 days prior to death but the LVN continued to document transfer bed/chair and the aide continued to document that a shower was given via shower chair. Also the aide documented shower via shower chair the same day as death when the LVN documented 15 minutes later the patient was unresponsive. In RRNHV#2, the nursing assessment for 4.13 stated no pain but in the narrative it was documented patient having back pain and Tylenol administered by visiting nurse per MD orders. There was also documentation that the nurse called to office to inform them of the back pain. Also in RRNHV#2, the aide care plan stated both bed bound and chair to bed. In RRNHV#3, the patient had orders for 2Liters Oxygen continuous. In multiple visits the LVN did not document continuous or PRN. Also in 3 different visits the flow rate was not the same as the orders. It varied from room air, 2.5 liters and 3.5 liters. In RRNHV#6, the patient visiting RNs documented on multiple occasions that the patient PPS was 50, KPS was 50 and the Fast was 7B. The physician documented at a recent face to face visit that the KPS was 50, PPS was 50 and the Fast was 7B. But the case manager who works in the office only, documented in her IDG note that the patient was KPS 40, PPS 50 and Fast 7C on multiple IDG notes. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 1 of 1 home visits conducted, of hospice visits with skilled nursing and medication reconciliation, the organization failed to maintain a medical record that reflected the patient's care, treatment, or services. During record review and home visit for RRHV#1, the Hospice Nurse Surveyor observed the medication list was inaccurate. The patient was taking a Men's Multi-Vitamin, Vitamin D and Vitamin B12 but they were not reflected on the medication list. The LVN stated that the family was paying for them so they were not included, but that she would be adding them post survey. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 2 patient records reviewed, with discharge, the organization failed to provide the physician and the Board and Care with a discharge summary. During record review for RRDC#1, the organization failed to provide the discharge summary. This was discussed and reviewed with the Hospice Team.