Every finding on record at Lake Regional Health System

Observed in Record Review. In 10 of 19 patient records reviewed, the nurse survey noted the goals were not specific to the needs of the patient. For example, for HOSRRNHV#2, HOSRRNHV#4, HOSRRHV#1, HOSRRNVH#1, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#9, HOSRRNHV#10, HOSBR#2, the following goals or timeframe is by the time of death/discharge for pain and dyspnea. Patient/Caregiver will verbalize understanding of purpose dose, frequency and side effects of medication; patient caregiver will implement ordered interventions to improve pain; patient will verbalize actions/interventions to mitigate pain. For dyspnea, patient/caregiver will recognize signs and symptoms of respiratory distress; patient/caregiver will report symptoms are controlled; patient will implement ordered interventions to relieve and reduce severity of symptoms. For HOSRRHV#2, the following goals or timeframe is by the time of death/discharge for cardiac symptoms; patient/caregiver verbalize actions/interventions to reduce symptoms of disease process, will verbalize understanding of purpose dose, frequency and side effects of medications. This was discussed with the director of nursing and clinical manager.

Observed in Record Review. In 2 of 19 patient records reviewed, the surveyor noted the plan of care did not include the scope and frequency for services to meet the patient's needs. For example, in HOSRRNHV#1, the agency did not provide a plan of care to address diabetes management to include the administration of insulin, monitoring of blood sugars by clinical staff or caregiver and addressing nutritional intake. In addition, in HOSRRNHV#1, the comprehensive assessment clinical note states the patient is a type 2 diabetic, however the patient is prescribed 2 types of insulin with injections for morning and evening doses. The comprehensive assessment also stated the patient has an ineffective nutritional intake, with family confirming patient is not eating or drinking enough. For HOSRRNHV#5, the patient is receiving insulin twice a day with a diagnosis of severe protein calorie malnutrition. This was discussed with the director of nursing and clinical manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not ensure implementation of activities for the prevention and control of communicable diseases. For example in HOSRRHV#1, the surveyor noted the staff person did not perform hand hygiene consistent with agency policy. The home health aide did not wash hands or utilize hand sanitizer during the visit in which she was performing a bath. The home health aide applied the hand sanitizer on the gloves and proceeded with providing care. This was discussed with the director of hospice and the clinical manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the agency did not conduct an effective medication assessment. For example for HOSRRHV#1, the surveyor noted the medication profile listed on the plan of care was different from the medication being administered in the home by the caregiver. For example for HOSRRHV#3, Cipro and Macrobid were not removed from the medication profile and Protonix was not on the medication profile. This was discussed with the director of hospice and the clinical manager.

Observed in Record Review. In 1 of 2 patient records reviewed, the surveyor did not send a discharge summary to the physician within five days of discharge. For HOSLiveDC#1, the discharge summary was sent to the physician on day six of the discharge. This was reviewed with the Director of hospice and the clinical manager.

Observed in Patient Home. In 3 of 3 home visits conducted, for hospice patients for which the home folder was available, the hospice agency failed to inform the patient/representative of their financial liability for hospice services. In conversation with the Hospice Program Coordinator, she indicated that the consent form has a section on financial liability. However this section discusses the patient's responsibility to pay for anything insurance does not cover but there is no disclosure of hospice charges and the patient's actual payment liability. In further discussion the Hospice Program Coordinator indicated that if the patient did not have Medicare or Medicaid their benefits department did check for coverage, deductibles, co-pays etc. and that information is communicated to the nurse who discusses the financial situation with the patient/caregiver but there is no documentation of that conversation with details of the patient's liability. In HOHV#1 and HOHV#3 there was no documentation of disclosure of payment liability in addition to the paragraph on the consent form. Therefore there was no evidence that the patient received in writing an estimate of the dollar amount they may be liable for to pay for hospice services.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice failed to conduct a multidisciplinary comprehensive assessment. In HORR#2 there was no documented evidence of a bereavement assessment, a social work assessment or a spiritual assessment and there was no explanation in the record as to why these were not completed. This was validated with the Hospice Program Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice medication profile included duplicate medications. In HORR#3 oxycodone and morphine were ordered for pain prn with no direction as to when to take which medication. In HORR#4 tramadol and morphine were ordered for pain prn without differentiation between medications. In HORR#10 Morphine and Tylenol were both ordered prn for pain with no differentiation. This was validated with the Hospice Program Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice plan of care did not include individualized goals for all identified issues. In HOHR#9 the multidisciplinary assessments documented anger at everyone/everything, difficulty not lashing out and guilt for that behavior but the MSW and spiritual care goals did not address this issue. This was validated with the Hospice Program Coordinator.

Observed in Record Review. In 11 of 13 patient records reviewed, the hospice plan of care did not include all services necessary to meet the specific needs of the patient and family as assessed in the comprehensive assessment. In HOHV#1 the patient was at risk for skin breakdown. The hospice was using Duoderm to prevent skin breakdown but maintaining skin integrity was not included in the plan of care. In HOHV#3 the social worker documented that the family asked for assistance with banking and disability issues but the only intervention was to tell the family to call the bank. There were no further interventions planned. In HORR#1 dyspnea, and pain were identified as issues with no mention in the plan of care. In HORR#3 the social worker noted a lack funeral arrangements and established a visit frequency but did not develop a psychosocial plan of care. In HORR#4 skin risk, and a stage 1pressure ulcer were identified with no corresponding plan of care. In HORR#5 the lack of funeral arrangements was not addressed. Similarly RR#6, RR#8, RR#9 and RR#10 did not address all assessed needs. This was validated with the Hospice Program Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice failed to provide care according to the plan of care. In HORR#1 the care provided to a wound was cleansed with NS and placed band-aid. The care ordered was cleanse with saline, pat dry, apply xeroform gauze, cover with roll gauze or aquacel foam if unwrappable. This was validated with the Hospice Program Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, for hospice patients who received aide services, the HHA care plan as prepared by the RN was inappropriate to the patient. In HOHV#1 the aide care plan had a bed bath every visit, a partial bath/shower per patient request and ability and a complete shower per pt request and ability. In conversation with Hospice Program Coordinator she indicated that initially the patient was receiving therapy services and was improving ability to transfer and to sit up and so the assignment was appropriate. However she reported that the patient did have a change that rendered him completely bedbound approximately 7 months prior to survey but the aide care plan was not updated to only allow the appropriate bath type.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice failed to maintain an accurate medical record. In HORR#1 there were 2 skin tears. standing orders treat skin tears differently based on the presence or absence of a skin flap. The wound charted blended the 2 orders and did not indicate which location was being treated or have a assessment of the wound flap that would determine which order to use. Observed in Patient Home. In 2 of 2 patient records reviewed, in which medication reconciliation was observed, the agency failed to maintain an accurate medication profile aligned with what the patient was actually taking. In HOHV#2 for a patient in a facility Morphine hospice orders were for every 2 hours the facility had hourly. Senna was ordered by Hospice but not on the facility medication list. In conversation with the nurse who had also recently done the admission she stated that both meds were communicated to the facility on the day of admission. She described the process for medication reconciliation to actually pull the facility med profile and compare as being done with every recertification. She was not able to describe a process for following up on medication changes communicated to the facility to make sure that medication lists actually align prior to the next recertification. In HOHV#3 Symbicort inhaler was on the medication list as a regularly scheduled medication but the patient stated he stopped taking it when he transferred down from out of state a month prior to survey. The nurse stated it remained on the medication profile in case he wanted to use it again but the order was not changed to prn.

Observed in Record Review. In 3 of 4 patient records reviewed, for hospice patients discharged alive, the hospice failed to provide or offer a discharge summary to another clinician or facility that would care for the patient after hospice services ended. In HORR#5 the patient revoked services. A discharge summary was written but there was no evidence that it was offered and/or provided to the receiving facility or physician. In HORR#7 and HORR#9 there was no discharge summary written. This was validated with the Hospice Program Manager.