Every finding on record at Lakeside Hospice Care, Inc.

Observed in Tracer Activities. On review of the organizations admission packet and patient handbook, it was noted that the hospice failed to provide written information to the patient concerning its policies on advance directives. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to maintain complete and accurate patient record. For example: on review of RRHV#2 the visit documentation for the CHHA visit that was observed by the surveyor was noted to be entered into the record and signed by an LVN yet the visit was observed to be conducted by the CHHA on site. This observation was reviewed with the DON and Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to ensure the individualized written plan of care reflect the patient and family goals that were specific, measurable, attainable, realistic, and time-bound. For example: in RRHV#1 an example was Facilitate optimum bowel movement for comfort and Promote rest status for Pt/Family/PCG during hospice care. in RRHV#2 goals read During hospice care, minimize risk for cardiac crisis episode and Minimize risk for fall during hospice stay. In RRHV#3 examples of goals were Anxiety will be on comfort level during hospice care and PCG will be able to provide hazard free environment during hospice care, yet the latter goal does not explain what type of hazards the PCG was to avoid. In RRNHV#4 a goal was PCG will verbalize understanding of safety intervention, proper oxygen use and storage. The goal was established on admission in September, but the target date for achieving the goal of understanding safety was set for the end of the benefit period in December. In RRNHV#5 examples were Maintain mobility and independence. Minimize complications due impaired mobility. Across all active records reviewed there were goals noted that were not specific, measurable, and time bound. These observations were reviewed with the Director of Nursing, Administrator, and the Nursing Staff.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. For example: on review of RRNHV#4 it was noted in the documentation the patient had a UTI with antibiotic treatment however the UTI was not reflected in the care plans. In RRNHV#8 the documentation noted issues with patient nutrition such as weight loss and loss of appetite, yet the issues were not reflected in the care plan, as the only goals pertained to dysphagia. In RRNHV#9 the documentation noted the patient had multiple falls, yet the care plans did not reflect the falls. These observations were reviewed with the DON and Nursing Staff.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#6 on the medication profile there were supplies listed for blood glucose monitoring, yet there were no physicians orders for blood glucose monitoring such as frequency, who was to perform, and when to report results. This observation was reviewed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, The organization failed to implement the infection prevention and control activities it had planned. For example: on home visit observation with the Hospice Aide the Aide was observed to not perform hand hygiene per the organization's policy. The Aide was observed to change gloves during patient without sanitizing hands per policy between glove changes. This observation was reviewed with the CHHA, DON, and Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to ensure the patient record contained information to reflect the patient's care, treatment, and services. For example: on review of RRNHV#10 the last documented SN visit noted in the record was greater than 10 days prior to survey. The staff was able to verify that visits were made by the LVN per plan of care yet the documentation had not been submitted to the record per the organization policy of submitting within 7 days. This observation was reviewed with the Director of Nursing and Nursing Staff.