Every finding on record at Langlade Hospital-Hotel Dieu of St Joseph of Antigo Wis

Observed in HR File Review. In 1 of 14 patient records reviewed, In 1 of 14 records reviewed the nurse survey noted for RRHV#1, the CNA care plan instructed the CNA to apply Nystatin cream to the abdominal folds of the patient after showers and to make sure the skin is dry before applying. In addition, the CNA care plan indicated for the CNA to apply Ketoconazole cream to hair during showers.  The agency policy was reviewed which allows the CNA to apply creams, lotions and ointments; however, the policy does not address the application of medicated or prescribed creams.  This was discussed with the manager of post-acute care/administrator and the supervisor for post-acute care. In addition, after the HR record review was completed for the CNA there was no evidence the CNA had completed the state approved required training program for medication administration. This was discussed with the Administrator and CNO.

Observed in Record Review. In 1 of 14 patient records reviewed, the nursing assessment showed evidence of a wound to the back of the chest, however, in RRNHV#4 there was documentation of wound care cleansed but clinical documentation did not specify what type of wound care was performed. This was reviewed with the manager and supervisor.

Observed in Tracer Activities. In review of the admission packet and patient handbook, it was noted that the organization did not comply with the requirements of the chapter regarding advance directives as the admission packet and patient handbook distributed to patients did not contain written information concerning its policies on advance directives, including a description of applicable state law. This observation was reviewed with the Hospice Manager, CNO, and Quality Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the interdisciplinary group, in consultation with the patient's attending physician, complete the comprehensive assessment no later that five calendar days after the election of hospice care. For example: on review of RR#7 the initial chaplain assessment did not occur until the sixth day after election, yet there was a spiritual plan of care established prior to the spiritual assessment. In RR#9 the initial spiritual assessment did not occur until the 6th day after election. There was documentation on day 4 that a message was left for the family to schedule, yet no further documentation to note the visit was refused or requested by the family to occur outside of the 5-day requirement. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure that the written plan of care was based on the patient's goals that were specific, measurable, achievable, realistic, and time bound. For example: on review of HV#2 examples of non-measurable goals were patient cardiac needs met without signs and symptoms of complications and Reduction in patient elimination and skin breakdown complaints. A pattern of goals that were not specific and non-measurable were patterned throughout the records. Further examples were in RR#4 of Absence of urinary and bowel complaints and skin breakdown, and in RR#5 elimination/management of edema and Decrease or stabilize edema. In RR#8 examples included Tina and her children will cope with caregiving, psychosocial, and end of life issues, and Patient exhibits/verbalizes respiratory ease. Further examples can be noted in RR#7, and RR#10. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 4 of 11 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 and related conditions. For example: on review of RR#11 the initial comprehensive nursing assessment documented a wound to the patient's coccyx, yet the wound was not reflected on the plan of care nor were there treatment orders noted until 10 days after admission when assessment noted a worsening of the wound. In review of RR#4 the documentation in the record on 4/25/23 noted a wound to have healed and the treatment changed to open to air, however the physicians order and the plan of care did not reflect the changes noted in the documentation. Example 2: on review of RR#8 and RR#9 the patient's medication profile included orders for hydrocodone and morphine for PRN use however there was no indication beyond PRN to guide the patient, caregiver, or clinician as to which pain medication to choose related to the type and severity of the pain experienced. On review of RR#4 the medication profile included an order for malto dextrin (Thick-it) powder. The order instructions stated take 1 each by mouth once daily. The order failed to address specific indications on how the powder was to be mixed to achieve specified consistency, and frequency in which to be used. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 1 of 9 patient records reviewed, were aide services were provided, the organization failed to ensure the registered nurse provide specific written patient care instructions. For example: on review of the hospice aide plan of care it was noted that the patient's assigned bath of a shower, and shampoo were noted to be assigned as PRN and not assigned a frequency for the aide to follow. This observation was reviewed with the hospice manager.

Observed in HR File Review. In 2 of 8 HR files reviewed, The organization failed to assess the skills and competence of all individuals furnishing care. For example: on review of the HR file for the Medical Director and the Volunteer Coordinator there was no documentation of competence assessment annually as required by organization policy. This observation was reviewed with the Hospice Manager and Leadership.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course that included all required elements. For example: on review of HV#1 and HV#3 the written physician's narrative on the CTI was minimal and specifically lacked current subjective and objective medical findings. On review of RR#10 the initial CTI lacked a physician's narrative. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the patient record contain information that reflected the patient's care, treatment, and services. For example: on review of the hospice aide documentation of HV#1 and RR#4 for week of survey the aide documented that issues during the visit were to be reported to the nurse but failed to identify who was contacted and when. In review of RR#6 the DME listed on the plan of care noted an O2 concentrator, yet no further documentation in the record indicated the patient was on O2. On discussion with the Hospice Director, it was determined that O2 was not ordered and was not present in the patient's home. These observations were reviewed with the Hospice Director.