Every finding on record at Lifeguard Hospice Care Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted by the nurse surveyor that for RRNHV#2 the RN did not visit the hospice patient no less than 15 days to conduct an assessment. The patient had been seen by LPNs for 23 days until a RN with a reassessment was conducted. Finding was verified by the DPCS and the RN Case Manager.

Observed in Record Review. In 14 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies for the skilled nurse, medical social worker, and spiritual counselor did not have a reason for when to make the as needed PRN visits (they were not qualified). For RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10, all PRN visit frequencies were quantified for a number of how many could be made, but not for the reason in which they would be made.. Finding was verified by the DPCS and the Nurse Case Manager.

Observed in Record Review. In 3 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that medication orders were not clear or complete. For RRHV#1 and RRHV#2, the families were encouraged to use zinc oxide on reddened areas on the patients' coccyx, however, there were no physician orders for the use of zinc on the plan of care. Findings were verified with the DPCS and the Nurse Case Manager. Observed in Record Review. In 1 of 14 patient records reviewed, It was noted during RRHV#3 that patient was prescribed zinc oxide for wound care, family was educated on use, but an order was not found and it was not listed on the medication list. This was discussed with the DPCS and administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, for active patients, the nurse surveyor noted that care was not provided according to the hospice plan of care. For RRHV#2, the skilled nurse frequency was 2xwk, however on the third week of service, the patient was seen by the SN one time. There was no explanation in the electronic record for the missed nurse visit. Finding was verified by the DPCS and the nurse case manager. Observed in Record Review. It was noted by the nurse surveyor that for RRHV#3 the hospice aide care visit was missed without orders or documentation of reason for missed visit noted. Findings were discussed with the administrator.

Observed in Patient Home. In 4 of 4 home visits conducted, it was noted by the nurse surveyor that the staff failed to follow acceptable practice and agency policy when performing patient care. During RRHV#1, the registered nurse hand sanitized, went over to the patient and before touching him, came across the room and touched other objects, he then went back to the patient without hand sanitizing. The skilled nurse did not hand sanitize again until he donned gloves for cleaning his equipment, then doffed the gloves without hand sanitizing per policy. During RRHV#2, the registered nurse set up her barriers, went into her bag without hand sanitizing, put her equipment on her barrier, cleaned it, put it back where she had initially laid it, then took the patient’s vital signs. She then put the equipment back in the same place on the barrier then later returned her equipment back to her bag without cleaning. The Registered nurse also went into her bag several times without hand sanitizing. Findings were verified by the Director of Patient care services (DPCS) who was present on the visits. Observed in Patient Home. it was noted by the nurse surveyor that the hospice staff did not complete hand hygiene consistent with policy. For RRHV#3, the chaplain went in and out of his bag without hand sanitizing after anointing the patient with oil, and placed the container back into the bag without cleaning it. For RRHV#4, the CHHA did not perform hand hygiene between glove changes after providing a bath/perineal care and before picking up notepad to chart per policy. Findings were verified by the Director of Patient Care Services (DCPS) who was present on the visit.

Observed in Record Review. In 13 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRHV#1, the patient was on continuous oxygen, the hospice aide care plan did not have any information regarding what the hospice aide was supposed to do with the oxygen during the patient’s bath. For RRHV#2, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5. the patient is was on PRN oxygen yet the care plan did not address what the aide should do regarding the oxygen should the patient be on it during the bath. Findings were discussed with the DPCS and the Nurse Case Manager. Observed in Record Review. it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRHV#3, RRHV#4, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#10, the patient is on continuous oxygen, the hospice aide care plan did not have any information regarding what the hospice aide was supposed to do with the oxygen during the patient’s shower/bath Findings were observed by the Director of Patient Care Services (DCPS) who was present onsite.

Observed in Record Review. In 3 of 13 patient records reviewed, for active patients with the hospice aide, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRHV#2, in the last month there was a hospice aide supervisory visit that was documented sixteen days apart. Findings were verified with the DPCS and the Nurse Case Manager.

Observed in Record Review. it was noted by the nurse surveyor that Leadership failed to draft and approve a functional policy that provided clear direction and oversite to medical staff regarding their expectations for the documentation of CTI (Certification of Terminal Illness) as evidenced by record review and that the following Condition of Participation was not met: §418.102.

Observed in Record Review. In 14 of 14 patient records reviewed, for active records, it was noted by the nurse surveyor that for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10 the physician’s certificate of terminal illness (CTI) did not contain the required narrative. The CTI was mostly blank stating “medical record reviewed” or was blank and did not contain any information regarding patient physical findings or the facts that were taken into account that demonstrated the patient was hospice appropriate. Findings were validated by the Administrator, the DPCS, and the Nurse Case Manager.

Observed in Record Review. In 3 of 3 patient records reviewed, for active patients who were recertified, it was noted by the nurse surveyor that for RRHV#1 (4 recertifications), RRNHV#4 (1 recertification), and RRNHV#7 (1 recertification), the physician’s certificate of terminal illness (CTI) for recertification did not contain the required narrative. The CTI was mostly blank stating “medical record reviewed” or was blank and did not contain any information regarding patient physical findings or the facts that were considered that demonstrated the patient was hospice appropriate. Findings were validated by the Administrator, the DPCS, and the Nurse Case Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, it was noted by the surveyor during the medication review by the nurse that the medication profile did not accurately reflect what the patient was taking. For RRHV#2, there was an order for nebulizer treatments, DuoNeb 3mg-).5mg/3ml. Solution for inhalation, 1 via nebulizer every 4 hours while awake, the medication profile did not reflect the specific instruction of using every 4 hours. This portion of the order had been left off. Finding was validated by the DPCS who was present during the visit.

Observed in Record Review. In 14 of 14 patient records reviewed, for active records for patients with oxygen, it was noted by the nurse surveyor that education related to the safe use of equipment or medical gases provided by the agency. For RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10.there was no documentation in the EMR related to use of the oxygen concentrator or back up cylinders. The written material provided was very limited and did not include any information regarding the care of the equipment. Finding was discussed with the DPCS and Nurse Case Manager.

Observed in Record Review. In 2 of 3 patient records reviewed, of patients with open wounds, the organization had not followed their Policy No. 2-63.A which directs clinicians to: assess wound size, characteristics and drainage, and document in the record: appearance, odor, and size of wound, amount and characteristics of drainage. In RR #4 and RR #13, patients had open wounds documented; however the clinical documentation had not contained the ongoing assessment of the wound characteristics, no repeat measurements nor documentation of the drainage. This was validated with the Director of Patient Care Services and the Quality Assurance/Performance Improvement Specialist.

Observed in Record Review. In 7 of 13 patient records reviewed, Patient care goals were non- specific and not measurable. Examples include: Patients pain will remain at comfortable level; Patient will maintain optimal mobility during care; Caregiver will demonstrate ability to cope with patient altered mental status; Promote optimal nutrition/hydration during care; Patients agitation will be controlled to manageable level; These findings were validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 5 of 13 patient records reviewed, medication orders with titration based on patient symptoms had not contained clinical parameters for the titration. For example: in RR #1 and #3, Morphine dosage had been written with a dose for mild pain, moderate pain, and severe pain; however there was no definition for what was considered mild, moderate, or severe. In RR #2, the Morphine order was incomplete. The dose had been provided; however there was no time frame for administration nor pain parameters. In RR #7 and #9, Lorazepam titrated dose had been ordered for mild and severe anxiety; without definition of what was considered mild/severe anxiety. The Morphine orders were corrected immediately by the Director of Patient Care services. This was validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the clinicians did not follow the agency policy No. 9-009.2 Infection prevention and control which states: 'Hand decontamination with an alcohol-based hand rub should be performed before having direct contact with patients, after contact with patients intact skin (when taking a pulse, blood pressure or lifting a patient), and after removing gloves.' During HV#1, The clinician had not sanitized her hands prior to having direct contact with patient, nor before entering her nursing bag (x3). The same clinician had not performed hand decontamination when changing her gloves. HV #2 the clinician did not sanitize hands with alcohol based hand rub when beginning care and after touching inanimate objects in the patient home. HV #3 the clinician had not utilized an alcohol based hand rub at the beginning of the visit, nor between all glove changes. This was validated with the Director of Patient Care Services who was present for the visits.

Observed in Record Review. The Hospice Aide provided wound care to a patient without instructions to complete.

Observed in Record Review. Clinical documentation in the patient record regarding care provided to the patient was inaccurate and conflicted with other documentation. For example, the registered nurse documented on 3 occasions that the patient was bedbound; however, the Hospice Aide had documented multiple times that the patient had been provided a shower. Observed in Record Review. In 2 of 3 patient records reviewed, of patients with open wounds, the organization had not followed their Policy No. 2-63.A which directs clinicians to: assess wound size, characteristics and drainage, and document in the record: appearance, odor, and size of wound, amount and characteristics of drainage. In RR #4 and RR #13, patients had open wounds documented; however the clinical documentation had not contained the ongoing assessment of the wound characteristics, no repeat measurements nor documentation of the drainage. This was validated with the Director pf Patient Care Services and the Quality Assurance/Performance Improvement Specialist. Observed in Record Review. In 3 of 3 patient records reviewed, of patients receiving wound care, the clinician has not documented the actual wound care provided. The surveyor was not able to validate whether wound care orders were followed as ordered. For example in RR #4 the clinician documented: wound care done. and in RR #13 the clinician documented: wound care rendered using clean technique. This was validated with the Director of Patient Care Services and the Quality Assurance/Performance Improvement Specialist.

Observed in Individual Tracer. In 2 of 12 patient records reviewed, of patients receiving Hospice Aide services, care was not provided according to the plan of care. The patients in RR # 2, #6 the plan of care had Hospice Aide services ordered for 2 times per week; however, the ordered Aide services were not provided as needed to the patient for a full week because the hospice aide was unavailable. This was validated with the Administrator and Director of Patient Care Services.