Every finding on record at Livingston Memorial Visiting Nurse Association - Hospice

It is required that each patient’s individualized written plan of care reflects patient, and family goals based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals based on problems identified in the initial and comprehensive assessments. CLINICAL RECORD 3: The patient elected hospice care on 03/21/2024 with a diagnosis of End Stage Heart Failure. A skilled nursing visit was completed on 01/30/2025. The documentation read in part "she reports uti sx of dysuria". A physician order was obtained on 01/30/2025 for Bactrim DS 800 mg-160 mg, 1 tablet twice a day for 5 days uti sx. The plan of care effective 01/15/2025-03/15/2025 and IDT reviews dated 01/30/2025 and 02/13/2025 did not include patient and family goals for the patient's genitourinary change in condition. CLINICAL RECORD 9: The patient elected hospice care on 08/01/2024 with a diagnosis of Alzheimer's Disease. A skilled nursing visit was completed on 01/31/2025. The documentation read in part "she reports uti sx of dysuria". A physician order was obtained on 01/31/2025 for Bactrim DS 800 mg-160 mg, 1 tablet twice a day for 5 days uti sx". The plan of care effective 01/28/2025-03/28/2025 and IDT reviews dated 02/06/2025 and 02/20/2025 did not include patient and family goals for the patient's genitourinary change in condition. During a joint record review and an interview on 04/02/2025, the Hospice Director confirmed that clinical record 3 and clinical record 9 did not include patient and family goals for urinary tract infection.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview and observation. In 2 of 4 (50%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. DOCUMENT 1: Policy IPC.1a Hand Hygiene review date 01/2025 read in part "All staff will reference the clinical procedure manual which follows the CDC and WHO hand hygiene recommendations. Staff will be evaluated against the approved Hand Hygiene competency." Hand Hygiene Competency revision date 01/2025 read in part "Hand hygiene must be performed before donning gloves and after removing gloves" and "Before transitioning from a contaminated-body site to a clean-body site, remove gloves, perform hand hygiene, and don new gloves." HOME VISIT 1: The patient elected hospice care on 12/08/2018 with a diagnosis of Alzheimer's Disease. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 04/01/2025, the RN flushed the sacral wound with normal saline, removed gloves and donned new gloves prior to applying the foam dressing to the sacral wound. The RN did not perform hand hygiene after removing their gloves per agency policy/hand hygiene competency. HOME VISIT 3: The patient elected hospice care on 03/21/2024 with End Stage Heart Failure. The Hospice Aide (HA) provided a bed bath including peri care during the home visit. After completion of the bed bath, the HA removed gloves and performed hand hygiene. The RN did not perform hand hygiene before transitioning from a contaminated-body site to a clean-body site per agency policy/hand hygiene competency. During an interview on 04/02/2025, the Hospice Director confirmed the finding and the agency policy that hands should be cleansed between and after glove removal and when moving from a contaminated-body site to a clean-body site.

Observed in Record Review. In 1 of 13 patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of the patient's record revealed HV# 1 had been on service for approximately five months with no documentation of an initial bereavement risk assessment. This was reviewed, discussed, and validated with the Director of Patient Care Services. Observed in Record Review. In 1 of 13 patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of the patient's record revealed HV# 1 had been on service for approximately five months with no documentation of an initial bereavement risk assessment. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 13 of 13 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 8, RR# 9, and RR# 10's patient record review, it was noted the organization had not ensured the patient's plans of care included goals and time frames. For example: review of 13 of 13 patient records with medical social worker (MSW) services revealed plans of care with goals that had no time frames such as, Patient/Caregiver will have coping mechanisms in place.. In addition, 7 of 7 patient records reviewed with chaplain services, HV# 1, RR# 2, RR# 3, and RR# 5, RR# 6, RR# 8, & RR# 10's revealed plans of care with chaplain frequency of visits and no documented goals. Review of HV# 2, and RR# 3's plans of care revealed the following goal Patient's pain will remain at a comfortable level, as identified by the patient throughout the plan of care. Patient's stated acceptable level of pain is ___________. These were reviewed, discussed, and validated by the Director of Patient Care Services. Observed in Record Review. In 13 of 13 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 8, RR# 9, and RR# 10's patient record review, it was noted the organization had not ensured the patient's plans of care included goals and time frames. For example: review of 13 of 13 patient records with medical social worker (MSW) services revealed plans of care with goals that had no time frames such as, Patient/Caregiver will have coping mechanisms in place.. In addition, 7 of 7 patient records reviewed with chaplain services, HV# 1, RR# 2, RR# 3, and RR# 5, RR# 6, RR# 8, & RR# 10's revealed plans of care with chaplain frequency of visits and no documented goals. Review of HV# 2, and RR# 3's plans of care revealed the following goal Patient's pain will remain at a comfortable level, as identified by the patient throughout the plan of care. Patient's stated acceptable level of pain is ___________. These were reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 10 of 13 patient records reviewed, During HV# 1, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 8, and RR# 10's patient records review, it was noted the organization had not ensured the patient's plans of care include interventions to manage the terminal illness. For example: review of HV# 1, RR# 2, RR# 3, and RR# 5, RR# 6, RR# 8, RR#10's plans of care revealed Chaplain visit frequencies with no documented interventions. In addition, review of HV# 3, RR# 1, RR# 3, and RR# 4's plans of care revealed medical social worker (MSW) visit frequencies with no documented interventions. This was reviewed, discussed, and validated by the Director of Patient Care Services. Observed in Record Review. In 10 of 13 patient records reviewed, During HV# 1, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 8, and RR# 10's patient records review, it was noted the organization had not ensured the patient's plans of care include interventions to manage the terminal illness. For example: review of HV# 1, RR# 2, RR# 3, and RR# 5, RR# 6, RR# 8, RR#10's plans of care revealed Chaplain visit frequencies with no documented interventions. In addition, review of HV# 3, RR# 1, RR# 3, and RR# 4's plans of care revealed medical social worker (MSW) visit frequencies with no documented interventions. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 2 of 13 patient records reviewed, During HV# 1, HV# 3's patient record review it was noted that plans of care had not been revised to reflect updated assessments and progress towards goals. For example: review of HV# 1's start of care plan of care and three subsequent plans of care, revealed the same documentation Mortuary will be chosen within first month of care. Review of HV# 1's patient record revealed mortuary services had been chosen approximately, three months prior to the surveyor review of the record. However, the two subsequent plans of care had not been updated to reflect the change. In addition, review of HV# 3's record revealed HV# 3 was admitted with a wound on the left heel and wound care orders approximately nine months prior to the surveyor's review of the record. Review of the current registered nurse recertification comprehensive assessment, completed approximately one month prior to the surveyor review of the record, revealed the wound on the left heel had healed. However, review of the plan of care and subsequent updates to the plan of care, revealed no documentation the wound had healed and included wound care orders. This was reviewed, discussed, and validated by the Director of Patient Care and Services. Observed in Record Review. In 2 of 13 patient records reviewed, During HV# 1, HV# 3's patient record review it was noted that plans of care had not been revised to reflect updated assessments and progress towards goals. For example: review of HV# 1's start of care plan of care and three subsequent plans of care, revealed the same documentation Mortuary will be chosen within first month of care. Review of HV# 1's patient record revealed mortuary services had been chosen approximately, three months prior to the surveyor review of the record. However, the two subsequent plans of care had not been updated to reflect the change. In addition, review of HV# 3's record revealed HV# 3 was admitted with a wound on the left heel and wound care orders approximately nine months prior to the surveyor's review of the record. Review of the current registered nurse recertification comprehensive assessment, completed approximately one month prior to the surveyor review of the record, revealed the wound on the left heel had healed. However, review of the plan of care and subsequent updates to the plan of care, revealed no documentation the wound had healed and included wound care orders. This was reviewed, discussed, and validated by the Director of Patient Care and Services.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 3's home observation it was noted the nurse did not follow the organization's bag technique policy.  For example: during the home observation the registered nurse (RN) was observed removing a plastic bag with vital sign equipment from the nurse bag and placed the plastic bag directly on the patient's bed. The RN was next observed assessing vital signs and placed each piece of equipment, to include the pulse oximetry, thermometer, and B/P cuff, directly on the patient's bed with no barrier. The organization's policy included that supplies taken out of the bag should be placed on a water proof barrier. This was observed, discussed, and validated by the Assistant Director of Patient Care Services present at the home observation. Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 3's home observation it was noted the nurse did not follow the organization's bag technique policy.  For example: during the home observation the registered nurse (RN) was observed removing a plastic bag with vital sign equipment from the nurse bag and placed the plastic bag directly on the patient's bed. The RN was next observed assessing vital signs and placed each piece of equipment, to include the pulse oximetry, thermometer, and B/P cuff, directly on the patient's bed with no barrier. The organization's policy included that supplies taken out of the bag should be placed on a water proof barrier. This was observed, discussed, and validated by the Assistant Director of Patient Care Services present at the home observation.

Observed in HR File Review. In 4 of 7 Hospice specific discipline competency assessments, During HR record review, it was noted the Medical Director, Bereavement Coordinator, Volunteer Coordinator and the Chaplain did not have documentation of a competency assessment on hire or at least every three years. This was reviewed, discussed, and validated with the Vice President/Chief Administrative Officer. Observed in HR File Review. In 4 of 7 Hospice specific discipline competency assessments, During HR record review, it was noted the Medical Director, Bereavement Coordinator, Volunteer Coordinator and the Chaplain did not have documentation of a competency assessment on hire or at least every three years. This was reviewed, discussed, and validated with the Vice President/Chief Administrative Officer.

Observed in Record Review. In 2 of 10 patient records reviewed with no home visit, During RR# 7 and RR# 8's patient record review it was noted the organization had not ensured the medication profile was accurate. For example: review of RR# 8's medication profile revealed a duplicate medication order of valproic acid capsule 250mg 2 caps in the morning, 1 cap in the evening and 2 caps at bedtime oral. In addition, Review of RR# 7's medication profile revealed duplication medication orders to include digoxin tablet 125 mcg(0.125 mg) 1 tablet every day oral; Levothyroxine tablet 50 mcg (0.05 mg) 1 tablet every day oral, and triple medication order to include Acetaminophen capsule 500mg 1 capsule every 3 hours as needed oral. This was reviewed, discussed, and validated with the Director of Patient Care and Services. Observed in Patient Home. In 2 of 2 home observation with medication reconciliation, During HV# 1 and HV# 3's home observations, it was noted the organization had not ensured the medication profile was accurate. For example: during HV# 3's registered nurse (RN) medication reconciliation, it was noted the medication profile listed Lorazepam in tablet form and Lorazepam in liquid form. Review of the medications revealed the patient had the liquid Lorazepam. Further review of the medication profile revealed both Lorazepam's were added to the medicaiton profile approximately nine months earlier at the start of care. In addition, during HV# 1's RN medication reconciliation, it was noted the medication profile listed aspirin 81mg chewable tablet. However, the patient's prescription located on the medication card was aspirin 81mg enteric coated tablet by mouth. This was observed, discussed, and validated with the Assistant Director of Patient Care Services present during the home observations. Observed in Patient Home. In 2 of 2 home observation with medication reconciliation, During HV# 1 and HV# 3's home observations, it was noted the organization had not ensured the medication profile was accurate. For example: during HV# 3's registered nurse (RN) medication reconciliation, it was noted the medication profile listed Lorazepam in tablet form and Lorazepam in liquid form. Review of the medications revealed the patient had the liquid Lorazepam. Further review of the medication profile revealed both Lorazepam's were added to the medicaiton profile approximately nine months earlier at the start of care. In addition, during HV# 1's RN medication reconciliation, it was noted the medication profile listed aspirin 81mg chewable tablet. However, the patient's prescription located on the medication card was aspirin 81mg enteric coated tablet by mouth. This was observed, discussed, and validated with the Assistant Director of Patient Care Services present during the home observations. Observed in Record Review. In 2 of 10 patient records reviewed with no home visit, During RR# 7 and RR# 8's patient record review it was noted the organization had not ensured the medication profile was accurate. For example: review of RR# 8's medication profile revealed a duplicate medication order of valproic acid capsule 250mg 2 caps in the morning, 1 cap in the evening and 2 caps at bedtime oral. In addition, Review of RR# 7's medication profile revealed duplication medication orders to include digoxin tablet 125 mcg(0.125 mg) 1 tablet every day oral; Levothyroxine tablet 50 mcg (0.05 mg) 1 tablet every day oral, and triple medication order to include Acetaminophen capsule 500mg 1 capsule every 3 hours as needed oral. This was reviewed, discussed, and validated with the Director of Patient Care and Services.