Every finding on record at Malta Hospice Care

Observed in Record Review. In 2 of 6 patient records reviewed, During RR# 1's patient record review, it was noted the plan of care did not include bleeding precautions for the for the patient that was on an anticoagulant. This was reviewed and discussed with the Quality Assurance Nurse and validated.

Observed in Record Review. During review of HV# 1's patient record, it was noted the organization had not ensured the plan of care included measurable outcomes anticipated from implementing and coordination of the plan of care. For example: review of the patient record revealed no goals or interventions on the initial plan of care approximately 108 days prior to the surveyor review of the record. Further review revealed four subsequent updates to the plan of care (POC)/ Interdisciplinary Group (IDG) with no goals or interventions. Review of the four subsequent updates to POC/IDG revealed two were signed by all the members of the IDG. This was reviewed and discussed with the Quality Assurance Nurse and validated.

Observed in Record Review. In 1 of 6 patient records reviewed, During review of HV# 1's patient record, it was noted the organization had not ensured the Medical Director signed the initial certificate of terminal illness (CTI). For example: review of the initial CTI dated approximately 108 days prior to the surveyor review of the patient record, revealed documentation Pre-mitigation record on the signature line. This was discussed with the Quality Assurance Nurse and validated.

Observed in Record Review. In 2 of 3 active patient records reviewed, During HV# 1 and HV# 2's patient records review, it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example review of the most current update to the plan of care (POC)/Interdisciplinary Group (IDG) revealed the date of Thanksgiving and the signatures of the IDG members as Thanksgiving. This was reviewed and discussed with the Quality Assurance Nurse that shared the date on the update POC/IDG was inaccurate and the meeting and the signature should of been two days prior to Thanksgiving when the meeting was held.

Observed in Record Review. In 6 of 6 patient records reviewed, During RR# 1, RR# 2, RR# 3, HV# 1, HV# 2, and HV# 3's patient record review, it was noted the organization had not ensured the patients' records contained all the physician orders. For example: review of the patients' records revealed no physician orders for a hospice evaluation. This was discussed with Quality Assurance (QA) Nurse and validated.