Every finding on record at Mary Washington Hospital, Inc.

Observed in Record Review. In 3 of 14 patient records reviewed, The surveyor noted that the plan of care (HOSHV#1, HOSNHV#2 and HOSNHV#8) that the plan of care did not reflect the patient's stated pain goal. Examples: In all three records the Problem Statement read Pain/physical Discomfort with a corresponding goal statement Pain will be reduced to the level of the patients stated goal. The patients pain level goal was not documented. Reviewed with Hospice Director.

Observed in Record Review. The surveyor noted in 1 out of 14 records (HOSNHV#3,) that the care was not provided in accordance to the plan of care. Example: the patient was evaluated on 5/15 for uncontrolled pain with a reported pain level of 7/10. The pain medication regimen was changed from morphine to methadone on 5/15. The patient was not re-assessed until 5/20; not in keeping with the two times per week ordered frequency. Reviewed with Hospice Director.

Observed in Record Review. In 3 of 14 patient records reviewed, The surveyor noted that a complete initial spiritual assessment was not performed in 3 out of 14 (HOSHV#4, HOSNHV#4 and HOSNHV#10) record reviews. Reviewed with Clinical Manager for Spiritual Care.

Observed in HR File Review. During a review of the human resource file for the volunteer coordinator, the hospice pharmacy surveyor noted that this individual did not have a written assessment of the skills and competence provided and then evaluated on hire. This omission was validated with human resources and hospice management at the time ofn the survey.

Observed in Patient Home. In 1 of 4 home visits conducted, The surveyor noted during HOSHV#3 that the medication profile in the home and medication list in the medical record was not accurate. Examples: Two medications the Wellbutrin 300 mg once a day and Megace 400 mg twice a day were still listed as current and had not been administered for the past month. Reviewed with Hospice Director.