Every finding on record at Mcalester Regional Health Center Authority

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: No evidence found of discussion taking place with pt/cg regarding choice of attending physician upon admission.

Upon patient record review, 7 of 14 (Patient #2, 4, 6, 7, 8, 9, & 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patients 2, 4, 6, 7, 8, 9, & 11: Patient medication list reveals multiple pain medications present with no clear instructions on when each drug is indicated based on severity of symptom. (Tylenol with Morphine, Tylenol with Tramadol, Tylenol, morphine liquid, etc.)

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 2: No evidence of bereavement assessment conducted upon admission.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: Hospice aide documentation on 1/30/24 reveals report given to RN of patient c/o pain 10/10. No evidence found of follow-up by RN.

Upon patient record review, 8 of 14 (Patient #1, 2, 4, 6, 7, 8, 9, & 11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1- Foley catheter order upon admission is incomplete. No evidence found of orders to change catheter and at what frequency, no orders related to catheter irrigation or other interventions indicated for problems. Patients 2, 4, 6, 7, 8, 9, & 11 - Plan of care reveals multiple pain medications with incomplete instructions on when each medication is indicated based on severity of symptom. (Tylenol with Morphine, Tylenol with Tramadol, Tylenol, morphine liquid, etc.)

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Volunteer services requested upon admission, 2/13/24, at a frequency of once per week. No evidence as of 2/20/24 of volunteer assignment or visit being completed.

Upon patient record review, 6 of 14 (Patient #1,2,3,4,6, & 9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients 1, 2, 3, 4, 6, & 9 - Aide Instructions all contain the templated phrase to observe "Oxygen, fall, diabetic, bleeding, and nebulizer precautions." No evidence that each patient warrants all of these precautions, this does not reflect individualized Aide instructions to meet each patients' needs. Patients 2 & 4- Aide instructions state for aide to utilize Wong scale to determine patient pain level. Patients with Alzheimer's/Dementia may not be cognitively able to comprehend and utilize pain scale appropriately. This would require the aide to assess the patient's cognitive ability which is outside scope of practice.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Admission Plan of care order reflects aide frequency of 3 times weekly. The aide frequency being followed from the time of admission is 2 times weekly.

Upon patient client record review, 5 of 14 (Patient #2, 3, 5, 7, & 8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 2, 3, 5, 7, & 8: No evidence found that Patient Notification of Hospice Non-Covered Items, Services, and Drugs was discussed upon election of the hospice benefit. Patient 5: Election statement does not address patient choice of attending physician.

Upon patient client record review, 4 of 14 (Patient # 1, 4, 7, & 9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1-Handwritten order found in chart documents instructing hospice to remove surgical staples and drain. Physician signature present but no evidence of date and time of order. Patient 4 - LPN supervisory visits completed each month from 10/23 - 1/24 indicating satisfactory or excellent care by LPN. No evidence of LPN visit since 8/29/23. Patient 7 - LPN supervisory visits completed each month from 10/23 - 1/24 indicating satisfactory or excellent care by LPN. No evidence of LPN visit since 9/11/23. Patient 9 - 1/29/24 RN assessment indicates pain score with 3 different pain scales... 9/10 per Edmonton scale, 5/10 per PainAd, & documents a primary pain score of 3/10.