Observed in Record Review. In 15 of 16 patient records reviewed, The surveyor observed that the need for volunteer services had not been documented. The surveyor discussed issue with hospice leadership and confirmed.
Every finding on record at Memorial Hospital of Laramie County
Cheyenne, Wyoming · CCN 531502
6 findings across 1 survey, in the inspector's own words.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Survey of August 3, 2023
6 findingsObserved in Record Review. In 4 of 4 patient records reviewed, the surveyor observed that the initial plan of care ordered for social worker to visit as needed no frequency was documented or reason for PRN visit. The issue was discussed and confirmed with leadership.
Observed in Individual Tracer. In 1 of 4 home visits conducted, the surveyor observed in hospice home visit 2 the SN had been since 5/5/23, draining the patients peritoneal pleurx drain tubing once per week and the patients wife was instructed by SN to drain pleurx drain 2 X week. The surveyor reviewed patient record with hospice leadership and found no evidence of an order for peritoneal pleurx draining.
Observed in Record Review. The surveyor observed that the CHHA on RR2 had been ordered to visit patient 2x per week, but during the week of July 10th no visits had been made and there was no evidence of adjustment to order or communication note of any kind. This was discussed and confirmed with hospice leadership.
Observed in Individual Tracer. The surveyor observed on the inpatient unit during wound change that the SN changing coccyx wound dressing had not cleaned hands or changed gloves between cleaning wound and dressing wound. This was observed with hospice leadership in room and confirmed. Observed in Individual Tracer. In 2 of 4 home visits conducted, the surveyor observed that the nurse did not change gloves or clean hands between glove changes and upon going in and out of nursing bag between assessment tasks . Further the surveyor observed in home visit #2 that the SN had not cleaned hands or change gloves between cleaning wound and applying clean wound dressing.
Observed in Building Tour. The surveyor observed one penetration above fire door #9. This was observed and discussed with engineer and hospice leadership. The issue was fixed onsite.
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Federal survey findings only. State licensure findings for hospices are not shown.
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