Every finding on record at Mymichigan Medical Center Midland

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to document patient involvement in the discharge process. During record review for HOSRRDC#2, the Hospice Nurse Surveyor observed the staff had documented conversation with the family about upcoming discharge. The notice of discharge was in the patient chart but was not signed and had only the same date of discharge on the line meant for date of presentation to the family. This was discussed with the Hospice Director.

Observed in Record Review. In 1 of 18 patient records reviewed, the organization failed to assess and reassess per policy. During record review for HOSRRNHV#9, the Hospice Nurse Surveyor observed the patient had a Stage 2 coccyx pressure ulcer for over a year and there was no documentation of the size of the wound. Per the policy Wound- Palliative Care/ Home Care provided by the Director of Hospice, the wound should be assessed including size with every dressing change. This was discussed and reviewed with the Hospice Director.

Observed in Record Review. In 1 of 18 patient records reviewed, the organization failed to assess its patients. During record review for HOSRRNHV#2, the Hospice Nurse Surveyor observed the psychosocial assessment was completed on day 8 with no documentation of an attempted visit or phone call previous to that date. This was discussed and reviewed with the Hospice Supervisor.

Observed in Record Review. In 4 of 18 patient records reviewed, the organization failed to plan the patients care. During record review and home visit for HOSRRHV#1, HOSRRNHV#2, HOSRRNHV#1, the Hospice Nurse Surveyor observed the medication list in the facility and in the EMR did not contain key elements. For example in HOSRRHV#1, the patient had preservation vitamins ordered but it did not say how often or what dose. The patient was also getting a multivitamin daily but the order did not include how many tabs. In HOSRRNHV#2, the patient had PRN Tylenol and Motril for pain with no instructions on when to take which medication. In HOSRRNHV#1, the patient had four PRN medications for constipation. For example the patient had four PRN constipation meds that did not include detailed instructions of when to stop one and begin the next. The medications included: MiraLAX- 17 gm with no directions for use, Milk of Magnesium if no BM for 3 days, , Dulcolax if no bm for 4 days, and Senna if no bm for two days. This was discussed and reviewed with the Hospice Supervisor. Observed in Record Review. In 4 of 18 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRNHV#9, the Hospice Nurse Surveyor observed the wound care orders were not completed. For example the orders stated mix secura cream and anti fungal powder apply to wound on bilat gluteal fold. may be applied by HHA OR RN or staff - BID. The order did not include how much cream and fungal powder to mix or how much mixture to place on the wound. This was discussed and reviewed with the Hospice Director.

Observed in Record Review. In 13 of 18 patient records reviewed, the organization failed to assess its patients. During record review for HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, and HOSRRDC#1, the Hospice Nurse Surveyor observed no documentation of a comprehensive spiritual care comprehensive assessment. For example in all records , the patients declined per the spiritual care phone call and there was no documentation of further conversation from the IDG. This was discussed and reviewed with the Hospice Director. Observed in Record Review. In 13 of 18 patient records reviewed, the organization failed to assess its patients. During record review for HOSRRHV#3, HOSRRHV#4, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9, HOSRRNHV#10, HOSRRNHV#11, and HOSRRDC#2, the Hospice Nurse Surveyor observed no documentation of a comprehensive spiritual care comprehensive assessment. For example in HOSRRHV#3, HOSRRHV#4,HOSRRNHV#10, and HOSRRDC#2, the patients declined per the spiritual care phone call and there was no documentation of further conversation from the IDG. In HOSRRNHV#7, the patient had a missed visit for the spiritual comprehensive assessment and no further contact. In HOSRRNHV#8, the patient declined the spiritual comprehensive assessment on day 12 with no earlier attempts. In HOSRRNHV#9, the spiritual counselor called on day 3 to schedule an appt for next week per his documentation. A follow up visit was made a week later but the comprehensive assessment was never completed. In HOSRRNHV#11, the patient was living in the Hospice inpatient facility and initial visits were completed with visit notes but after conversation with the Manager of the inpatient unit, it was determined that the full comprehensive assessments were not available to document to. This was discussed and reviewed with the Hospice Director.

Observed in HR File Review. During the Human Resources/Competency Tracer, the surveyor noted that in the record of 1 of 4 hospice staff members hired within the last 3 years, documentation of initial orientation to the hospice was unavailable. The information was missing from the file of the employed medical director. This was discussed with the Director of Hospice.

Observed in Record Review. The hospice nurse surveyor noted (HOSARR#2) that there were no orders on the plan of care or in the record for the size and balloon of a Foley catheter, before the nurse changed it, the last week in August. This was confirmed with the nurse reviewer.

Observed in Individual Tracer. In 4 of 17 patient records reviewed, the Hospice did not evaluate the need for volunteer services. RR#5, who was on the IPU unit, did not have an evaluation for volunteer services. There was no evaluation for volunteer services for RR#8, RR#9, or RR#4. This was based on a review of the initial assessments and initial IDT. Per the manager, although the need for volunteer services was assessed for all patients, this assessment is not routinely documented in the record.

Observed in Individual Tracer. In 4 of 17 patient records reviewed, the target dates for the goals were not individualized based on the assessment. For example, clinical issues identified based on the assessment for RR#1 included shortness of breath and risk falls. All of the target dates for the goals for RR#1 were the same date which was within xx/xx/xxxxx or within two weeks. Similarly, RR#5 which was located on the IPU unit and had respiratory issues , had target dates set for all problems for xx/xx/xxxxx or within two weeks. RR#3 had issues with pain and had nausea and vomiting and the target dates for these goals were in two weeks. The goals for RR#9 predated the start of care by several weeks. Based on discussions with the RN and the manager, the Hospice routinely set target dates for goals for every two weeks to coincide with the IDT.

Observed in Individual Tracer. In 2 of 17 patient records reviewed, the Hospice plan of care did not include did not comprehensively reflect complete orders/interventions required based on the patient assessment. RR#2 had a Foley and the orders reflected the following- to change as needed. There was no further qualification of this prn order. There was no further clarification of this order. RR#12 had an ankle wound requiring dressing. The orders did not reflect the frequency of the dressing change. This observation was discussed with the manager.

Observed in Individual Tracer. In 1 of 17 patient records reviewed, the Hospice plan of care did not include did not comprehensively reflect complete orders/interventions required based on the patient assessment. The medication profile for RR#2 reflected that the patient was taking nicotine patches prn as needed. There was no further clarification of this order.

Observed in Leadership Session. Staff were not held accountable for their responsibilities as evidenced by condition level non compliance with 418.56. Leadership did not ensure that staff comprehensively and or accurately completed the comprehensive care plan for hospice patients.

Observed in Individual Tracer. In 1 of 17 patient records reviewed, the hospice record did not accurately reflect the medication that patients were taking. RR#3 resided in an ALF and the medication administration record ((MAR) did not reflect that the patient was taking an analgesic and another medication used to treat arthritis although the Hospice medication profile reflected these medications. This observation was discussed with the manager.

Observed in Individual Tracer. In 1 of 1 patient records reviewed, the hospice did not provide the transfer/discharge summary to the next provider. RR#13 was transferred to another hospice and there was no documentation available at the time of the survey that the summary was sent to the receiving hospice. This observation was discussed with the manager.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, the Hospice did not send the discharge summary to the attending physician upon discharge from the program. Both RR#14 and RR#15 no longer required services and was discharged from the hospice. There was no documentation at the time of the survey that the summaries were sent to the attending physicians. RR#16 and RR#17 both revoked and there was no documentation that the summaries were sent to the attending physicians. This observation was discussed with the manager.

Observed in Individual Tracer. In 1 of 1 patient records reviewed, the Hospice did not provide education and or reeducation related to oxygen use. RR#1 was on continuous oxygen and the external air filter was occluded with dust. Per the husband who was the primary caretaker, he cleans the filter every two weeks. There was no documentation in the home related to oxygen education received nor was there documentation in the record. This observation was discussed with the manager.

Observed in Building Tour. The Hospice did not comply with Policy #13240628 titled -Date Marking Ready to Eat Potentially Hazardous Food Procedures related to storage of food in the freezer. Surveyor observed multiple opened packages of food in the freezer in the IPU unit that did not have a date of when it was opened or had a discard date. These food items included; a package of loose chicken tenderloins, a package of loose crispy chicken strips, a package of loose Texas toast, and multiple ice cream cartons. This observation was discussed with the manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not completed a patient-specific comprehensive assessment. For example, in review of the medical record for HosRR4, multiple sections of the assessment had been left blank. Areas that were not assessed, included home safety, fire safety, lung sounds (even though the patient exhibited increased respiratory effort), bowel sounds (even though there was documentation of constipation), and integument. In review of the medical record for HosRR8, areas not assessed included eyes, ears, nose and throat. These observations were verified by the hospice quality nurse and/or the Quality Information Management Specialist assisting with record review.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor found that the organization had not consistently identified measurable outcomes. For example, in review of HosHV1 and HosRR1, a measurable outcome was not found related to the patients' identified risk for falls. This was verified by the hospice facility supervisor assisting with the review of the medical record. In review of the medical record for HosRR2, the surveyor noted that the bereavement goal was that bereavement needs would be assessed and services offered. Another goal was that the patient/family/caregiver would receive emotional support and education. In HosRR3, a goal present on the plan of care was that the patient verbalizes/exhibits respiratory ease. In HosRR5, a goal present on the plan of care was to Explore patient and family spiritual journey... This was verified by the hospice quality nurse assisting with record review.

Observed in Record Review. In 8 of 13 patient records reviewed, the hospice surveyor found that the plan of care did not include all drugs and treatments necessary to meet the needs of the patient. For example, in review of the medical record for HosHV1 and HosRR1, the patients were noted to be on oxygen and at risk for falls. The plan of care did not have an order for oxygen or interventions to address the patient's fall risk. In HosHV1 and HosHV2, the patient also had an indwelling catheter. The plan of care did not have a complete order for the catheter and referred to it in an intervention as maintain indwelling catheter or perform straight catheterization. In review of the medical record for HosRR2, the patient had a safety goal of teach back strategies to alleviate safety risks in living environment. There was only one intervention related to this goal and it was to assess risks. There were no interventions to teach strategies. In review of the medical record for HosRR5, documentation and the certificate of terminal illness identified the patient as having dysphagia but this was not addressed in the plan of care. In review of the medical record for HosRR6 and HosRR7, the goal was to verbalize three healthy ways of coping but the only intervention was to assess. In review of the medical record for HosRR9, the order was for gabapentin 1 capsule (100mg total) by mouth 3 (three) times a day. Start at PM and gradual work to 300mg three times daily titrate to effect. The order was not clarified and did not follow the organization's policy on titration of medication. In review of the medical record for HosRR10, the goal for nutrition was to verbalize understanding of nutritional needs but all interventions addressed nausea/vomiting These observations were verified by the hospice facility supervisor and/or the hospice quality nurse and/or the Quality Information Management Specialist assisting with review of the medical record.

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not provided care based on the patient's individualized plan of care. For example, in review of the medical record for HosRR4, the plan of care required the nurse to obtain daily weight information from the patient and to initiate the fall risk careplan. Weights were not documented during the first month and not consistently documented for two subsequent months. In addition, the fall risk careplan had not been initiated. In HosRR6, the aide was scheduled 1 time per week but did not complete the required visit. There was no documentation that the patient or caregiver had refused the scheduled visit. This was verified by the Hospice Quality nurse and/or the Quality Information Management Specialist assisting with review of the medical record.

Observed in Tracer Activities. In 1 of 3 home visits conducted, the surveyor noted that the staff member did not follow manufacturer's instructions for use related to cleaning of equipment. For example, during the home visit for HosHV2, the surveyor observed the staff member clean her reusable medical equipment with Oxivir wipes. In review of the manufacturer's instructions for use related to cleaning of the temporal thermometer, the manufacturer required the device be cleaned with 70% isopropyl alcohol. This was discussed with leadership team.

Observed in Record Review. In 3 of 7 patient records reviewed, where the patient had hospice aide services ordered, the hospice surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HosHV1, the patient was on oxygen and had a foley catheter in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for HosRR1, the patient was on Coumadin and had oxygen in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. There were also items not completed on the aide plan of care that the hospice surveyor was told should have been completed. This was verified by the hospice facility supervisor assisting with review of the medical record. In review of the medical record for HosHV3, the patient was observed to have bilateral nephrostomy tubes during the home visit. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to the nephrostomy dressings and/or appliances. This was verified by the hospice quality nurse assisting with review of the medical record.

Observed in Tracer Activities. In 2 of 13 patient records reviewed, the hospice surveyor found that the medication profile was not accurate. For example, during the home visit for HosHV2, the nurse reviewed the hospice medication profile with the medication list provided by the facility. The facility medication list included Zofran ODT. The hospice nurse stated this medication was not on the hospice medication profile and had been previously discontinued. In review of the medical record for HosRR5, Erythromycin eye ointment was ordered for five days but was still present on the medication profile approximately three weeks after the scheduled end date. This was verified by the Hospice Quality nurse assisting with record review. Observed in Tracer Activities. In discussion with the hospice quality nurse the surveyor learned that documentation provided by volunteers from patient encounters was not entered into the medical record. Volunteer documentation was kept with the Volunteer Coordinator

Observed in Record Review. In 8 of 8 patient records reviewed, where the patient had oxygen ordered, the hospice surveyor found that the organization had not educated the patient and/or family member on the safe and effective use of the oxygen concentrator and oxygen related supplies provided by the organization - Information on the storage, handling, and access to medical gases and supplies. For example, this education was not found for HosHV1, HosRR1, and HosRR5. During the home visit for HosHV1, the family member also stated she had not received this information. In review of the medical record for HosHV2, HosRR4, HosRR6, HosRR9, and HosRR10, education on causes of fire, fire risks to surrounding residences and buildings and ways to prevent fire related injuries was not found. These observations were verified by the Hospice Facility manager and/or the Hospice Quality nurse and/or the Quality Information Management Specialist assisting with review of the medical record.