Every finding on record at Nathan Adelson Hospice

Observed in Record Review. In 11 of 20 patient records reviewed, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. For example, a review of the Hospice Election and Consent Form revealed that patients were not informed of their financial responsibility prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services. During a review of the Hospice Election and Consent Form in the medical record for HV#1, HV#2, RR#8, RR#10, RR#11, and RR#12, there was no documented evidence that the patient received information about the services covered under the hospice benefit. The consent states I acknowledge that I have been provided with information about my financial responsibility for certain hospice services (drug copayment and inpatient respite care). However, this document did not indicate the amount of financial responsibility and was signed by the patient or the patient's caregiver. Example #2: The organization did not ensure the patient's right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for HV#1, the Line titled Provider First/Last Name did not include the provider's complete name, but an abbreviated nick-name. In addition, the line-item Provider NPI # was blank. Example #3: During a review of the consent in the medical record for HV#2, HV#3, and HV#5, RR#1, and RR#5, the line-item Provider NPI# was blank. Example #4: During a review of the consent in the medical record for HV#4, the Line titled Provider First/Last Name did not include the provider's complete name. In addition, the line-item Provider NPI # was blank. This observation was reviewed with the VP of Quality and Education, and the Chief Nursing Officer.

Observed in Individual Tracer. In 2 of 20 patient records reviewed, the organization did not ensure that its defined criteria for pain assessments consistent with the patient’s condition was implemented. For example, during a review of the medical record for HV#1, and RR#8, it was noted the clinician used a numeric scale to assess pain for a cognitively impaired patient. This observation was reviewed with the Clinical Manager, and the Chief Nursing Officer.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that the plan of care did not include all required elements. For example, a review of the medical record for RR#4 revealed that the comprehensive assessment (falls risk assessment) patient was high risk for falls. In addition, the Physical/Musculoskeletal section of the comprehensive assessment indicated the patient experienced increased fatigue, activity intolerance, uses rolling walker, needs assist with transfers, and needs assistance of others to ambulate. The plan of care did not include interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate the effectiveness of interventions.

Observed in Record Review. In 1 of 3 patient records reviewed for patients receiving Hospice Aide services, it was noted that the organization did not ensure the visit frequency for aide services were completed as ordered. For example, the plan of care for RR#1 indicated Hospice Aide services were to be provided 3 times per week. During week 2 of services the Hospice Aide completed 2 visits. This observation was reviewed with the VP of Quality and Education.

Observed in Record Review. In 1 of 20 patient records reviewed, it was noted that the organization did not ensure the plan of care included all required information. For example, during a review of the updated assessment for RR#4 it was noted that during week 5 of services the patient experienced a fall with injury. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate the effectiveness of interventions.

Observed in Individual Tracer. In 2 of 5 Individual Tracers, the organization did not ensure that standard precautions were implemented during patient care activities. For example, during HV#1, it was noted that the clinician used the patient’s dishwashing liquid for hand hygiene and the dishwashing liquid did not include an antimicrobial agent. Example #2: During HV #3, it was noted that the clinician removed gloves after performing vital signs and did not perform hand hygiene prior to applying new gloves. This observation was reviewed with the Clinical Manager and the Chief Nursing Officer.

Observed in Infection Control System Tracer. During the Infection Prevention Session, the surveyor noted that the organization had not implemented any measures to improve compliance with hand hygiene guidelines. The organization had not established any goals for hand hygiene compliance. This finding was discussed with the Quality Director.

Observed in Infection Control Tracer. During tracer activities, the surveyor noted that the organization's education to the patient and caregiver did not include infection prevention and control, oral health, personal hygiene, nutrition, or education on the safe disposal of hazardous medications and waste. Additionally, the materials were not written at a reading level suitable for fourth graders or below. This finding was discussed with the Quality Manager.

Observed in Record Review. In 1 of 2 patient records reviewed for patients discharged or transferred from the organization, it was noted that organization did not ensure information was provided to the receiving organization as required. For example, a review of the medical record for RR#3, revealed that the receiving organization was not provided with a copy of the hospice discharge summary and requested documents from the medical record. This observation was reviewed with the VP of Quality and Education.

Observed in Record Review. In 2 of 2 patient records reviewed, for patients discharged or transferred from the organization, it was noted that the discharge/transfer summary did not include all required information. For example, during a review of the discharge/transfer summary for RR#2, and RR#3, it was noted that the document did not include a summary of the patient's stay, including treatments, symptoms, and pain management. This observation was reviewed with the VP of Quality and Education.

Observed in Individual Tracer. In 5 of 5 Individual Tracers, the organization did not ensure that a copy of its written policies and procedures on the management and disposal of controlled medications was provided to the patient or the patient’s representative and family. For example, during HV#1, HV#2, HV#3, HV#4, and HV#5, it was noted that a copy of the organizations written policies and procedures related to the use and disposal of controlled medications was not present in the home folder. This observation was reviewed with the Chief Nursing Officer.

Observed in Individual Tracer. During 5 of 5 Individual Tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency was established. For example, during a review of patient education information in the home for HV#1, HV#2, HV#3, HV#4, and HV#5, an individualized disaster/emergency management plan was not identified. This observation was reviewed with VP of Quality and Education.

Observed in Building Tour. During the review of the above ceiling area in corridor #1, of the Hospice Inpatient Building Tenaya, it was noted that the piping for the automatic sprinkler system was supporting other items – a coiled conduit was resting on this piping. This observation was reviewed with the Director of Facilities, Director of Inpatient, and the Chief Nursing Officer. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The organization did not ensure that fire protection features were designed and maintained to minimize the effects of fire, smoke, and heat. For example, during the building tour of Hospice Inpatient Building Tenaya - corridor #1, it was noted that the smoke barrier door had a gap between the bottom of the door and the floor that was larger than 3/4 of an inch. This observation was reviewed with the Director of Facilities, Director of Inpatient, and the Chief Nursing Officer. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Individual Tracer. During observation of a Hospice home visit and confirmed by the RN, it had been identified that there had not been consistent medication reconciliation to include multiple medications that the patient had been taking. Example: During observation of HOSv#1 the caregiver had stated that the patient had been taking multiple medications to include Vit D3 fish oil, multi vitamin, Tylenol, eye drops for macular degeneration and dry eyes, that had not been reconciled during a Hospice home visit . The RN confirmed that she had been unaware of the medications.

Observed in Individual Tracer. In 1 of 5 patient records reviewed and confirmed by the quality manager. The updated plan of care had not been reflective of the updated comprehensive assessment. Example: during review of HOSv#2 the plan of care had not been updated to reflect the patient assessment. The RN had documented that the patient had been having dysphagia. The plan of care had not addressed dysphagia as a problem with goal and interventions to manage.

Observed in Individual Tracer. In 2 of 5 patient records reviewed and confirmed by the Quality Manager. The documentation to updated plan of care had not included the progression to goals. Example: During review of record HOSv#1, there had not been any documentation with regard to progress to goals. Review of HOSv#2 the update to the plan of care after the IDT meeting had not addressed progression to the identified goals. The update had documented that in next two weeks the plan would be to monitor the effectiveness of the plan of care.

Observed in Patient Home. During A Hospice home observation and confirmed by the RN. The organization had not ensured that the patient and caregivers had received instruction in the safe use of Oxygen or the Oxygen equipment. Example: During observation of HOSv#1 and confirmed by the RN. The oxygen had been ordered for 4 liters, but the oxygen level had been placed at 3.5L by the care giver. The Caregiver stated it changes according to what the patient wants. Documentation had not been clear for instruction that caregiver able to demonstrate appropriate use and maintenance of oxygen, as well as maintaining oxygen level as ordered. There had also been several E tanks upright full against the wall unsecured. Caregiver had been unaware of how to safely store E tanks. Documentation had been limited to the use of oxygen and the concentrator.