Every finding on record at Nexus Legacy, Inc.

Observed in Record Review. In 11 of 11 patient records reviewed, the Hospice surveyor noted the goals in patient records were not measurable and/or specific to the intervention and care needs of the patient. On review of HSHV/RR #1, the goals for care are not measurable and specific to the care, for example, facilitate optimal bowel movement and ADL's will be met to an optimal level and Promote optimal rest. Another example is patient has severe malnutrition and the goal is patient will have adequate food and fluids which is not measurable or specific for this patient's unique needs. On review of HSHV/RR #2, the goals are not measurable and specific to the care, for example ADL at optimal level, minimize complications of immobility and Increase strength for optimal function. On review of HSHV/RR #3, the goals were not measurable and specific to care, for example ADL's at optimal level, Optimal bowel elimination, urinary elimination at acceptable level, all of which are not measurable. On review of HSRR #4, the goals were not measurable for example the goal of Patient will maintain a comfortable state daily with no definition of what that defined comfortable state would be. In addition, patient was assessed as a moderate fall risk and there were no interventions related to falls. On review of HSRR #5 goals were not measurable of specific, for example Optimal bowel elimination and increase strength/energy for optimal function. In addition, during course of care patient developed toe wound that was being treated and no goals were developed around that issue. On review of HSRR #6 goals were not measurable and specific to the patient, for example ADLs met at optimal level, optimal BS management for patient comfort, optimal mobility and independence. On review of HSRR #7, patient has a nephrostomy tube and there are no goals related to the care of this tube. On review of HSRR #8, goals were not measurable and specific. Examples include Facilitate optimal bowel movement, maintain optimal circulation, ADL's are met at optimal level, all of which are not measurable or specific to care. On review of HSRR #9, the goals are not measurable and specific to the patient. Examples include, Pt will maintain optimal peripheral circulation, and Optimal bowel elimination/comfort which are not measurable. On review of HSRR #10 and HSRR #11 the goals were not measurable and specific with examples that mirror the previous charts reviews. This finding was reviewed with the DPCS.

Observed in Data Session. The organization had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was discussed and reviewed with the DPCS and Administrator. Observed in Data Tracer. The organization identified and collected performance improvement data over time, however the data was not compiled in a manner it could be analyzed or used to identify performance trends or variances. For example, medication errors, falls and complaints data was collected but not analyzed to show trend or goals set for improvement. This was discussed and reviewed with the DPCS and Administrator.

Observed in Patient Home. In 1 of 3 Hospice Home visits the registered nurse did not follow agency protocol to reduce the risk of infections associated with supplies/equipment. Agency Bag Technique Policy (9.014.2) states that alcohol will be used to clean vital sign equipment. During HSHV/RR #1 the Register Nurse used Clorox wipes to clean vital sign equipment in the patient home which was outside the agency policy. This finding was reviewed with the DPCS who was present for the visit.

Observed in Patient Home. In 2 of 3 the hospice nurse surveyor noted that the patient’s record did not contain the pertinent clinical information related to medications. On HHHV/RR #1, on reconciliation of the medication it was noted that the medical record had the patient taking Megace but the family reports that the nurse came and took that awhile ago and patient has not been taking for awhile. On HHHV/RR #2, the patient had a prescription for Baclofen dated 2/13/23, fleets enema and Vitamin D these changes were not reflected on the medication profile. This finding was reviewed with the DPCS.

Observed in Record Review. On review of 11 of 11 patient records reviewed the surveyor noted that there was no documentation provided to the patient regarding their policy on controlled substance disposal. Agency Home Use and Disposal of Controlled Substance Policy (3.005.1) states admitting nurse will provide written copy of the policy on controlled substance. On review of all charts and the admission packet, it was noted the organization did provide FDA Consumer Health Information on How to Dispose of Unused Medications, but it did not provide a copy of its written policies and procedures on the management and disposal of controlled medications to patients and families/caregivers when controlled medication were ordered. This was reviewed and confirmed with the DPCS.