Every finding on record at Peacehealth

Observed in Record Review. In 2 of 4 patient records reviewed with wound care, During RRHV# 6 and RRNHV# 7's patient records review it was noted the organization had not ensured staff followed the organization's policy Wound Care Documentation that included wound measurements regularly and as needed, at a minimum of once a week. For example: review of RRHV# 6's patient record revealed RRHV# 6 was admitted with a wound to the coccyx. Further review of RRHV# 6's patient record revealed seven weekly visits with wound care performed and no documentation of the wound measurements. Review of RRNHV# 7’s patient record revealed RRNHV# 7’s start of care was approximately 25 days prior to the surveyor review of the patient record. Further review of RRNHV# 7’s patient record revealed a sacral wound at start of care. However, further review of the record revealed no documented wound measurements. This was reviewed, discussed, and validated with the Nurse Manager.

Observed in Record Review. In 15 of 20 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RRHV# 5, RRHV# 6, RRNHV# 1, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 7, RRNHV# 8, RRNHV# 9, and RRNHV# 12's patient records review it was noted the organization had not ensured the patients' plans of care were based on the patient's goals and the time frames required to meet the goals. For example: review of RRHV# 1's plan of care revealed the goal Patient/Caregiver will report acceptable level of cardiac comfort with no indication what was acceptable level or a time frame. Further review of the plan of care was a Chaplain goal Patient will display increase resolution with illness and dying process with no indication what increase resolution was or a time frame. Review of RRHV# 2's plan of care revealed the goal Patient/Caregiver will report an acceptable level of cardiac comfort with no indication what an acceptable level of cardiac pain for RRHV# 2 and no time frame. Further review of RRHV# 2's plan of care revealed a pain goal Patient will demonstrate increase level of comfort with no indication what was an acceptable level for RRHV# 2 or a time frame. Review of RRHV# 3's plan of care revealed the goal Patient/Caregiver will report an acceptable level of cardiac comfort with no indication of what was an acceptable level for RRHV# 3 or a time frame. Review of RRHV# 4's plan of care revealed the goal Patient/Caregiver will verbalize understanding of hospice services with no time frame. Review of RRHV# 5's plan of care revealed the goal Patient/Caregiver will verbalize understanding of hospice services with no time frame. Further review of RRHV# 5's plan of care revealed the goal Patient/Caregiver will report an acceptable level of cardiac comfort with no indication what an acceptable level of cardiac pain for RRHV# 5 and no time frame. Review of RRHV# 6's plan of care revealed the goal Patient/Caregiver will report an acceptable level of cardiac comfort with no indication what an acceptable level of cardiac pain for RRHV# 6 and no time frame. Review of RRNHV# 1's plan of care revealed the goal Patient/Caregiver will verbalize understanding of hospice services with no time frame. Review of RRNHV# 3's plan of care revealed the goal Patient/Caregiver will verbalize understanding of hospice services with no time frame. Further review of the plan of care revealed a pain goal of less than 3 out of 10. However, review of RRNHV# 3's patient record revealed RRNHV# 3 had a stated pain goal of zero out of 10. Review of RRNHV# 4, RRNHV# 5, RRHV# 6, and RRNHV# 8’s plans of care revealed the goal Patient/Caregiver will verbalize understanding of hospice services with no time frame. Review of RRNHV# 7’s plan of care revealed the pain goal “Patient and/or Caregiver will verbalize and/or demonstrate increased level of comfort using verbal and/or non-verbal pain scale” with no indication what an acceptable comfort level was for RRNHV# 7 or a time frame. Review of RRNHV# 9’s plan of care revealed a pain goal that included pain less than 5/10. However, review of RRNH# 9’s RN comprehensive assessment revealed RRNHV# 9 had a verbalized pain goal of 2/10. Review of RRNHV# 12’s plan of care revealed a goal “Patient and/or Caregiver will verbalize or demonstrate increased level of comfort” with no indication what an increased level of comfort was for RRNHV# 12 or a time frame. This was reviewed, discussed, and validated with the Nurse Manager.

Observed in Record Review. In 6 of 20 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 5, RRNHV# 6, RRNHV# 9, RRNHV# 10's patient records review it was noted the organization had not ensured the plan of care included all services needed for palliation and management of the terminal illness and related conditions, including: Interventions of manage pain and symptoms. For example: review of RRHV# 1's patient record revealed RRHV# 1 was a insulin dependent diabetic. Review of the Assisted Living Facility (ALF) plan of care revealed Lantus 30 units every morning and blood glucose finger sticks (FSBG) every morning with parameters to call the physician of FSBG was less than 80 or greater than 400. Review of the hospice plan of care revealed Lantus 30 units every morning and no documentation of a daily blood glucose finger sticks or blood glucose parameters interventions. Further review of RRHV# 1's patient record revealed RRHV# 1 was a fall risk. However review of RRHV# 1's plan of care revealed no documentation of fall precautions. Review of RRHV# 2's patient record revealed RRHV# 2 was diabetic with oral hypoglycemic medications. However, there were not goals or additional diabetic interventions. Further review of RRHV# 2's patient record revealed RRHV# 2 was on an anticoagulant and a fall risk. However, review of RRHV# 2's plan of care revealed no bleeding precautions or fall precautions. In addition, review of RRHV# 2's plan of care revealed goals and interventions for the Chaplain. However, the Chaplain services had been declined. Review of RRHV# 5's patient record revealed a co-morbidity terminal diagnosis of dysphagia. However, review of RRHV# 5's plan of care revealed no interventions or goal for dysphagia. Review of RRNHV# 6’s patient record revealed a start of care RN comprehensive assessment with documentation RRNHV6’s had a history of colon cancer and had a colostomy and RRNHV# 6 was concerned about experiencing gas when RRNHV# 6 ate big or heavy meals. However, review of RRNHV# 6’s plan of care revealed no interventions related to the colostomy or who was to manage the colostomy. Review of RRNHV# 9’s patient record revealed a RN comprehensive assessment with documentation that RRNHV# 9 had a pureed diet and thickened liquids due to dysphagia. However, review of RRNHV# 9’s plan of care revealed no documentation regarding RRNHV# 9’s puree diet, thickened liquids or dysphagia. Review of RRNHV# 10’s patient record revealed an RN comprehensive assessment with documentation that RRNHV# 10 had aspiration precautions. However, review of RRNHV# 10’s plan of care revealed no documentation regarding RRNHV# 10’s aspiration precautions. This was reviewed, discussed, and validated with the Nurse Manager.

Observed in Record Review. In 2 of 20 patient records reviewed, During RRHV# 4 and RRNHV# 1's patient records review it was noted the organization had not ensured it provided patient with care, treatment, or services according to the patient's individualized plan of care. For example: review of RRHV# 4's plan of care revealed a frequency for the Chaplain of 1-3 visits every month. Review of RRHV# 4's patient record revealed no Chaplain visits for July. Review of RRNHV# 1's patient record revealed a plan of care frequency for the MSW of 1-3 visits every month. Review of RRNHV# 1's patient record revealed no MSW visits for June. This was reviewed, discussed, and validated with the Nurse Manager.

Observed in Patient Home. In 2 of 4 home visits conducted with reusable patient equipment, During RRHV# 1 and RRHV# 2’s home observations it was noted the organization had not implemented infection prevention and control activities related to cleaning and performing disinfection of medical supplies and devices. For example: during RRHV# 2’s home observation the registered nurse (RN) cut off a soiled dressing with a pair of scissors and then cut the xeroform dressing without cleaning the scissors. In addition, during RRHV# 2’s home observation the RN cleaned the reusable patient equipment with Sani-wipes and immediately placed the equipment back into the supply bag not allowing for dry time/wet time. During RRHV# 1’s home observation the RN placed the Stethoscope, pulse oximetry, thermometer, and BP cuff into the supply bag without cleaning the equipment prior to returning to supply bag per agency policy Home Care Bag Policy and Procedure No. 13234418. This was discussed and validated with the Hospice Manager. Observed in Patient Home. In 2 of 6 home visits conducted, During RRHV# 2 and RRHV# 5's home observations it was noted the organization had not ensured it implemented the infection prevention and control activities it had planned that included staff performing hand hygiene consistent with organization policies Hand Hygiene Policy No 13094659 and Home Care Bag Policy and Procedure No 13234418. For example: during RRHV# 2's home observation the registered nurse (RN) was observed removing a soiled foot wound dressing removed gloves and put new gloves on without hand hygiene, then cleaned the wound removed gloves and put new gloves on without hand hygiene. Then applied new dressing removed gloves and performed hand hygiene and then washed hands. During RRHV# 5's home observation the RN was observed performing hand hygiene and entering the bag and removing the thermometer and performing a temperature assessment then placed the thermometer down and entered the bag without hand hygiene and removed the pulse oximetry and assessed the patient's oxygen saturation and placed the pulse oximetry down and entered the bag without hand hygiene and removed the B/P cuff. This was discussed and validated with the Nurse Manager.

Observed in Record Review. In 9 of 11 patient records reviewed with Hospice aide, During RRHV# 2, RRHV# 3, RRHV# 5, RRHV# 6, RRNHV# 1, RRNHV# 5, RRNHV# 8, RRNHV# 11, and RRNHV# 12's patient records review it was noted the organization had not ensured the registered nurse prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 2's patient record revealed RRHV# 2 was on oxygen at 2lpm via nasal cannula as needed. Review of the Hospice aide written patient care instructions revealed no safety concerns or instructions that included safety concerns to report to the nurse with regard of the oxygen and had not instructed the aide for the removal of oxygen during the shower, if necessary. In addition, RRHV# 2 was assessed as a fall risk and the hospice aide written patient care instructions did not include fall precautions. Review of RRHV# 3's patient record revealed RRHV# 3 was on oxygen 2lpm via nasal cannula as needed. Review of RRHV# 3's Hospice aide written patient care instruction revealed no safety concerns or instruction that included safety concerns to report to the nurse with regards to oxygen and had not instructed the aide for the removal of oxygen during the shower, if necessary. In addition, RRHV# 3 was assessed as a fall risk and the hospice aide written patient care instructions did not include fall precautions. Review of RRHV# 5's patient record revealed RRHV# 5 was assessed as a fall risk. However, review of RRHV# 5's hospice aide written patient care instructions revealed no documentation of fall precautions. Review of RRHV# 6's patient record revealed a wound on the coccyx with a dressing. Review of RRHV# 6's hospice aide written patient care instruction had not included instructions regarding the wound dressing when performing the task of a shower. In addition, RRHV# 6 was assessed as a fall risk. However, the hospice aide written patient instructions did not include fall precautions. Review of RRNHV# 1's patient record revealed RRNHV# 1 was assessed as a fall risk. However, the hospice aide written patient instructions did not include fall precautions. Review of RRNHV# 5, RRNHV# 8, RRNHV# 11 and RRNHV# 12's patient record revealed the patients were assessed as a fall risk. However, the hospice aide written patient instructions did not include fall precautions. This was reviewed, discussed, and validated with the Nurse Manager.

Observed in HR File Review. The HR representative confirmed that the backup medical director had not completed competencies in the last three years.

Observed in Patient Home. In 6 of 20 home visits conducted with medication review, During RRHV# 1, RRHV# 2, RRHV# 4, RRHV# 5, RRNHV# 1, and RRNHV# 5's home observation or patient records review it was noted the organization had not ensured it maintained and communicated accurate patient medication information and patient response to care, treatment, and services.. For example: during RRHV# 2's home observation the registered nurse performed a medication review that revealed the hospice medication profile with Glipizide 5mg tablet take ½ to 1 tablet two times a day before meals. However, review of the RRHV# 2’s bottle revealed Glipizide 5mg take 1 tablet two times a day before meals. Further review of the medication profile revealed Ramipril 2.5 mg take 1 capsule daily. However, the RRHV# 2’s medication bottle revealed Ramipril 5mg take 1 capsule daily. In addition, during the medication review the RN discovered the Nitroglycerin 0.4mg sublingual tablets were expires 19 months prior to the home observation. Review of RRHV# 1's patient record revealed a recertification plan of care inaccurately dated four days after the recertification date. Review of RRHV# 4's patient record revealed and Interdisciplinary Group (IDG)/Plan of care update with documentation by the registered nurse 18 days after the meeting date. Review of RRHV# 5's patient record revealed and IDG/Plan of care update dated two weeks prior to the actual IDG/Plan of care update meeting date. Further review of RRHV# 5's revealed three IDG/Plan of care updates with documentation dated after the IDG/Plan of Care update meeting date. In addition, review of the recertification plan of care revealed it was dated five days prior to the recertification. Review of RRNHV# 1's patient record revealed a recertification plan of care dated one day prior to the recertification. Review of RRNHV# 5's patient record revealed an IDG/Plan of care update dated two weeks after the actual IDG/Plan of care meeting. This was discussed, and validated with the Nurse Manager.