Every finding on record at Peacehealth

Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: on review of RRNHV#3 the initial spiritual assessment was not documented as completed until day 7. In RRNHV#6 there was no documentation that the initial spiritual assessment was completed within 5 calendar days of admission. There was documentation that the Chaplain had left a message for the patient family, yet no further documentation of why the assessment could not be completed within the required timeframe. This observation was reviewed with the organization Leadership.

Observed in Record Review. In 3 of 20 patient records reviewed, the organization failed to conduct a patient-specific comprehensive assessment and reassessment that identifies the patient's need for hospice care and services. For example: on review of RRHV#3 there was no documentation of a wound assessment noted in the clinical record over the last 3 weeks visits with the last documented wound assessment being the 1st week of March. Further, during home observation there was reported new occurring odor to the wound yet no wound assessment was completed. Policy noted that wound assessment should be documented weekly and with changes in status. In RRNHV#6 there was documentation of changes in the wound and updated wound orders, yet no documented wound assessment for a 21 day period between March and April. In RRNHV#5 there was documentation of a surgical wound on admission with documentation of wound care provided, yet no documentation of a comprehensive wound assessment throughout the record. These observations were reviewed with the organization Leadership.

Observed in Individual Tracer. A review of 1 of 20 patient records revealed that the organization did not ensure that initial assessments by members of the interdisciplinary group included all required information. For example, a review of the initial comprehensive assessment for RRHV#5, revealed that an initial bereavement risk assessment was not completed. This observation was reviewed with agency leadership.

Observed in Record Review. In 6 of 20 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 the patient's primary terminal diagnosis was Congestive Heart Failure with shortness of breath, yet there was no cardiac plan of care nor one that reflected the patient's use of oxygen. In RRHV#3 the documentation noted a wound to the patients foot/toe yet the care plan for skin integrity only noted a sacral wound and there was no reflection of the wound to the patient's foot. In RRNHV#2 the documentation noted patient issues with nausea and vomiting yet there was no care plan established to reflect the nausea and vomiting issues documented. In RRNHV#3 the patient was utilizing oxygen, had a colostomy and a g-tube yet they were not reflected in the care plans. Further, there was documentation of a hospital bed, oxygen, and a hoyer lift in the record, yet no DME listed on the plan of care. In RRNHV#4 the documentation noted issues with nausea and vomiting requiring alternating Zofran and Compazine to control but there was no care plan to reflect the issues with nausea. In RRNHV#5 the documentation noted an infection in January prior to replacing the peritoneal drain but no infection care plan opened to guide the care. These observations were reviewed with the organization leadership.

Observed in Record Review. In 9 of 20 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 during the home visit the patient was using oxygen at 3 liters per minute per nasal cannula, yet there were no orders for oxygen noted on the plan of care. In RRNHV#1 there was documentation that the patient was using oxygen and a cough assist device, yet there were no orders for their utilization noted on the record. In RRNHV#4 the order for oxygen was incomplete simply stated 1-10 liters. The order did not include a route, frequency, nor did it include instructions on when to utilize what liter flow of oxygen. In RRNHV#6 the oxygen order did not include an indication as required. In RRNHV#5 the patient had documentation of a surgical wound with documentation of treatment, yet no physicians order for dressing changes to the site. Further the patient had a peritoneal drain, yet no physicians order for care to the drain site. There was an order noted to drain once a week yet no specifics such as who was perform the care. In RRNHV#3 the documentation noted the patient with a colostomy and a g-tube but no physicians orders for care of the colostomy or the g-tube and site. In RRNHV#4 there were orders for PRN laxatives senna and Bisacodyl yet no specific instruction of which medication to use for which situation. The patient was also ordered two PRN antiemetics Zofran and Compazine but no instructions on when to use which medication. In RRNHV#2 the was an order for Seroquel that stated take once as needed but no frequency beyond once. In RRNHV#7 the Tylenol and Naproxen lacked indication as required. Further there were no specific instructions to guide the user as to which medication to choose for what type of pain or situation. These observations were reviewed with the Organization Leadership.

Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to ensure the individualized plan of care was reviewed, revised and documented as frequently as the patient's condition requires but no less frequently that every 15 days. For example: on review of RRHV#2 the plan of care noted massage therapy for the patient's pain, however documentation in the record noted that massage therapy was discontinued per caregiver request in October. Discontinuing massage therapy was not updated in the plan of care as the massage therapy care plan remained and active care plan to date of survey. In RRNHV#5 the documentation noted that the peritoneal drain had to be replaced however there was no documentation that the care plan was reviewed and revised to reflect the change in the patient status. This observation was reviewed with the organization Leadership.

Observed in Infection Control System Tracer. The senior quality manager for hospice confirmed the organization did not have a written hand hygiene goal, current rate of compliance or plan for improvement, but they have been collecting hand hygiene data.

Observed in Record Review. In 2 of 20 patient records reviewed, the organization failed to conduct and document patient-specific comprehensive assessment for spiritual concerns or needs. For example: on review of RRNHV#6 there was documentation that spiritual assessment was delayed as the spiritual coordinator attempted to contact the patient family. Months later spiritual visits began directly with the patient, however there was no documentation that an initial spiritual assessment was conducted prior to beginning the routine visits. This observation was reviewed with the organization Leadership. Observed in Record Review. Example #2: During a review of the medical record for RRNHV#12, it was noted that the Chaplain member of the interdisciplinary team did not complete an initial spiritual assessment before starting Chaplain visits to the patient's home. The Chaplain documented missed home visits during week 4, and week 8 of hospice services. The first completed home visit was documented during week 9 of services. This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 15 patient records reviewed, where hospice aide services were elected, the organization failed to ensure registered nurse provide written patient care instructions for the hospice aide. For example: on review of RRHV#2 the patient was utilizing oxygen that the RN on home observation noted was being utilized continuously, yet there was no indication on the Aide plan of care instructions of oxygen precautions or how to handle oxygen during the patient's bath. Similarly in RRHV#4 the patient was using oxygen during the home visit to observe the aide, the oxygen was removed and replaced, however there was no specification on the aide plan of care for oxygen precautions, nor whether the oxygen could be safely removed for bathing. In RRNHV#3 the patient had a colostomy and a g-tube yet there were no instructions for the aide on how to handle these devices while carrying out the aide's assigned tasks. In RRNHV#5 the patient had a peritoneal drain and a wound but no instruction to guide the aide on how to handle to drain and wound while providing care. These observations were reviewed with the organization Leadership.

Observed in HR File Review. In 2 of 4 nurse aide records reviewed, annual supervisory visits were missing. The accreditation specialist confirmed that one was missing the supervisory visit for 2023 and the other was missing the supervisory visit for 2022 and 2023.

Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to ensure the patient record contain all information that reflects the patient's care, treatment and services. For example: On home observation for RRHV#2 during medication reconciliation there RN noted that the patient was using Tylenol as needed yet the order on the medication profile noted to be taken scheduled 2 times a day and an additional as needed order. In discussion with the RN and caregiver the patient had not been taking the scheduled Tylenol for an extended period of time since prior to the last comprehensive assessment. Further the medication profile noted senna twice daily yet the caregiver confirmed the patient had not been taking the laxative and asked should she be taking Senna? These observations were reviewed with the Nurse Manager.

Observed in Building Tour. The IPU nurse manager confirmed that the pediatric pads for the AED had expired 10/23.

Observed in Building Tour. During the review of the above ceiling area in hallway #1 of the Hospice Inpatient Building Longview, it was noted that the piping for the automatic sprinkler system was supporting other items – gray cords were resting on this piping. In hallway #2 of the Hospice Inpatient Building Longview, it was noted that gray cords and a coiled conduit was resting on this piping. This observation was reviewed with agency leadership. 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 facilities personnel confirmed a penetration in the ceiling of the IPU mechanical room around AC refrigerant lines and pipe. 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 IPU nurse manager confirmed that they had not been checking the food served to patients to ensure proper cold or hot temperatures. The patient food temperature log found in the kitchen had been altered to be a family room soup pot temperature log. The log stated that hot food should be >165-180, but it was consistently documented >180. No follow up actions were documented when the temperature was out of range as stated on the log. Cold food serving temperatures for patients had not been monitored. Per policy, Dietary Department Hygiene and Sanitation, Cold food is held at 41 degrees or colder, and is checked with a metal stick thermometer. Hot food is held at 140 degrees or hotter, and is checked with a metal stick thermometer.

Observed in Building Tour. The organization did not ensure that freezer temperatures were monitored to reveal opportunities for inadequate storage. For example, during a review of the freezer temperature logs it was noted that a parameter for acceptable freezer temperatures was not documented on the log. This observation was reviewed with agency leadership.

Based on document review, record reviews, and interview, the agency staff failed to follow the plan of care as ordered by the physician for 11 of 20 patient records (Patient #106, #109, #113, #114, #120, #501, #502, #503, #504, #505, #512). Failure to follow the plan of care, as ordered by the physician, could place the patient at risk of not receiving the care and services ordered. Findings included: 1. Document review of the agency's policy titled, "IDG Care Planning Process," (last revised: 05/18/21) showed that the plan of care specifies the care and services necessary to meet the patient and family-specific needs. 2. Record reviews of the patient charts (Patient #106, #109, #113, #114, #120, #501, #502, #503, #504, #505, #512) showed: a. Patient #106 was admitted on 09/10/21 with Senile Degeneration of the Brain. The physician ordered Skilled Nursing (SN) services for 1 visit every 7 days for 86 days. There were no SN visits between 10/03/21 and 10/09/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. b. Patient #109 was admitted on 07/20/21 with Vulvar Cancer. The physician ordered SN services for 3 visits every 7 days for 80 days. There were no SN visits between 07/26/21 and 10/13/21 and between 10/11/21 and 10/13/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. c. Patient #113 was admitted on 06/25/21 with Hypertension and Congestive Heart Failure. The physician ordered Social Work (SW) services for 1 visits every 30 days for 85 days. There were no SW visits between 06/30/21 and 07/29/21 and between 09/29/21 and 09/22/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. d. Patient #114 was admitted on 07/28/21 with Malignant Neoplasm of Prostate. The physician ordered SW services for 3 visits every 5 days for 5 days. There were 2 SW visits missed between 07/28/21 and 08/01/21. In addition, the physician ordered Hospice Aide (HA) services 2 visits every week for 28 days. There was 1 HA visit missed between 09/28/21 and 10/04/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. e. Patient #120 was admitted on 10/12/21 with Chronic Obstructive Pulmonary Disease (COPD). The physician ordered SN services 3 visits every 5 days for 5 days. There were no SN visits between 10/12/21 and 10/16/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. f. Patient #501 was admitted on 08/11/21 with Senile Degenerative Brain. The physician ordered Skilled Nursing (SN) services and Hospice Aide (HA) for 1 visit every 7 days. There were no SN visits between 11/18/21 and 11/29/21, and there were no HA visits between 11/08/21 and 11/29/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. g. Patient #502 was admitted on 09/07/21 with Cancer to the Right Lung. The physician ordered HA services 1 to 2 visits every week. There were no HA visits have been completed. As of the date of record review, there have been no HA visits completed. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. h. Patient #503 was admitted on 12/29/20 with Senile Degenerative Brain. The physician ordered SN services 1 to 3 visits every week and HA visits 1 to 2 every week. There were no SN and HA visits between the week of 09/29/21 and 10/07/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. i. Patient #504 was admitted on 06/26/21 with COPD. The physician ordered SN services 1 to 3 visit every week and Social Work (SW) 1 to 2 visits every monthly. There were no SN visits between the week of 08/18/21 and 08/25/21, and no SW visits between 09/22/21 and 10/26/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. j. Patient #505 was admitted on 09/13/21 with Rectal Cancer. The physician ordered Dietician services 1 visit every 15 days for 15 days. There were no Dietician visits between 09/18/21 and 10/03/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. k. Patient #512 was admitted on 03/21/21 with Lewy Body Dementia. The physician ordered HA services 1 to 2 visits every week. There were no HA visits between 09/15/21 and 09/25/21. There was no documentation in the record to explain the missed visits, nor evidence that the agency notified the patient's physician. 3. On 12/01/21 at 11:30 AM, Surveyor #1 interviewed the Registered Nurse (Staff #111) about the missed visits. Staff #111 acknowledged the findings and stated that she was unable to locate documentation explaining the missed visits. 4. On 12/01/21 at 1:20 PM, Surveyor #5 interviewed the Assistant Nurse Manger (Staff #108) about the missed visits. Staff #108 acknowledged the findings and stated that she was unable to locate documentation explaining the missed visits.

Based upon record review and staff interviews on December 1, 2021 between approximately 1330 to 1430 hours the facility has failed to conduct have a proper safety system for the kitchen equipment. This could result in the spread of a fire which would endanger the patients, staff and/or visitors within the facility. The findings include: The family room had a kitchen available to all families to cook meals for patients and families. The kitchen had an oven and stove with a residential kitchen hood. The facility staff was unsure if it met the requirements of NFPA 101 (2012) 19.3.2.5.4. The facility staff was not sure of the following: (3)*The hood systems have a minimum airflow of 500 cfm (14,000 L/min). (4) The hood systems that are not ducted to the exterior additionally have a charcoal filter to remove smoke and odor. (5) The cooktop or range complies with all of the following: (a) The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document ' s scope. (b) A manual release of the extinguishing system is provided in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 10.5. (c) An interlock is provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated. (9)*A switch meeting all of the following is provided: (a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range. (b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision. (c) The switch is on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cooktop or range, independent of staff action. The facility will ensure that all safety standards are met. The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on December 1, 2021 between approximately 1330 to 1430 hours the facility has failed to provide the proper equipment for direct vent gas fireplaces in smoke compartments that contain patient sleeping areas. This could lead to the building up of toxic gases, harming the patients, staff, and visitors inside the smoke compartment. The findings include: The family room had a gas fireplace. Facility staff was unsure if it was a direct vent fireplace. The facility staff was unsure if the smoke detectors in the room were combination smoke/carbon monoxide detectors. The facility will determine if electronically monitored carbon monoxide detectors are required. NFPA 101 (2012) 19.5.2.3 The above was discussed and acknowledged by the facility staff.