Every finding on record at Peacehealth

Observed in Record Review. In 9 of 27 patient records reviewed, Confirmed by the RN Program Manager. The hospice individualized plan of care goals had not been measurable and had not been reflective of the patient's goal. . Example: During review of HOSv#2 the plan of care goal had documented that spiritual resources are identified to include beliefs and practices that support or impair hospice experience. The patient will be knowledgeable in the management of bleeding. HOSv#5 goal had stated that the pain level would remain at a 3/10, however during assessment the patient pain goal had been to remain 1/10. HOSrr#13 the plan of care pain goal had documented to remain at 4/10, however the patient goal on assessment had been 1/10. HOSv#4 goal had documented that patient will identify their beliefs that support or impair hospice experience. Observed in Record Review. In 5 of 27 patient records reviewed, Confirmed by the RN Program Manager. The Hospice had not developed a plan of care to reflect interventions based on the problems identified in the comprehensive assessments. Example: During review of HOSv#3 the plan of care had not documented care to a decubitus ulcer and swallowing difficulties. HOSrr#13 had not included the wound care and treatment .

Observed in Record Review. In 3 of 27 patient records reviewed, Confirmed by the RN Program Manager. The plan of care had not been updated to reflect changes to the care or treatments. Example: During review of HOSrr#12 the patient had a wound being treated . The change in treatment to include medi honey had not been updated in the plan of care. During review HOSv#2 nursing notes it had been documented that the patient had complained of dizziness and prednisone had been ordered. It had not been updated to the plan of care. HOSv#3 plan of care had not been updated with the changes in treatment being provided to the sacral wound.

Observed in Patient Home. In 1 of 6 hospice visits observed and confirmed by the RN Program Manager. Staff had not followed accepted standards of practice. Example: During observation of HOSv#5 the SN had changed gloves frequently without cleansing her hands between glove changes per CDC guidelines and organization policy, Observed in Patient Home. In 1 of 6 Hospice patient visits observed and confirmed by the RN Program Manager. Staff had not followed accepted standards of practice or organization policy. Example: During observation of HOSv#5 staff had not followed agency policy and had placed her bag on the floor . Policy had stated that the bag should not be placed on the floor unless it had been a rolling bag.

Observed in HR File Review. The organization had not defined competencies for nursing staff that care for pediatric patients. The organization did not have evidence that pediatric competencies had been performed by the staff that provided care for pediatric patients.

Observed in Record Review. In 2 of 3 patient records reviewed, Confirmed by the RN Program Manager. During review of Hospice live discharge records , it had been identified that the organization had not completed a discharge summary to contain all required elements. Example : During review of HOSd/c#2 and #3 staff had been unable to retrieve a documented discharge summary.

Based on record review and interview, the agency failed to complete bereavement risk assessments were completed as part of the initial comprehensive assessment for 5 of 20 patients (Patient's #107, #114, #116, #117, and #119). This failure has the potential to delay or overlook the needs of the patient's family and others in their ability to cope with the patient's death. Findings included: 1. Document review of the agency's policy titled, "Bereavement Services Policy," (last revised: 01/21/21) showed that the bereavement risk assessment is initiated by the medical social worker upon the admission. 2. Record review of the patients charts for 5 patients (Patients #107, #114, #116, #117, and #119) showed: a. Patient #107 was admitted on 01/07/22. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. b. Patient #114 was admitted on 08/13/21. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. c. Patient #116 was admitted on 04/09/21. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. d. Patient #117 was admitted on 11/05/21. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. e. Patient #119 was admitted on 10/23/20. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. 3. The Surveyor interviewed the Holistic Care Supervisor (Staff #117) on 01/27/22 at 2:00 PM regarding the findings. Staff #117 acknowledged the issues with the missing initial bereavement assessments. .

Based on record review and interview, the agency failed to provide detailed reasons for orders that included skilled nursing visits designated as "as needed" (PRN) for 18 of 20 patients (Patient #101, # 102, #103, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, and #120) (Item #1); and failed to establish a frequency for nursing services designed to ensure an appropriate level of nursing services to meet patient and family needs for 16 of 20 patients (Patient #102, #103, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #118, #119, and #120) (Item #2). Failure to provide appropriate reasons for PRN nursing visits and establish frequency for nursing services puts patients' and families' needs at risk and preventing the patient from receiving quality hospice care. Findings included: Item #1 - As Needed (PRN) Nursing Visits 1. Document review of agency's policy titled, "Hospice Plan of Care Updates," (last revised: 12/18/2020) showed that the plan of care should contain a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. 2. Record review of patient charts for 18 of 20 patients (Patient #101, # 102, #103, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, and #120) showed: a. Patient #101 was admitted on 04/19/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. b. Patient #102 was admitted on 10/28/20 with nursing orders for 1-20 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. c. Patient #103 was admitted on 05/07/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. d. Patient #106 was admitted on 01/07/22 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. e. Patient #107 was admitted on 01/07/22 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. f. Patient #108 was admitted on 05/01/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. g. Patient #109 was admitted on 01/13/22 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. h. Patient #110 was admitted on 03/31/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. i. Patient #111 was admitted on 01/03/22 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. j. Patient #112 was admitted on 12/22/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. k. Patient #113 was admitted on 10/20/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. l. Patient #114 was admitted on 08/13/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. m. Patient #115 was admitted on 09/27/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. n. Patient #116 was admitted on 04/09/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. o. Patient #117 was admitted on 11/05/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. p. Patient #118 was admitted on 12/15/20 with nursing orders for 1-30 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. q. Patient #119 was admitted on 10/23/20 with nursing orders for 1-30 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. r. Patient #120 was admitted on 04/27/21 with nursing orders for 1-25 PRN nursing visits. There is no documentation of clinical reasons associated with the nursing orders that would initiate a PRN nursing visit. . Item #2 - Frequency of Nursing services 1. Document review of agency's policy titled, "Hospice Plan of Care Updates," (last revised: 12/18/2020) showed each patient is to have an individualized plan of care specific to patients' goals and symptoms. 2. Record review of patients charts for 16 of 20 patients (Patient #102, #103, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #118, #119, and #120) showed: a. Patient #102 was admitted on 10/28/20 with a diagnosis of Colon cancer, Sepsis, Chronic Obstructive Pulmonary Disease (COPD), and Weakness. Skilled Nursing services were ordered for 1 to 2 visits every 2 weeks for 15 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. b. Patient #103 was admitted on 05/07/21 with a diagnosis of Alzheimer's, Diabetes, and Chronic Kidney Disease (CKD). Skilled Nursing services were ordered for 1 to 2 visits every 14 days for 90 days. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. c. Patient #106 was admitted on 01/07/22 with a diagnosis of Alzheimer's disease and recurrent Urinary Tract Infection. Skilled Nursing services were ordered for 1 to 2 visits every 2 weeks for 9 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. d. Patient #107 was admitted on 01/07/22 with a diagnosis of Brainstorm Multiple Sclerosis, Right Foot Cellulitis, and COPD. Skilled Nursing services were ordered for 1 to 2 visits every 2 weeks for 13 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. e. Patient #108 was admitted on 05/01/21 with a diagnosis of Alzheimer's disease, Pneumonia, and Urinary Tract Infection. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 13 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. f. Patient #109 was admitted on 01/13/22 with a diagnosis of Bronchogenic carcinoma of the left lung, COPD, and Liver Cirrhosis. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 13 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. g. Patient #110 was admitted on 03/31/21 with a diagnosis of Acute Ischemia of Intestine, Aneurysm of the Iliac Artery, and Chronic Atrial Fibrillation. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 15 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. h. Patient #111 was admitted on 01/03/22 with a diagnosis of COPD, Dysphagia, Pneumonitis, and Peripheral Vascular Disease. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 14 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. i. Patient #112 was admitted on 12/22/21 with a diagnosis of Interstitial Pulmonary Disease, Hypertension, and Gastroesophageal reflux disease. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 12 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. j. Patient #113 was admitted on 10/20/21 with a diagnosis of Acute Cardiac Injury, Diastolic Congestive Heart Failure, and CKD. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 13 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. k. Patient #114 was admitted on 08/13/21 with a diagnosis of Acute Myeloblastic Leukemia, Coronavirus Disease (COVID-19), and Protein-Calorie Malnutrition. Skilled Nursing Services were ordered for 1 to 2 visits every 14 days for 90 days. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. l. Patient #115 was admitted on 09/27/21 with a diagnosis of Vascular Dementia, COVID-19, Cerebrovascular Disease, and Hypertension. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 13 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. m. Patient #116 was admitted on 04/09/21 with a diagnosis of Oropharyngeal Dysphagia, Protein Calorie Malnutrition, and Recurrent Aspiration Pneumonia. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 15 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. n. Patient #117 was admitted on 11/05/21 with a diagnosis of Alzheimer's Disease, Dementia, Dysphagia, and Aspiration Pneumonia. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 15 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. o. Patient #118 was admitted on 12/15/20 with a diagnosis of Acute Myeloid Leukemia. Skilled Nursing Services were ordered for 1 to 2 visits every 2 weeks for 14 weeks. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. p. Patient #119 was admitted on 10/23/20 with a diagnosis of COPD, Coronary Artery Disease, Dependence on Supplemental Oxygen, and Deep Venous Thrombosis. Skilled Nursing Services were ordered for 1 to 2 visits every 14 days for 90 days. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. q. Patient #120 was admitted on 04/27/21 with a diagnosis of Renal Cell Carcinoma, Metastasis to Lung, Anemia, and Recurrent Falls. Skilled Nursing Services were ordered for 1 to 2 visits every 14 days for 90 days. There is no documentation to indicate the need for longer intervals of nursing care visits that reflect the patient's goals and symptoms. 3. On 01/27/22 at 9:00 AM, Surveyor #1 interviewed the agency's Regulatory Consultant (Staff #113) of the findings regarding as needed and frequency nursing visits. Staff #113 acknowledged the findings and wasn't aware of the issues. .

Based on observation and staff interview on 1/25/2022 during the physical tour of the facility between approximately 1030 and 1200 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility. The findings include: - The fire extinguisher located at the exit door, near resident room #12, has not been serviced since 2020 according to the tag. - The fire extinguisher located at the exit door, near resident room #3, has not been serviced since 2020 according to the tag. - The fire extinguisher located near the main entrance restrooms, has not been serviced since 2020 according to the tag. NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.12, 9.7.4.1, NFPA 10 (2010 ed) 7.3.1.1.1 The above was discussed and acknowledged by the Facility Service Line Director who stated he was aware of the fire extinguishers being due for service, and has already scheduled a date for service of the extinguishers.

Based on observation and staff interview on 01/25/2022 during the physical tour of the facility between approximately 1030 and 1200 hours the facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment. The findings include: - The rated fire door that opens from the kitchen to the corridor, failed to fully close and latch when tested. NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.6.3.5. The above was discussed and acknowledged by the Facility Service Line Director who stated he was unaware of the door not fully closing and latching.

Based on observation and staff interview on 01/25/2022 during the physical tour of the facility between approximately 1030 and 1200 hours the facility has failed to maintain electric equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm. The findings include: - The electrical panel labeled #GC, located in the electrical room near the front entrance, was blocked by wheelchairs. Corrected at inspection. NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2A, 110.26 A (2) The above was discussed and acknowledged by the Facility Service Line Director who stated he was unaware of the electrical panel being blocked, and immediately removed the wheelchairs.