Every finding on record at Pinnacle Hospice Care

Observed in Record Review. In 3 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, and RR# 4's patient records review it was noted the organization had not ensured it assessed the patient's pain per organization policy Pain Assessment No. 2-032 that included worst pain, least pain, and pain goal. For example: review of RRHV# 1's patient record revealed the start of care RN comprehensive assessment with documentation that RRHV# 1 had a pain intensity of mild with current pain management was not acceptable to RRHV# 1. However, further review of the RN comprehensive assessment revealed no documentation of the worst level of pain, best level of pain or pain goal. Review of RRHV# 2's patient record revealed documentation that RRHV# 2 verbalized pain on movement that was mild. However, further review of RRHV# 2's patient record revealed no documentation of the worst level of pain, best level of pain or pain goal. Review of RR# 4's patient record revealed documentation that RR# 4 had a pain intensity of mild. However, further review of RR# 4's patient record revealed no documentation of worst level of pain, best level of pain or a pain goal. This was reviewed, discussed, and validated with the Clinical Manager,

Observed in Patient Home. In 3 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, and RRHV# 3's home observation it was noted the organization had not ensured clinician's followed the organization policy Ongoing Comprehensive Assessment No. 2-031 that included assessing the skin integrity. For example: during RRHV# 1, RRHV# 3, and RRHV# 4's home observation the registered nurses did not complete an assessment of the skin that included assessing the skin that was covered with clothing. This was discussed and validated with the Clinical Manager.

Observed in Record Review. In 1 of 16 patient records reviewed, During RRDC# 1's patient record review it was noted the organization had not ensured it maintained accurate patient records. For example: review of RRDC# 1's patient record revealed Interdisciplinary Group (IDG) documentation that RRDC# 1 was no longer eligible for hospice due to extended prognosis and discharge planning to ensure a smooth transition back into the community. Further review of RRDC# 1's patient record revealed documentation four days prior to discharge by the Medical Director stating patient is still appropriate for hospice. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 6 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 4, RR# 4, RR#5, and RR# 6's patient records review it was noted the organization had not ensured the patient's plan of care was based on the individual patient's goals and the time frames, setting, and services required to meet those goals. For example: review of RRHV# 1, RRHV# 2, RRHV# 3, RR# 4 and RR# 5's patient plans of care revealed the pain goal “patient will be pain free or verbalize an acceptable pain level with current pain management”. Further review of RRHV# 1, RRHV# 2, and RR# 4's patient records revealed no documentation of an acceptable pain level/goal. Further review of RRHV# 3's patient record revealed RRHV# 3 was unable to verbalize pain. Further review of RR# 5's patient record revealed documentation that RR# 5 had a pain goal of mild. Review of RRHV# 4's patient record revealed RRHV# 4 had a wound to the left heel with interventions. However, further review of RRHV# 4's plan of care revealed no documentation of a wound goal. Review of RR# 6's patient record revealed RR# 6 had a volunteer with three documented volunteer visit notes. However, review of RR# 6's plan of care revealed no goals for the volunteer. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 3 of 16 patient records reviewed, During RRHV# 3's patient record review it was noted the organization had not ensured the plan of care included interventions to manage symptoms. For example: review of RRHV# 3's patient record revealed a co-morbidity diagnosis of Seizures with an anticonvulsant medication. Review of RRHV# 3's plan of care revealed no documentation of the safety precaution for seizures. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 6's patient record review it was noted the organization had not ensured the patient's plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: review of RR# 6's patient record revealed three volunteer visit notes. Review of RR# 6's plan of care revealed no documentation of a volunteer or a frequency of visits. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 2 of 16 patient records reviewed, During RRHV# 3 and RR# 5's patient records it was noted the organization had not ensured the patient's plan of care included drugs and treatments necessary to meet the needs of the patient. For example: review of RRHV# 3's medication profile revealed an order for Trazodone 50mg tablet take 1 and 1/2 tablet by month. However, there was no documentation of the dose of 75mg. Review of RR# 5's plan of care RR# 5 had multiple wounds to include a Stage 4 pressure ulcer to the coccyx with wound care dressing changes to be completed by the Skilled Nursing Facility (SNF). However, further review of the plan of care revealed no documentation of what wound care was being done or how often the wound dressings were changed. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 4 of 14 patient records reviewed with hospice aide, During RRHV# 3, RRHV# 4, RR# 7, and RR# 9's patient records review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 3's patient record revealed RRHV# 3 had a co-morbidity diagnosis of Seizures with an anticonvulsant medication. Review of RRHV# 3's hospice aide patient written instructions revealed no documentation of seizure precautions. During RRHV# 4's patient record review revealed RRHV# 4 had a wound to the left heel with a wound dressing. Review of the hospice aide patient written instructions revealed the task of a shower. Further review of the hospice aide patient written instructions revealed no documentation of a wound or instructions on what to do if the wound dressing was to get wet during a shower. Review of RR# 7's patient record revealed RR# 7 was a risk for fall and had oxygen at 2lpm via nasal cannula intermittently. However, review of RR# 7's hospice aide patient written instructions revealed no documentation of fall precautions or oxygen precautions. Review of RR# 9's patient record revealed RR# 9 had oxygen at 2lpm via nasal cannula. However, review of RR# 9's hospice aide patient written instructions revealed no documentation of oxygen precautions. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Patient Home. In 1 of 3 Home visits conducted with medication reconciliation, During RRHV# 1's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's treatment. For example: during RRHV# 1's home observation the RN was observed completing a medication reconciliation that revealed RRHV# 1 had been taking Dulcolax stool softener daily for constipation and Voltaren topical cream to the right wrist as needed for pain for approximately two months prior to the home observation. In addition, review of the Assisted Living Facility’s (ALF) medication administration record revealed Ipratropium Bromide two sprays orally/INH three times a day dated approximately 10 weeks prior to the home observation. However, the hospice medication profile revealed Ipratropium nasal 42 mcg/INH spray, administer 2 spray(s) intranasally three times a day. This was discussed, and validated with the Clinical Manager.

Observed in Record Review. In 1 of 3 patient records reviewed with live discharge, During RRDC# 1's patient record review it was noted the organization had not ensured it provided the physician with the discharge summary after a discharge to the community. For example: review of RRDC# 1's patient record revealed RRDC# 1 was discharged from hospice due to extended prognosis approximately 35 days prior to the surveyor review of the record. Further review of RRDC# 1's patient record revealed no documentation of a discharge summary. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. The initial comprehensive assessment by the Hospice Chaplain had not been completed within five calendar days of the patient electing the hospice benefit. This was identified in RR #9 and RR #10. RR #10, there was no visit made by the chaplain during the entire plan of care. RR #11 AND RR #12 There was no documented Medical Social Work evaluation completed during the entire plan of care. This was validated with the QAPI. These issues have already been corrected by the agency as of March 2022. There is an active Performance Improvement monitoring plan in place.

Observed in Record Review. During RR #9, The surveyor noted an initial bereavement risk assessment completed on Hospice Admission. Family identified as low bereavement risk; however, the patients son was verbalizing denial of patient condition and expressing grief. There was no repeat bereavement assessment completed, and no repeat visit by spiritual care nor medical social worker. This was validated with the Administrator and QAPI. This issue has been corrected and is part of an active performance improvement plan and monitored. Observed in Record Review. In 6 of 13 patient records reviewed, an Initial bereavement assessment had not been completed. During review of Hospice HV #1, HV #2, HV #3, RR #7, RR #9 RR #11 the patients did not have an Initial Bereavement Risk assessment completed and no available bereavement documentation identified in the patient record. This was validated with the Hospice Administrator and the QAPI. This finding has already been addressed by the organization and is an active QAPI performance improvement project with monitoring.

Observed in Record Review. during review of RR #5, the surveyor noted the patient with pulmonary management issues; however, there had been no interventions or goals to address this assessment finding. The Nurse indicated on multiple visits the patient had increased shortness of breath, SPO2 levels in the 70's and the patient refused to wear Oxygen. The MD documented that the patient had been having increased respiratory distress and the need for increased nebulizer treatments. The findings were not included in the patients individualized Plan of Care. This was validated with the Administrator and the QAPI. Observed in Record Review. In 9 of 9 patient records reviewed, patient care goals had not been measurable and without an appropriate time frame for achievement. Each goal had been expected to be achieved by the end of the plan of care. Examples include: Patient/Family will express satisfactory control of symptoms; target date [end of plan of care]. Minimize risk for skin breakdown during hospice stay; [end of plan of care]. Pt/CG can describe /demonstrate measures to improve/maintain skin integrity; target date [end of plan of care]. Patient/caregiver will verbalize understanding of pain management regimen: target date [end of plan of care]. The findings were validated by the Administrator and the QAPI.

Observed in Record Review. The Surveyor noted the patient plan of care had not been updated to reflect the change in patient condition. in RR #9, the patient had been documented by the physician and registered nurse as bedbound and transitioning with terminal agitation; however, the Hospice Aide documented that patient had been up to a shower chair. This was validated with the Administrator and QAPI.

Observed in Record Review. During RR #11, the Surveyor identified no patient assessment documentation for six patient care visits. The Nurse visit notes contained a narrative note only without a full systems assessment that included vital signs. This was validated with the Administrator and QAPI. This issue has been addressed and corrected and is actively monitored through performance improvement plan.

Observed in Record Review. The Surveyor noted during RR #6 the Registered Nurse had documented an indwelling catheter that was 'last changed' on the date of the Hospice initial visit. Further review of the patient record and plan of care revealed no orders for the catheter insertion nor ongoing care of the catheter (size of catheter, balloon size, frequency of change, etc.). The Nurse documentation had not indicated whether the patient had the catheter present on admission to hospice, or if it had been inserted by the clinician. This was validated with the QAPI