Every finding on record at Princeton Healthcare System, A Nj Nonprofit Organization

Observed in Record Review. In 1 of 16 patient records reviewed, the record did not have an updated comprehensive assessment. RR HV#3 was started on a laxative due to constipation and although the visit notes were updated, the comprehensive assessment was not updated related to this new treatment in the subsequent IDT meetings. This observation was discussed with the RN manager.

Observed in Record Review. During a review of 1 of 16 patient records, there were duplicate medications for constipation on the medication list in the medical record, including senna, lactulose and polyethylene glycol with insufficient delineation as to when to give the polyethylene glycol versus the bowel regimen that included lactulose and senna. This observation was confirmed with the Hospice Director.

Observed in Patient Home. In 2 of 3 patient records reviewed, that had a hospice aide, the aide care plan did not include all of the written instructions required based on the assessment. RR HV#1 was on aspirin, and the aide care plan did not reflect bleeding precautions. Similarly, RR HV#3 was oxygen dependent and the hospice care plan did not reflect oxygen precautions. This observation was discussed with the RN manager.

Observed in Individual Tracer. In 1 of 16 patient records reviewed, the medication list was discovered to be inaccurate during home visit RR HV#4. The medication administration record in the residence of RR#4 reflected that the patient was on an antacid to treatan ulcer. This medication was given to the patient in excess of 2 weeks and did not appear on the hospice medication profile. This observation was discussed with the RN manager. Observed in Record Review. In 1 of 3 patient records reviewed, that had a hospice aide, the record did not have documentation of the type of bath provided. Multiple aide visit notes in RR HV#1, did not reflect the type of bath given. This observation was discussed with the RN manager.

Observed in Record Review. During a review of 1 of 16 patient records, a chaplain note was found in the record (RRNHV12) for a different patient. This observation was confirmed with the Hospice Director and quality nurse.

Observed in Record Review. In 1 of 3 patient records reviewed, that were oxygen dependent, the record did not have documentation of education/re education provided on the use of durable medical equipment. RR HV#3 was oxygen dependent and the external filter was observed to be occluded with dust. Based on a review of the home chart and patient record, there was no specific documentation related to this risk. This observation was discussed with the RN manager.

Observed in Competency Session. Staff competence was not assessed and documented as part of orientation. During review of the Volunteer Program, the surveyor learned that visit volunteers did not have competence assessed for home visits as part of the onboarding process. This was validated during the HR competence assessment and confirmed by the Hospice Director.

Observed in Record Review. In 3 of 13 patient records reviewed, information regarding medications was not current or did not match bottle labels. For example, for HOHV#1 there were discrepancies for the following: Fludrocortisone 0.1 mg; Fluticasone-Salmeterol 100-50 mcg/dose diskus inhaler; Ipatropium-Albuterol 0.5-2.5 mg/3ml nebulizer solution; Lidocaine 4% patch; and Senna 8.6 mg tablet. At HOHV#2 there were discrepancies for the following: Alprazolam 0.5 mg tablet; and Gentamicin 0.3 % ophthalmic solution. This was reviewed with Hospice leaders.