Every finding on record at Prisma Health Tuomey

Observed in Record Review. In 2 of 16 patient records reviewed, During HOSRRNHV# 4 and HOSRRNHV# 8's patient records review it was noted the organization had not ensured it assessed and managed the patient's pain according to the organization policy Pain Assessment and Reassessment that included history of pain including non-pharmacological and pharmacological treatment, characteristic of pain, intensity, description, pattern, location and radiation, frequency, timing and duration; impact of pain on the quality of life, and factors that precipitate or exacerbate pain. For example: review of HOSRRNHV# 8's patient record revealed documentation HOSRRNHV# 8 had fallen in the assisted living facility and fractured the left hip and was no longer able to bear weight on the left leg. Review of the SN visit note two days after the fall revealed documentation “patient stated she is painful in the pelvic region”. Further review of the SN visit note revealed documentation under, Patient has pain: Active or Controlled: “No” and “pain 0” with no documentation of description, pattern, radiation, frequency, timing and during or the impact of pain on the quality of life. Review of HOSRRNHV# 4’s start of care RN comprehensive assessment revealed HOSRRNHV# 4 had a diagnosis of pancreatic cancer with a pain intensity of “9 excruciating unbearable”. Review of HOSRRNHV# 4’s patient record revealed a SN visit note one day after the start of care with documentation under, Patient has pain: Active or Controlled: “No” with no documentation of history of pain. Review of the SN visit note dated three days after the start of care revealed documentation under, Patient has pain: Active or Controlled: “No” with no documentation of history of pain. Review of HOSRRNHV# 4’s SN visit dated four days after the start of care revealed the Hospice Aide had called the RN to report HOSRRNHV# 4 was having unrelieved pain and when the RN arrived HOSRRNHV# 4 was lying in a fetal position guarding her abdomen and stated the pain was 10/10, was grimacing and had tears. A subsequent SN visit note dated three days later or seven days after the start of care revealed documentation under, Patient has pain: Active or Controlled: “No” with no documentation of history of pain, frequency, timing and factors that precipitate or exacerbate pain. This was reviewed, discussed, and validated with the Administrator and Manager.

Observed in Record Review. In 1 of 19 patient records reviewed, During HOSRRNHV# 3's patient record review it was noted the organization had not ensured the completed the comprehensive assessment no later than five calendar days after the election of hospice care. For example: review of HOSRRNHV# 3's patient record review revealed an initial bereavement assessment completed six days after the hospice election of benefit (EOB) with no documentation to indicate why the initial bereavement assessment was not completed within five days of the hospice EOB. This was reviewed, discussed, and validated with the Administrator and Manager

Observed in Record Review. In 3 of 16 active patient records reviewed, During HOSRRHV# 1, HOSRRHV# 4, and HOSRRNHV# 3's patient records it was noted the organization had not ensured the patient's plan of care included services needed for palliation and management of the terminal illness and related conditions. For example: review of HOSRRHV# 1's patient record revealed HOSRRHV# 1 had received Chaplain services for 14 certification periods and then declined Chaplain services on the 15th certification period. However, review of the plan of care for the 15th certification period had documentation of Chaplain goals and interventions. Review of HOSRRHV# 4's plan of care revealed an order for Silvadene to a wound on the coccyx. Review of HOSRRHV# 4's patient record revealed the wound had healed approximately four months prior to the surveyor review of the record. Review of HOSRRNHV# 3's patient record revealed documentation HOSRRNHV# 3's had oxygen order on admission. Review of HOSRRNHV# 3's plan of care revealed a goal for oxygen safety and an intervention for assessing oxygen safety each visit. However, further review of the plan of care revealed a goal for oxygen safety and an intervention to assess oxygen safety, but no documentation of an order for oxygen. This was reviewed, discussed, and validated with the Administrator and Manager.

Observed in Record Review. In 1 of 16 patient records reviewed, During HOSRRHV$ 1's patient record review it was noted the organization had not ensured care was provided according to the hospice plan of care. For example: review of HOSRRHV# 1's plan of care revealed a Stage IV pressure ulcer on the sacrum with orders to assess the wound for infection, odor, and pain every visit. Review of HOSRRHV# 1's patient record revealed 12 Skilled Nurse visits with no documentation of an assessment of the wound for signs of infection or odor. This was reviewed, discussed, and validated with the Administrator and Manager.

Observed in Record Review. In 4 of 16 patient records reviewed, During HOSRRNHV# 8, HOSRRHV# 3, HOSRRNHV# 6, and HOSRRNHV# 7's patient records review it was noted the organization had not ensured the registered nurse prepared complete patient care instructions for the hospice aide. For example: review of HOSRRNHV# 8's patient record revealed HOSRRNHV# 8 had fallen at the assisted living facility and suffered a fractured left hip. Further review of the patient record revealed HOSRRNHV# 8 was no longer able to bear weight on the left leg. However, the Hospice Aide patient written instructions had no documentation to include additional transfer/safety instructions to address the change in HOSRRNHV# 8's ability to ambulate or transfer. Review of HOSRRHV# 3's patient record revealed HOSRRHV# 3 had been assessed as a fall risk on admission and had oxygen ordered approximately 30 days prior to the surveyor review of the record. However, review of the HOSRRHV# 3's Hospice Aide written instructions revealed no documentation of Fall Precautions or Oxygen Precautions. Review of HOSRRNHV# 7's patient record revealed This was reviewed, discussed, and validated with the Administrator and Manager.

Observed in Patient Home. In 2 of 2 home visits conducted with medication reconciliation, During HOSRRHV# 2 and HOSRRHV# 3'S home observations it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of HOSRRHV# 2's Nursing Home medication administration record (MAR) revealed documentation of Tylenol 325mg two tablets every six hours for generalized pain. However, HOSRRHV# 2’s medication profile revealed Tylenol 325mg two tablets every six hours for fever. Review of HOSRRHV# 3’s medication profile revealed duplicated Levothyroxine 75 mcg daily with start date approximately 9 weeks prior home visit. In addition, HOSRRHV# 3’s medication had documentation of Paxil 10 mg daily. However, HOSRRHV# 3 had not taken Paxil for over a month the RN shared during the home observation . This was observed, discussed, and validated with the Assistant Manager.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for HosHV#2, it was noted that during week 11 of the 1st benefit period, the patient was started on oxygen therapy. The plan of care was not updated to include a goal statement and patient care interventions related to respiratory needs and oxygen safety. This observation was reviewed with the Hospice Clinical Manager.