Every finding on record at Renown Regional Medical Center

Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not maintained confidential patient records in accordance with privacy and security standards of the Health Insurance Portability and Accountability Act (HIPAA). During HSHV#2, the surveyor found a medication list for a different hospice patient than the patient being seen in the patient's home folder. This was observed by the Supervisor also in attendance during the home visit.

Observed in Record Review. In 2 of 19 patient records reviewed, the hospice had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the record for RRNHV#7, neither the spiritual care nor social work assessments were completed within five days of the election. In the chart for RRNHV#16, the initial spiritual care assessment was not completed within the five day window. This was verified and discussed with the Supervisor assisting with record review.

Observed in Record Review. In 1 of 19 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for psychosocial and emotional care. In the chart for RRNHV#8, the patient had a PHQ-9 score of 9 and a history of suicide in the family upon the initial comprehensive assessment. No further assessment of depression nor suicidal thoughts or plans was in the record. It was confirmed with the Nursing Supervisor assisting with the record review that there is an expectation that there should be further assessment of these risks either by nursing or the social worker, though it was confirmed there was no written policy for when further screening was required for a patient with a high depression score, nor a suicide risk score which was other than none.

Observed in Record Review. In 1 of 19 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals.In the chart for RRNHV#11, the patient developed bowel issues, MiraLAX was added to the treatment plan, yet the plan of care was not updated with a goal for bowel management. This was discussed with the Supervisor assisting with record review.

Observed in Record Review. In 6 of 19 patient records reviewed, the hospice plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: medications and treatments necessary to meet the patient’s needs. In the charts for RRHV#1, RRHV#2, RRHV#3 and RRHV#4, the hospice plans of care did not include patient specific interventions related to fall risk reduction interventions, rather a generic statement to implement fall reduction interventions. In the chart for HSHV#3, there was an order for an oxygen concentrator, however no order on the plan of care for any oxygen administration, route or liter flow. In the chart for RRNHV#6, medications had been ordered upon admission such as Tylenol, Bisacodyl, Docusate, but not added to the hospice plan of care. In the chart for RRNHV#8, the patient was assessed to have a high depression score on the PHQ9 upon admission, yet the plan of care included no interventions other than medication to address this risk. This was discussed with the Supervisor assisting with record reviews.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not contain the following clinical information, any medications administered, including dose. In the chart for HSRRHV#2, the nurses consistently did not include the type of enema administered to the patient in their documentation. This was observed by and discussed with the Supervisors assisting with record reviews.

Observed in Record Review. In 1 of 19 patient records reviewed, when a verbal order was received, the individual who received it did not record it and sign it immediately. In the chart for HSHV#3, the RN documented in a visit note more than 40 days prior to the date of the hospice survey that an order was received to remove the patient's foley catheter, however did not document the order for the prescriber to sign in accordance with state and federal regulations. This was verified with the Supervisor assisting with record review.