Every finding on record at River City Hospice of Texas, LLC

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRHV#1 there were physicians orders for wound care to the Rt Heel (unstageable) and Lt Heel (stage 3) yet in the nursing documentation there was only documentation of assessment of the Left Heel weekly as required. There was documentation of assessment of the Rt Heel noted in the record twice in October, once in November and again in December where it was documented as healed. This observation was reviewed with the Alt. Director of Nursing.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure a complete and accurate patient record. On review of RRHV#1, the most recent wound care documentation specified the assessment of a Lt Heel wound yet the documentation of the dressing change performed was noted to be for the Rt. Heel. There was no documentation noted for the right heel to clarify why it was conflicting. This conflicting documentation was also noted on multiple additional notes in the latest benefit period. This observation was reviewed with the Administrator and Alt. DON.

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to ensure the plan of care was based on the patient's individualized goals that were specific, measurable, and time-bound. Throughout all active records reviewed there was a lack of the plan of care goals being specific, measurable and time-bound. For example: in RRHV#1 a goal read Pain will be managed at a level acceptable to the patient per certification period and Patient/caregiver will verbalize/demonstrate appropriate pain management per certification period. In RRHV#2 an example was Patient will follow an effective bowel program to prevent/relieve constipation throughout cert. In RRHV#3 a goal was Patient will have safety needs met while on hospice services. In RRNHV#5 a goal read Changes in neurologic status will be addressed appropriately per certification period. Further examples can be seen in all active records RRNHV#4,RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10. These observations were reviewed with the Administrator, and Alt. Director of Nursing.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#2 there was documentation of a urinary tract infection with antibiotics ordered yet the issue was not reflected on the plan of care. In RRHV#3 during the home observation the patient noted issues with nausea, vomiting and the inability to eat as desired. She noted antiemetics has been ordered yet there was no care plan to guide the care. Further there was documentation of growing lesions/masses to the patient's chest yet the issue was not reflected in the care planning process. In RRNHV#4 documentation noted a skin infection to the elbow yet no care plan to guide its care. In RRNHV#6 there was documentation of an eye infection but no care plan to guide the care. In RRNHV#7 the patient was noted to have skin cancer wound/lesions, issues with gout that required colchicine, and was taking insulin for diabetes yet the care plan did not reflect the issues documented in the record. In RRNHV#8 there was documentation of an APS referral for issues noted in the home but no care plan guiding the care. In RRNHV#10 there was documentation of lab draws for CBC, CMP, and UA C&S and medication for BPH was increased for symptom control, yet the issues were not reflected in the care plans. These observations were reviewed with the Administrator, and Alt Director of Nursing.

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the patients needs. On review of RRNHV#7 there were oxygen orders that noted a range of O2 2-10 liters per nasal cannula continuous yet there were no specific instructions to guide the patient to know when to use what liter flow. In RRNHV#10 there were multiple as needed pain medications of Tramadol 50mg and Hydrocodone 5/325 mg every 6 hours as needed and Morphine 0.25 ml sublingual every 2 hours as needed yet there were no specific instructions to guide the patient/caregiver to know which medication to choose for which situation. Further the oxygen order had a range of 5-10 liters per minute but no specific instruction to guide the user in liter flow selection. These observations were reviewed with the Administrator, and Als Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. For example: on home observation for RRHV#1 the RN missed multiple opportunities to perform hand hygiene per the organization policy and current guidelines. The RN performed the patient assessment with gloves and then without doffing gloves and performing hand hygiene was noted to access the nursing bag multiple times, document on computer, and cleanse equipment. Further, the RN while performing wound care removed the existing dressing, cleansed the wound, replaced the dressing, and went back to performing patient care all without removing gloves and performing hand hygiene. These observations were reviewed with the RN, the Administrator, and Alt. DON.

Observed in Record Review. In 3 of 6 patient records reviewed, The organization failed to ensure the Registered Nurse provided written patient care instructions for the hospice aide. For example: on review of RRHV#1 the documentation showed the patient with bilateral heel wounds with wound care dressings, however there were no written care instruction for the hospice aide on how to handle the dressings while providing care. In RRHV#3 there was documentation that the patient had growing cancerous lesions/masses to the chest, yet there were no instruction to guide the Aide on bathing or providing care around the area of the lesions/masses In RRNHV#10 the patient had Oxygen in the home yet the Aide assignment did not include oxygen precautions. These observations were reviewed with the Alt Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the patient record contain information that reflected the patient's care, treatment, and services. On home observation for RHV#1 during the RN's medication reconciliation, it was noted that the Lorazepam in the home was oral liquid concentrate and the caregiver noted that the liquid concentrate was what was being given yet the medication profile had listed Lorazepam pills. In RRHV#2 during medication reconciliation the bottle for Trazadone in the home was for 50 mg and the wife confirmed she was giving 50mg yet the medication profile reflected 100mg tabs to be given. This observation was reviewed with the Administrator, and Alt DON.

Observed in Patient Home. In 1 of 1 home visits conducted, where medications were reviewed, the surveyor found that the organization had not completed a comprehensive assessment of the patient's medications at the time of admission. For example, during the home visit for HV2, the surveyor found, in discussion with the paid caregiver, that clotrimazole cream was being applied to the patient's penis. The caregiver stated that the cream had been in use on a daily basis since before the admission which was approximately one month prior to the survey visit. This was discussed with the Administrator, the Director of Nursing and others in the leadership team.

Observed in Record Review. In 6 of 11 patient records reviewed, the surveyor found that the organization had not consistently identified measurable outcomes with time frames for completion for each patient problem identified. For example, in review of the medical record for HV1, HV2, RR1, RR2, and RR5, the outcome for pain was that Pain will be managed at a level acceptable to the patient. In review of the medical record for HV1, HV2, RR1, RR2, RR3, and RR5, the outcomes did not have time frames established for completion. This was discussed with the Administrator and the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the surveyor noted that the plan of care did not include all services necessary to manage symptoms. For example, during the home visit for HV2, the surveyor noted that he was at risk for falls and had finasteride ordered. Precautions and safety measures related to fall risk and finasteride had not been addressed on the plan of care. In review of the medical record for RR1, the patient was on Eliquis and at risk for falls. Precautions and safety measures related to fall risk and Eliquis had not been addressed on the plan of care. In review of the medical record for RR2, there was no physician's order found for the oxygen that was documented as being in use. This was discussed with the Administrator.

Observed in Record Review. In 7 of 11 patient records reviewed, the surveyor found that the plan of care did not include all information on medications and treatments needed to meet the needs of the patient. For example, in review of the medical record for HV1, the surveyor found that the patient had acetaminophen with codeine and tramadol ordered as needed for pain without further defining when to give each medication. In review of the medical record for RR1, the surveyor found that the patient had acetaminophen with hydrocodone and tramadol ordered as needed for pain without further defining when to give each medication. In review of the medical record for RR3, the surveyor found that the patient had acetaminophen with hydrocodone and Tylenol Extra Strength ordered as needed for pain without further defining when to give each medication. In review of the medical record for RR5, the surveyor found that the patient had compazine and ondansetron ordered as needed for nausea/vomiting without further defining when to give each medication. In review of the medical record for RR8, the surveyor found that the patient had morphine sulfate and acetaminophen ordered as needed for pain without further defining when to give each medication. This same patient had orders related to care of skin tears which did not specify the type of dressing to apply other than an appropriate dressing. In review of the medical record for RR4 and RR9, the patient had IV push morphine 4mg/ml and 2mg/ml ordered but a dosage for each was not specified nor were there parameters specified for when the different strengths should be used. This patient also had IV push lorazepam ordered as needed but a dosage was not specified. This was discussed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor found that the organization had not provided care according to the patient's plan of care. For example, in review of the medical record for RR8, the surveyor noted that the plan of care included oxygen at 2-4lpm via nasal cannula. During one nursing visit, the oxygen was set at 5lpm and there was no indication the setting was adjusted to return it to the ordered flow rate or that the physician was contacted to approve the increased flow rate. The plan of care also included orders to cleanse skin tears with normal saline, apply TAO and cover with an appropriate dressing. On at least one occasion the nurse cleansed the skin tear with wound cleanser and then applied a dressing with padding. TAO was not noted as being applied. This was discussed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HV1, the patient was on Coumaden, had a risk for skin breakdown and falls, and oxygen ordered as needed. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for RR8, the surveyor noted that the patient had been diagnosed with COVID, had dressings to a pressure ulcer and skin tears in place, was at risk for further skin breakdown, was at risk for falls, and had oxygen. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. Similar findings were noted in RR2, RR3 and RR5. Additionally, the aide plan of care for HV1, had not been updated within the past 5 months to capture the patient's decline in function. Though the patient was bed bound as confirmed in discussion with the caregiver, there were still tasks to be completed each visit such as ambulate with stand by assistance and assist to bedside commode/toilet present on the aide plan of care. These tasks were consistently being documented as not completed. This was discussed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor found that the physician had not completed the Certificate of Terminal Illness (CTI) by providing a narrative that included the required elements needed for clinical justification of services. For example, in review of the CTI for RR2, the surveyor found that the narrative did not include information on the following: - Current subjective and objective medical findings - Current medication and treatment orders - Information about the medical management of the patient’s conditions unrelated to the terminal condition. This was verified with the Administrator..