Every finding on record at Rockies Community Hospice LLC

Observed in Record Review. In 3 of 12 patient records reviewed, During RRNHV# 2, RRNHV# 3, and RRNHV# 7's patient records review it was noted the organization had not ensured the patients' plans of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: review of RRNHV# 2 and RRNHV# 3's patient records revealed RRNHV# 2 and RRNHV# 3 were taking Eliquis, an anticoagulant and the plans of care did not include bleeding precautions. Review of RRNHV# 7's start of care RN comprehensive assessment revealed RRNHV# 7 was on oxygen at 2 lpm continuous at night. However, review of the medication profile revealed no oxygen order until approximately 25 days after the start of care. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 3 of 12 patient records reviewed, During RRHV# 1, RRNHV# 3, and RRNHV# 4's patient records review it was noted the organization had not ensured the registered nurse prepared complete written patient care instructions for the hospice aide. For example: review of RRNHV# 3’s patient record revealed RRNHV# 3 had a wound to the left lower leg with a dressing. Review of RRNHV# 3’s hospice aide written patient care instructions revealed no documentation of a wound or what to do if the dressing got wet during bathing. Review of RRNHV# 4’s patient record revealed RRNHV# 4 had seven different wounds with dressings. Review of RRNHV# 4’s hospice aide written patient care instructions revealed no documentation of the wounds or what to do if the dressings got wet during bathing. Review of RRHV# 1's hospice aide written patient care instructions revealed it was created at the start of care with no further updates until the day of the surveyor’s home observation. Review of RRHV# 1's patient record revealed RRHV# 1 had two different wounds with dressings over the past three months with no documentation of the wound or wound dressings on the hospice aid written patient care instructions. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 4 of 12 patient records reviewed, During RRHV# 1, RRNHV# 3, RRNHV# 4, and RRNHV# 5's patient records review 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 RRNHV# 4’s patient record revealed RRNHV# 4 had seven wounds with different wound care dressing orders. Review of the Skilled Nurse (SN) revealed documentation of left elbow, left buttock; left leg ; midline back; midline buttocks; midline buttocks prolapse; right foot; completed wound care visit on all wounds with no further documentation on what wound care was provided. Review of RRHV# 1's recertification RN comprehensive assessment revealed documentation of a wound to the coccyx with wound care provided per plan of care with no further documentation. Review of RRHV# 1's plan of care revealed two different wound care orders for the coccyx. Review of RRNHV# 3’s patient record revealed RRNHV# 3 had a wound on the lower left leg with an absorbent dressing to be applied and secured with Kerlix and a stage 2 pressure ulcer on the midline sacrum with barrier cream to be applied 3 times a day by the facility staff. Review of the SN visit notes revealed documentation under the midline buttock sacrum and left lower leg revealed “wound cleansing/dressing change per care plan” with no further documentation. Review of RRNHV# 5’s start of care RN comprehensive assessment revealed RRNHV# 5 had an open blister to the left foot and “wound dressed per orders” with no other documentation. This was reviewed, discussed, and validated with the Clinical Manager.

Observed in Record Review. In 5 of 11 patient records reviewed, updates to the comprehensive assessment and collaboration among the interdisciplinary team were not consistently documented. According to organizational policy Initial and Comprehensive Assessment No 3.008, the comprehensive assessment is updated every 15 days by the interdisciplinary team and each discipline will complete a note for the team meeting. Upon review of the record for HV#1, HV#2, and Interdisciplinary Group (IDG) notes, it was noted documentation regarding the updates to the comprehensive assessment was not consistently present from the social worker and spiritual counselor, and there was no documentation to validate collaboration had occurred with nursing and the physician regarding the patient’s status. Upon review of the record for HV#3, RR#7, RR#8, and IDG notes, it was noted documentation regarding the updates to the comprehensive assessment was not consistently present from the spiritual counselor, and there was no documentation to validate collaboration had occurred with nursing, social work, and the physician regarding the patient’s status. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the plan of care did not include measurable outcomes or goals. According to organizational policy Plan of Care No. 3.002, the plan of care should include goals that are realistic and measurable. Upon review of the plan of care for all records, not all goals were individualized and measurable. Examples included the following: the patient will maintain adequate nutrition/hydration, the patient’s peripheral edema will be reduced within limitations of disease process, the patient/family will express satisfactory control of symptoms. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. According to organizational policy Plan of Care No. 3.002, the plan of care will include interventions reflective of the patient's/family's needs. Upon review of the record for HV#3, it was noted the spiritual counselor’s initial assessment documentation indicated ongoing support would be provided and the patient requested to participate in communion monthly. On review of the plan of care, there were no interventions established related to spiritual care and support. This was reviewed and validated with the Executive Director. Observed in Record Review. In 2 of 2 patient records reviewed with wound care, the plan of care did not include complete wound care orders. Upon review of the plan of care and wound care orders for HV#1, it was noted the patient was receiving wound care for a skin tear; however, the order did not include a frequency with which wound care was to be provided. The order was written as follows: Wash with normal saline, pat dry ,apply non-adherent dressing, and secure with tape. Upon review of the plan of care and wound care orders for HV#2, it was noted the patient was receiving wound care on their right foot and left lower leg; however, the orders did not include a frequency with which wound care was to be provided. The orders were written as follows: For blister on right foot - apply Xeroform Petrolatum Dressing, cover with 4x4 non-adherent dressing, and wrap with Kerlix bandage. For the cancer lesion to left lower leg - wash with wound cleanser, pat dry, apply hydrofera blue, use skin prep around the lesion, and cover with retention tape. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 1 of 2 patient records reviewed with oxygen therapy, oxygen orders were not present. Upon review of RR#9 and the nursing start of care assessment, the patient had a terminal diagnosis of Chronic Obstructive Pulmonary Disease and was on 5 Liters of oxygen continuously; however, on review of the plan of care and physician orders, there was no documentation to validate an order for oxygen therapy was received. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care was not revised based on updates to the comprehensive assessment. According to organizational policy Plan of Care No. 3.002, the plan of care will be reviewed and revised as needed during the interdisciplinary team meetings. Upon review of the record for HV#1, it was noted the patient developed a urinary tract infection (UTI) and was started on antibiotics; however, the plan of care was not revised to include interventions or goals related to the patient’s infection. Upon review of RR#5, it was noted the patient was started on medication for difficulty sleeping; however, the plan of care was not revised to include interventions or goals related to the patient’s insomnia. This was reviewed and validated with the Executive Director.

Observed in Patient Home. In 1 of 1 home visits conducted in which reusable equipment was utilized, standard precautions were not used to reduced the risk of infection related to disinfection of equipment. According to organizational policy Cleaning and Disinfection of Clinical Equipment No. 2.024, the contact time for cleaning and disinfecting the vital sign equipment is that specified by the manufacturer, or if unknown, a minimum of 1 minute. During HV#3, the clinician was observed cleaning their vital sign equipment with a multi-purpose disinfecting wipe and placing the equipment immediately back into their bag without observing the manufacturer's guidelines of a 4-minute wet time. This was discussed with the Executive Director following the visit.

Observed in Record Review. In 3 of 5 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of the record for HV#2 and RR#8, it was noted the patients were started on anti-coagulant therapy; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions. On review of the aide plan of care for RR#6 and RR#8, it was noted the aide was assigned to perform a SSE if no BM in 3 days; however, in discussion with the Executive Director, aides are not permitted to perform soap suds enemas, the task populates automatically when assigned notify the RN if no BM in 3 days and should be deleted by the RN when creating the care plan. This was reviewed and validated with the Executive Director.

Observed in HR File Review. In 2 of 9 HR files reviewed, competence was not assessed during orientation. Upon review of HR#1 and HR#6, it was noted the Medical Director and Spiritual Counselor joined the hospice team in 2022 and there was no documentation to validate competencies had been assessed upon hire. This was reviewed and validated with the Executive Director.

Observed in Patient Home. In 3 of 3 patient records reviewed in which home visits were conducted, the medication profile in the patient's record was inaccurate. During HV#1 in discussion with the caregiver, the patient is taking Vitamin D, fluticasone, and a daily multi-vitamin; however, on review of the medication profile in the record, these medications were not included. The medication profile in the record indicated the patient was taking Zyprexa; however, in discussion with the caregiver, this medication was discontinued roughly 6 months ago. During HV#2 in discussion with the caregiver, the patient takes Guaifenesin as needed; however, on review of the medication profile in the record, this medication was not included. During HV#3 in discussion with the caregiver, the patient is taking Escitalopram 20 mg daily and Mirtazapine routinely at night. On review of the medication profile in the record, Escitalopram was listed twice, one order for 10mg daily and the other order for 20mg daily, and Mirtazapine was listed twice, one as routine and one as needed. This was reviewed and validated with the Executive Director.