Every finding on record at Roper Hospital, Inc.

Observed in Patient Home. In 1 of 4 home visits, surveyor noted that the nurse did not perform a complete assessment of patient's skin per the organization's policy for comprehensive and subsequent routine visit reassessments to identify all potential areas of skin breakdown. For example, the nurse assessed patient's sacral area, however, the anterior portion of patient's body from patient's shoulders down to patient's toes and patient's posterior lower extremities were not assessed for potential skin breakdown. This was reviewed with the QAPI Nurse Leader/Clinical Manager.

Observed in Record Review. In 4 of 14 records reviewed, surveyor noted that the plan of care was not individualized based on the patients' needs with measurable goals and appropriate timeframes for goal attainment. For example, In HV#2, NHV#1, NHV#4 the goal for the problem of pain stated patient will experience effective relief from pain control measures as evidenced by deceased/stable pain level, in NHV#1 the goal for the problem of constipation stated patient's constipation is controlled, and in NHV#2 the goal for the problem of anxiety stated patient's stress and anxiety will be reduced or eliminated This was reviewed with the Clinical Manager.

Observed in Tracer Activities. During an interview with the organization's volunteer coordinator and in review of the documentation provided for that program, the hospice pharmacist surveyor noted that the organization did not currently consistently document ongoing efforts to recruit volunteers for the hospice program as required. This omission was validated with the volunteer cordinator at then time of then survey.;

Observed in Record Review. In 1 of 16 patient records reviewed, The surveyor noted that in HOSRR#7 was ordered wound care to bilateral lower and extremities and toes. However, there were no documentation in the record that shows that the wounds were assessed. According the agency policy Documenting wound, measurement and assessment: Wound to be assessed and measured initially and weekly . The patient was visited by a Registered Nurse twice weekly but failed to assess and measure the wounds initially and weekly. This was validated by the Director of Nursing.

Observed in Record Review. In 12 of 16 patient records reviewed, It was noted in review of HOS RR# 1-12 , the goals were not measurable and did not have time frames for achieving goals. The goals for all disciplines involved in the interdisciplinary group were standardized. for examples: the Nursing goals Included: A nursing plan of care will be established, Pain will be managed at a level acceptable to the patient' . Chaplain goals were written as follows: chaplain plan of care will be established. Patient/Caregiver will feel relief from spiritual concerns. Funeral/Final Arrangements acknowledged and completed per the patient's / family's wishes. Social Worker goals included: A medical social worker plan of care will be established; Patient caregiver will have decreased fear/anxiety regarding death and dying process. Patient/caregiver will express an increased sense of closure and peacefulness at the end of life. Caregivers will experience a sense of accomplishments at having supported the dying person. This was validated by the Director of Nursing. Observed in Record Review. In 4 of 16 patient records reviewed, the hospice surveyor found that the organization had not developed an individualized plan of care that identified measurable goals based on problems identified in the initial, comprehensive and updated comprehensive assessments. For example, in review of the medical record for HosHV1, HosHV2, HosHV3 and HosHV4, the surveyor noted that the goals did not include a time frame for completion and the goal for pain was not measurable (Pain is currently managed at a level acceptable to patient). There were also problems for Altered Neurological Status and Altered Nutrition/Hydration that had no associated goals, only interventions. Other goals found that were not measurable included Patient exhibits reduction/relief of any cardiopulmonary symptoms and Patient will exhibit a reduction or cessation of nausea and vomiting. The observations related to plan of care goals were discussed with the Director of Hospice.

Observed in Record Review. In 4 of 16 patient records reviewed, the hospice surveyor noted that the plan of care did not contain all interventions to manage pain and symptoms. For example, in review of the medical record for HosHV1, the surveyor noted that the patient was on Eliquis and had Braden score indicating a moderate risk for skin breakdown but these things were not addressed in the plan of care. In review of the medical record for HosHV2, Hydromorphone was ordered as 1-2 tablets for breakthrough pain without further defining when 1 tablet should be taken verses when 2 tablets should be taken. The surveyor found that this patient also had both prochlorperazine and promethazine ordered as needed for nausea and vomiting without further defining when each medication should be taken. In review of the medical record for HosHV4, the surveyor found that patient had both MiraLax and Dulcolax ordered as needed for constipation without further defining when each medication should be taken. In HosHV1, HosHV2, HosHV3 and HosHv4, the patient had an order for Morphine Sulfate, 0.25ml-1ml as needed for pain without further defining when 0.25ml should be taken verses a larger dose. These observations were discussed with the Director of Hospice.

Observed in Record Review. In 1 of 16 patient records reviewed, the hospice nurse surveyor noted (HOSRR# 7) that the patient wound care orders were not followed. The treatment orders were for wound care to bilateral lower extremities to be completed 3 x week, however the registered nurse visited the patient 2 x weekly and there were no documentation in the record that shows that wound care was provided. Also, The POC was not updated to include goals and interventions to address the wounds. This was confirmed with the Director of Nursing. Observed in Record Review. In 1 of 16 patient records reviewed, the hospice nurse surveyor noted in (HOSRR#11 ) that there were no goals for the problems identified in the nursing assessment including: Urinary Urgency frequency, use of an anticoagulant and high risk for fall. Plan of care did not include safety precautions such as bleeding precautions for a patient on anticoagulants or fall safety precaution for high fall risk. This was confirmed by the Director of Nursing.

Observed in Record Review. In 2 of 16 patient records reviewed, during record review, the surveyor noted that more than one medication for pain had been ordered for pain, the surveyor noted that there had not been instructions or directions for the patient regarding which pain medication to take when. For example, in HOSRR #5 the medication profile had morphine to be taken 0.25ml- 1ml every 4hrs PRN. Their were no qualifier to indicated when the patient should take the 0.25 ml morphine or the 1ml morphine. In HOS RR# 6, it was noted that both morphine 0.25 ml - 1ml every 4hrs PRN and tramadol every 6hrs as needed were ordered, but no qualifier was indicated. This finding was validated with Director of Nursing

Observed in Record Review. In 2 of 16 patient records reviewed, the hospice surveyor noted that the plans of care had not been revised to reflect updated assessments and progress towards goals in HOSRR #1 and HOSRR # 3. For example, in record review of HOSRR # 1, the surveyor noted that most of the goals on the updated re-certification plan of care were dated April of 2021. The most recent recertification plan of care started in February of 2022. This was confirmed with the Director of Nursing.

Observed in Record Review. In 3 of 6 patient records reviewed, where the patient had hospice aide services ordered, the hospice surveyor found that the aide had not followed the aide plan of care. For example, in review of the medical record for HosHV1 and HosHV4, the surveyor noted that the aide plan of care instructed the aide to assist with a shower. On multiple visits, the aide documented that a bedbath was completed. In review of the medical record for HosHv3, the aide was to document the date of the last bowel movement and notify the nurse if greater than 3 days. In three of four visits no date was documented only Y This was discussed with the nurse assisting with record review and the Director of Hospice.