Every finding on record at Ryder Memorial Hospital, Inc.

Observed in Record Review. In 14 of 14 patient records reviewed, It was noted by the nurse surveyor that the need for volunteer services was not assessed for HOSRRHV#1, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRDC#1, HOSRRDC#2, HOSRRBR#1, and HOSRRBR#2 as the agency did not have a hospice volunteer since 2021 to provide support or services. Finding was discussed with the Hospice Coordinator. Observed in Record Review. The hospice nurse surveyor noted that for HOSRRHV#2, HOSRRHV#3, HORRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4 the need for volunteer services to offer support or respite to the patient or family was not being assessed. The hospice did not have any volunteers available to provide services since 2021, and therefore had not been assessing the need for volunteer services. This was verified by the Hospice Coordinator.

Observed in Record Review. In 4 of 14 patient records reviewed, the goal time frames were not being updated based on the current individualized assessments. HOSRRNHV#1 included nursing goals with target dates of more than 2 weeks prior to survey. HOSRRNHV#2 included nursing and chaplain goal target dates in the past. HOSRRNHV#3 included a nursing constipation goal date in July more than 2 months prior to survey. HOSRRNHV#4 included a goal related to a urinary infection with a target date of more than a month prior to survey and social work goals with target dates in the past. This was reviewed with the Hospice Coordinator during record review.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted by the nurse surveyor that for HOSRRHV#1, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRDC#1, HOSRRDC#2, HOSRRBR#1, and HOSRRBR#2 the visit frequency as established by the IDG (interdisciplinary group) did not include a duration for services. Finding was discussed with the Hospice Coordinator. Observed in Record Review. The hospice surveyor noted from record review that the frequency of visits planned did not include the duration of services necessary to meet the patient needs. HOSRRHV#2, HOSRRHV#3, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, and HOSRRNHV#4 included a plan for frequency for all disciplines, nursing, social work, chaplain, medical director, and hospice aide without any duration included for the planned frequency for any discipline. This was confirmed with the Hospice Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, the prn medication orders in the plan were incomplete. HOSRRHV#3 included 3 prn medications, Ipratropium, Levalbuterol, and Budesonide, all ordered for congestion without any specific indications. This was confirmed with the Hospice Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, there was no evidence that the interdisciplinary group had reviewed the plan at least once every 15 calendar days. HOSRRHV#3 record included that at the time of the survey it had been 19 days since the most recent documented interdisciplinary meeting to review the plan. This was confirmed by the Hospice Coordinator.

Observed in Record Review. The hospice nurse surveyor noted that for HOSRRNHV#3 the plan for aide frequency of visits was not followed. The frequency of aide visits was included in the plan as 3x a week and after the second week of aide care when the patient refused further aide services the plan was not updated, there was no evidence in the record that the interdisciplinary team was informed of the change in services. This was confirmed by the Hospice Coordinator during record review. Observed in Record Review. In 2 of 14 patient records reviewed, it was noted by the nurse surveyor that care was not being provided care per the hospice plan of care. For HOSRRHV#1, the order for oxygen was for 5 liters BNC continuously, during the home visit it was noted that the oxygen concentrator was set on 4 liters. Additionally, there was an order that the oxygen could be increased to 10 liters BNC for acute episodes of shortness of breath, however, in the home it was being provided by mask. Findings were validated by the Hospice Coordinator who was present on the Home Visit.

Observed in Patient Home. In 2 of 2 home visits conducted, where equipment disinfection was observed, the surveyor noted the organization had not implemented its infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example HOSRRHV#2 and HOSRRHV#3 the nurses placed the dirty equipment on the clean barrier. After the equipment was cleaned it was placed back on the area where the dirty equipment was placed. In addition, during HOSRRHV#2 the nurse wrapped the blood pressure cuff as soon as she wiped it with the disinfectant wipe without leaving it open to allow for the manufacturer required 1 minute wet time. During HOSRRHV#3 the nurse cleaned the equipment with the same gloves used to check the patient's skin, which included removing the patient's adult disposable brief and checking the peri area for skin breakdown. This was reviewed with the Hospice Coordinator who accompanied the surveyor on the visits.

Observed in Tracer Activities. It was noted by the nurse surveyor that the hospice did not have an organized bereavement program. There was a bereavement coordinator in place (their social worker) visited each family at time of death. At that time, the family was asked if they wanted bereavement follow-up (comfort/condolence support). If the family said no, (which they all did), no further follow-up was provided. The hospice did not have any standardized mailing program or set time frames for follow-up with the bereaved if they should want bereavement follow-up (comfort/condolence support). Finding was discussed with the Hospice Coordinator.

Observed in Record Review. In 3 of 3 patient records reviewed, with the Hospice Aide, it was noted by the nurse surveyor that the hospice aide care plan did not include all of the information for the hospice aide to effectively provide care. For HOSRRHV#1, the patient was on continuous oxygen and there were no instructions to indicate if the patient’s oxygen could be removed for her bed bath. Additionally, there were no instructions as to when to notify the nurse, resuscitation status, or incontinence care. HOSRRNHV#7, the patient was on continuous oxygen and there were no instructions to indicate if the patient’s oxygen could be removed for her bed bath. Additionally, there were no instructions as to when to notify the nurse, resuscitation status, incontinence care, or what to do regarding a necrotic hand wound. Findings were discussed with the Hospice Coordinator. Observed in Record Review. The hospice nurse surveyor noted for HOSRRNV#3 that the aide care plan did not include all of the necessary written patient care instructions. The aide care plan did not include for example the patient's resuscitation status, incontinence management instructions, what to do with the oxygen, or when to notify the nurse. This was reviewed with the Hospice Coordinator.

Observed in Record Review. In 1 of 3 patient records reviewed, with the Hospice Aide, it was noted by the nurse surveyor that for HOSRRHV#1, Hospice Aide Supervisory visits were not documented the required every fourteen days. For four consecutive weeks they were one day late (15 days apart). Findings were verified with the Coordinator of the Hospice Program.

Observed in Tracer Activities. It was discussed during the volunteer program review that the organization had not had any volunteers since 2021 and did not have any at the time of the survey. Therefore, there was no evidence of any documented cost savings. This was confirmed with the Director.

Observed in Tracer Activities. It was discussed during the volunteer program review that the organization had not had any volunteers since 2021. and did not have any at the time of the survey despite significant ongoing documented recruitment efforts. Therefore, there was no evidence that the hospice had provided at least 5% of their day-to-day administrative and/or direct patient care services through volunteer staff. This was confirmed with the Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed that the medication list had not been reconciled and was not accurate. During HOSRRHV#3 it was noted that the medication list included Ipratropium 2 x a day routinely and the patient had not been using it. This was confirmed by the Hospice Coordinator who accompanied the surveyor on the visit.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care did not include all interventions/orders to meet the patient's needs. Upon review of the record for HOSHV#2, it was noted the patient had a foley catheter in place, which was documented as recently changed due to an obstruction. On review of the plan of care, there was no order for foley catheter changes. The patient had a wound to their left shin and per the RN, was receiving wound care twice a week; however, on review of the plan of care and wound care order, there was no documented frequency in which the wound care was to be performed. The order was written as follows: cleanse with normal saline, apply Derma gran nonadherent dsg, cover with gauze and tape. Upon review of the record for HOSHV#3, it was noted the patient had a condom catheter in place; however, on review of the plan of care, there was no order for a catheter. Upon review of HOSRR#4, it was noted the patient had a wound to their left/ right gluteal folds and left trochanter area; however, on review of the plan of care and wound care orders, there was no documented frequency in which the wound care was to be performed. The order was written as follows: cleanse with normal saline, apply Derma gran nonadherent dsg, cover with gauze and tape. Upon review of HOSRR#9, it was noted the patient had a wound to their sacrum; however, on review of the plan of care and wound care orders, there was no documented frequency in which the wound care was to be performed. The order was written as follows: cleanse with normal saline, apply Derma gran nonadherent dsg, cover with gauze and tape. This was reviewed and validated with the Hospice Supervisor and Quality Director.

Observed in Record Review. In 5 of 5 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of HOSHV#1, it was noted several of the assigned tasks on the aide plan of care were indicated as needed/PRN and did not include a specific frequency in which the task was to be performed. Upon review of the record for HOSHV#3, HOSRR#4, HOSRR#5, and HOSRR#6, it was noted several of the tasks included a frequency of each visit and “as needed/PRN”. Upon review of RR#6, it was noted the patient was on oxygen therapy; however, on review of the aide plan of care, there were no instructions provided to the aide regarding oxygen precautions. This was reviewed and validated with the Hospice Supervisor and Quality Coordinator.

Observed in Record Review. In 4 of 5 patient records reviewed with aide services, the hospice aide did not provide care as assigned. Upon review of the record for HOSHV#3, it was noted on multiple visit notes the aide consistently documented the following tasks as completed that were not assigned on the plan of care: changing external catheter, performing peri care, and emptying the catheter bag. Upon review of HOSRR#4, it was noted on multiple visit notes the aide consistently documented to cleaning the gastrostomy site, which was not assigned. The aide was assigned to empty the catheter bag and document the output every visit; however, on review of aide visit notes, these tasks were not consistently documented as done each visit. Upon review of HOSRR#5, it was noted on multiple visit notes the aide did not consistently document the following tasks as completed that were assigned on the plan of care: combing hair and cleaning the catheter. Upon review of HOSRR#6, it was noted on multiple visit notes the aide consistently documented the following tasks as completed that were not assigned on the plan of care: combing hair. This was reviewed and validated with the Hospice Supervisor and Quality Coordinator.

Observed in Record Review. In 4 of 5 patient records reviewed with aide services, aide supervision did not confirm the aide was following the patient's plan of care as assigned. Upon review of the record for HOSHV#3, HOSRR#4, HOSRR#5, and HOSRR#6, it was noted aide visit documentation reflected the aide was not following the plan of care; however, the supervisory visit documentation completed during the time frame in which those visits were made, reflected the aide was providing services according to the plan of care. This was reviewed and validated with the Hospice Supervisor and Quality Coordinator.