Every finding on record at Saddleback Memorial Medical Center

Observed in Patient Home. In 1 of 3 visits with wound care, the plan of care states wounds will be measured weekly yet no measurements were observed or found in the medical record, including the admission visit. This was verified with the Hospice director and the quality improvement coordinator.

Observed in Record Review. In 2 of 8 patient records reviewed, of patients with CHHA on the case, the surveyor found that CHHA missed multiple schedule visits without communication of any kind. For example RRNV # 4 during the weeks 11/3/24, 11/11/24, 11/18 and 12/29 each week had at least one missed aide visit without communication of any kind. Further during review of record associated with HHV#6 it was observed in record that during the weeks of 10/3/24, 11/18/24, 11/25/24, 12/31/24, 1/20/25, 2/3/25 and 2/10/25 each week had at least one missed aide visit without communication of any kind. The surveyor confirmed with hospice quality RN , who had reviewed records along with surveyor, that the IDG had not been informed or that any communication note had been completed related to aide missed visits.

Observed in Patient Home. In 1 of 6 visits, multiuse equipment was not cleaned before being put back in the bag with clean equipment, which was not consistent with the organization's Nursing Bag Technique policy. This was discussed and confirmed with the Hospice Director and the Quality Improvement Coordinator. Observed in Patient Home. The surveyor observed the hospice CHHA give a bed bath to a patient that had been discharged status post sepsis, without following organization policy or CDC guidelines. The surveyor observed the CHHA wash hands at start of visit and never again during visit, which included cleaning fecal matter, handling foley catheter. At one point the surveyor observed the CHHA don 3 pair of gloves and just remove and continue with care without cleaning hands. The surveyor also observed during visit the aide leave patient bath to go into patient clean closet with dirty gloves on.

Observed in Tracer Activities. In 1 of 1 hospice aide competency files reviewed, the organization was not able to validate that a hospice aide had completed at least 12 hours of in-service training during the past 2 year period. This finding was discussed with the hospice leaders at the time of discovery.

Observed in Individual Tracer. The hospice surveyor observed that the hospice aide Care Plan had included two types of baths , a shower and a bed bath organization policy requires that one bath type be ordered on care plan. When discussed with organization leadership it was stated that the admit nurse put one type of bath and the case manager RN changed to other type, however no nurse removed any of the two baths and therefore had not complied with organization policy. The surveyor discussed and confirmed with hospice quality RN that reviewed records with surveyor that this was an issue.

Observed in Record Review. In 3 of 18 patient records reviewed, In 3 of 18 records, hospice aide supervision was not conducted every 14 days or less. Days late were anywhere from 2 days to 7 days late. This was confirmed by the Quality Improvement Coordinator.

Observed in Tracer Activities. The organization was not able to validate that its volunteer staff provided day to day administrative or direct patient care in an amount that equals at least 5% of the total patient care provided by the organization. The organization's calculated volunteer activity for Fiscal Year 2024 was 4.4%. This finding was discussed with hospice leadership.

Observed in Record Review. In 3 of 3 patient records reviewed, of hospice patients that revoked and went to hospital the surveyor found no evidence that the discharge summary had been provided to the next provider. This issue was discussed with hospice leaders and confirmed.

Observed in Tracer Activities. The organization's contracts for pharmacy services, and durable medical equipment did not have a stipulation that the outside agency would complete a criminal background check on contracted employees who provide direct patient care of have access to patient records. This finding was discussed with hospice leadership.

Observed in Record Review. In the record of HO RR#2 the comprehensive reassessment did not include weekly wound measurements as required by the Assessments and Reassessments policy. The nurse documented and measured a wound on the lateral aspect of the patient’s right foot in the initial comprehensive assessment, however measurements had not been documented in the three months since then. This was confirmed by the Quality Coordinator.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that completion dates for most goals were the last day of the current benefit period. For patients who received services for more than one benefit period, that date was changed to the last day of the next benefit period. This was confirmed by the Quality Coordinator.

Observed in Record Review. In the record of HO RR#3 an order for oxygen was not included in the plan of care despite the patient having used it since he was admitted. And in HO RR#7 there was no order for oxygen in the plan of care, but the patient was using oxygen at five to ten liters per minute. This was confirmed by the Quality Coordinator.

Observed in Record Review. In 5 of 14 patient records reviewed, an assessment of the quality of care and services was not completed by a registered nurse every fourteen days as required by policy and law. Note that since the 1135 waivers were initiated in response to COVID the hospice was meeting the fourteen days requirement overall. These findings were recent and were found in the records of HO RR#1, HO RR#3, HO RR#5, HO RR#9 and HO RR#10 and was confirmed by the Quality Coordinator.

Observed in Record Review. In 4 of 4 patient records reviewed, where the patient was discharged alive, the hospice did not notify the primary physician within five business days that a discharge summary was available. This was found in the records of HO RR #6, HO RR#7, HO RR#8 and HO RR#9. This was confirmed by the Quality Coordinator.

Observed in Record Review. In 4 of 4 home visits conducted, and ten record reviews the surveyor did not find emergency plans created for patients based on individualized needs identified in comprehensive assessments and reassessments. This was confirmed by the Hospice Director.