Every finding on record at Saint Elizabeth Medical Center, Inc.

Observed in Individual Tracer. In 1 of 6 individual tracers, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. The organization did not ensure the patient's right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for RRHV#5, the options to choose an attending physician was not a part of the election statement or consent form. This observation was reviewed with the Administrator and Nurse Manager.

Observed in Individual Tracer. In 3 of 6 individual tracers, the organization did not ensure that updated comprehensive assessments included progress towards desired outcomes. For example, a review of RRHV#1, revealed that since a goal statement related to choking was not established; the requirement to ensure the updated comprehensive assessment included the patient's progress toward goals and outcomes related to choking was not documented.Example #2: A review of RRHV#2, and RRHV#3, revealed that since a goal statement related to falls prevention was not established, the requirement to ensure the updated comprehensive assessment included the patient's progress toward goals and outcomes related to falls prevention was not documented. This observation was reviewed with the Administrator and Nurse Manager.

Observed in Individual Tracer. In 6 of 6 individual tracers, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRHV#1, the following information was noted: The patient's primary diagnosis was Respiratory Failure, unspecified. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Respiratory Failure, unspecified. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. In addition, during week 2 of the 1st benefit period, the clinician documented that the patient was experiencing a new symptom of choking. The plan of care was not updated with a goal statement to evaluate, the care, treatment and services related to the change in patient's condition related to the symptom of choking. Example #2: During a review of the medical record for RRHV#2, the following information was noted: The patient's primary diagnosis was Chronic diastolic heart failure. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Chronic diastolic heart failure. In addition, the comprehensive assessment identified that the patient was at risk for falls. During week 2 of the 1st benefit period, the clinician documented that the patient had experienced a fall. The plan of care was not updated with a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. During home visit activity, the patient stated he had experienced a new fall 2 days prior to the date of survey. Example #3: During a review of the medical record for RRHV#3, the following information was noted: The patient's primary diagnosis was Cancer with unknown primary site. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Cancer with unknown primary site. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. During week 3 of the 1st benefit period, the clinician documented that the patient had experienced a fall. The plan of care was not updated with a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. Example #4: During a review of the medical record for RRHV#4, the following information was noted: The patient's primary diagnosis was Anaplastic thyroid carcinoma. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Anaplastic thyroid carcinoma. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. Example #5: During a review of the medical record for RRHV#5, the following information was noted: The patient's primary diagnosis was Pancreatic carcinoma metastatic to liver. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Pancreatic carcinoma metastatic to liver. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. Example #6: During a review of the medical record for RRHV#6, the following information was noted: The patient's primary diagnosis was Respiratory failure, unspecified chronicity. The plan of care problem statement was Patient has a terminal illness with a prognosis of six months or less. The goal statement for this problem was Patient will be well-palliated through end of life by management of pain, dyspnea, nausea/vomiting, constipation, and any other symptoms that may arise during Hospice care. The goal statement did not include a method to evaluate the response to care, treatment, and services related to the terminal illness diagnosis of Respiratory failure, unspecified chronicity. The stated timeframe of ...through end of life... is not a realistic measurement to assess the implementation of problem interventions. This observation was reviewed with the Administrator and the Nurse Manager.

Observed in Individual Tracer. In 3 of 6, individual tracers, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRHV#1, revealed the clinician documented that the patient was experiencing a new symptom of choking. The plan of care was not updated with interventions to address the change in the patient's condition related to the symptom of choking. Example #2: A review of the medical record for RRHV#2, revealed that the patient experienced a fall during week 2 of the 1st benefit period. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall interventions. During home visit activity, the patient stated he had a new fall 2 days prior to the date of survey. A review of the medication profile revealed that the patient was taking Eliquis 2.5mg 1 tablet by mouth 2 times daily, drug class: anticoagulant/blood thinner. The plan of care did not include interventions for education and safety precautions related this high risk medication. Example #3: A review of the medical record for RRHV#3, revealed that the patient experienced a fall during week 3 of the 1st benefit period. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall interventions. This observation was reviewed with the Administrator and the Nurse Manager.

Observed in Individual Tracer. In 6 of 6 individual tracers, it was noted that the organization did not ensure the plan of care was revised based on updated comprehensive assessments. For example, a review of the medical record for RRHV#1, revealed that during week 2 of the 1st benefit period, the clinician documented that the patient was experiencing a new symptom of choking. The plan of care was not updated with a goal statement to evaluate, the care, treatment and services related to the change in patient's condition related to the symptom of choking. Since a goal statement related to choking was not established, the requirement to address the patient’s progress toward goals and outcomes related to choking was not completed. Example #2: During week 2 of the 1st benefit period for RRHV#2, the clinician documented that the patient had experienced a fall. The plan of care was not updated with a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. Since a goal statement related to falls prevention was not established, the requirement to address the patient’s progress toward goals and outcomes related to falls prevention was not completed. Example #3: During week 3 of the 1st benefit period for RRHV#3, the clinician documented that the patient had experienced a fall. The plan of care was not updated with a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. Since a goal statement related to falls prevention was not established, the requirement to address the patient’s progress toward goals and outcomes related to falls prevention was not completed. This observation was reviewed with the Administrator and the Nurse Manager.

Observed in Data Session. During a review of the data for fall risk in the Hospice patient population, the hospice pharmacy surveyor noted that fall data was collected quarterly by the organization; however analysis of this collection was not being used to identify opportunities and priorities for improvement, This omission was validated with the QAPI team at the time of the survey. Observed in Data Tracer. Since the organization was not currently analyzing the data collected on falls as noted by the hospice pharmacy surveyor, improvement opportunities could not be identified in this area of the QAPI requirement. This omission was validated with nursing management at the time of the survey.

Observed in Data Session. During the quality improvement (QAPI} session, the Hospice pharmacy surveyor noted that although performance improvement events and actions were analyzed to determine reasons for patient falls and implement actions to avoid or improve these fall numbers in the hospice patients, the goal set to be at 3.3/1000 patient days was not met for any of the quarters in 2024 remaining at twice the desired goal of around 7/1,000 patient days.. This issue was validated with the QAPI Coordinator at the time of the survy

Observed in Record Review. In 2 of 3 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for RRHV#2, and RRHV#3, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with Administrator and the Nurse Manager.

Observed in Building Tour. Above the entrance to Room 1101, there was insulation and IT cables using the sprinkler pipe for support. Confirmed by the Facilities Staff. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Individual Tracer. In 1 of 15 records reviewed, the Hospice RN surveyor noted in RR 9, that on admission and the visit the next day the patient reported a pain level of 6 and was prescribed opioids however a follow up visit to reassess pain was not done until 7 days later. There was no documentation that contact had been made with the patient during that time. This was validated in a discussion with and observation by the Clinical Manager.

Observed in Building Tour. During the LSC document review, the Hospice RN surveyor noted that the organization did have auto regulated hot water, that there was no process to check the water temperature in the patient rooms. This was validated in a discussion with and observation by the Director of Senior Services.