Every finding on record at Saint John Hospice

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure its policy related to pain assessment was implemented. For example, during a review of the medical record for RRHV#1, it was noted that during week 5 of services, the LVN member of the health care team documented the presence of generalized pain. This was the first documentation of pain since the start of hospice services. A subsequent visit 2 days after the LVN visit, completed by the RN member of the health care team, identified the presence of pain in the patient’s abdomen and back. The pain assessment completed by the RN member of the team did not include the following information related to the patient’s pain: Intensity, Frequency, Duration, and Relief Measures. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the plan of care was not revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#1 revealed that during the 11th benefit period the interdisciplinary team documented that the patient had experienced multiple falls. The plan of care was not updated with a goal statement to evaluate the response to care, treatment, and services related to fall prevention activities. This observation was reviewed with agency leadership. Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the organization did not ensure that the plan of care included outcome measures for specific care activities. For example, the comprehensive assessment for RRHV#1, identified a problem with the patient’s skin integrity. The clinician documented the presence of two stage 1 pressure ulcers at the patient’s sacral area. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the patient’s altered skin integrity. Example #2: A review of the plan of care for RRHV#2, and RRNHV#6, revealed the following goal statement: Prevent/manage cardiac/circulation episodes. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #3: During a review of the medical record for RRNHV#7, the comprehensive assessment included the description of an unstageable pressure ulcer at the left heel, an unstageable pressure ulcer at the right heel, and a stage 4 pressure ulcer at the sacrum. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the plan of care was not revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#1 revealed that during the 11th benefit period the interdisciplinary team documented that the patient had experienced multiple falls. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the agency leadership team. Observed in Record Review. In 2 of 10 patient's records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, the comprehensive assessment for RRHV#1, identified a problem with the patient’s skin integrity. The clinician documented the presence of two stage 1 pressure ulcers at the patient’s sacral area. In addition, the clinician documented that the pressure areas were treated with Calmoseptine ointment. The plan of care did not describe interventions to provide care, treatment, and services to address the skin impairment, and measures to protect the patient’s skin integrity. Example #2: During a review of the medical record for RRNHV#7, the comprehensive assessment included the description of an unstageable pressure ulcer at the left heel, an unstageable pressure ulcer at the right heel, and a stage 4 pressure ulcer at the sacrum. The plan of care did not include interventions related to wound care. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 4 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#1, the patient was on oxygen. There was no goal on the POC related to the primary caregiver understanding or implementing oxygen safety precautions. In the chart for RR#2, in the current POC, there are no goals related to fall prevention for this patient at high risk for falls. The goal for spiritual care was an intervention, not a goal and not individualized to this non-verbal, disoriented patient who is unable to make his needs known. Patient will receive once a month SC visits in next 30 days. - SC will encourage patient to verbalize his feelings during visits in next 30 days. The Psychosocial goal had not been individualized to the patient. Problem is patient lacks understanding and would benefit from emotional support. Goal Increase understanding of disease process. Increase emotional support status. for this patient who is unable to communicate and participate in his care. In the chart for RR#3, the Spiritual Goal on the POC was that the Chaplain would visit the patient once per month; an intervention, not a goal of care. The potential for psychosocial distress goal was Pt's POA/family will receive psychosocial support to cope with pt illness by next follow up session with LCSW in 1 month; an intervention, not a goal of care. In the chart for RR#5, the Spiritual and Volunteer goals are interventions, not goals. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, and did not include medications and treatments necessary to meet the patient’s needs. In the chart for RR#1, oxygen was ordered prn during the admission visit. The POC did not include any interventions related to instructing the primary caregiver on safety precautions related to the use of oxygen. In the chart for RR#2, the patient was at high risk for falls. The POC did not include any interventions related to fall prevention. In the chart for RR#3, the patient had orders for daily wound care to pressure ulcers. The POC did not indicate if facility staff or hospice SN were to perform the wound care. Patient was at risk for falls however there were no interventions on the POC other than education of PCG to expect increased weakness and fatigue. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. For example, in the chart for RR#2, the patient is in his 5th certification period. The 3 most recent IDT's did not address any progress toward goals. Rather, the target date for each goal is moved forward to the next IDG meeting and marked controlled with no documentation of any discussion related to any actual progress. The problem of patient lacks understanding and would benefit from emotional support, with a goal of Increase understanding of disease process. Increase emotional support status. for this patient who is unable to communicate and participate in his care has been present since admission, yet there is no documented progress toward this goal. In the chart for RR#4, there was no documentation about progress toward goals for the MSW or the Chaplain. In the chart for RR#5, there is no documented progress toward goals for MSW, Volunteer and Chaplain services. IDG notes reiterate the frequency of visits and the target dates for goals is simply moved to the future at each IDT. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the charts for HV#3 and RR#3 the patients with multiple wounds, the nursing staff are not documenting the actual care provided to each wound, rather documenting wound care provided or wound care per MD order. This was discussed with the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, in which a live discharge occurred, the hospice discharge summary did not include the following: A summary of the patient’s stay, including treatments, symptoms, and pain management. In the chart for RR#6, the patient revoked the hospice benefit. The discharge summary did not include a summary of the stay. This was discussed with the DPCS.

Observed in Document Review. In 1 of 1 contracts reviewed, for hospice care provided to residents of a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), the written agreement did not include the following: A provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was confirmed with the owner and Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not provided care, treatment or services in accordance with regulation. In the chart for HV#3, the documentation indicated that the patient's caregiver requested the hospice addendum outlining services not covered by hospice. The patient was on 3 medications Rosuvastatin, Vitamin C and Folic Acid which were not covered by hospice. There was no documentation in the record to indicate the addendum was provided as discussed with the DPCS.