Every finding on record at San Bernardino Hospice, Inc.

Observed in Record Review. In 11 of 12 patient records reviewed, it was noted that the written plan of care was not individualized for each patient. For example, in RRBR#1 the bereavement plan of care included only interventions, no goal. In records HV#1,#2 and#3, and RR#1 through RR#7 all goal's time frames were not individualized, each goal's time frame was for the next recertification date. For example, the goal Bring down pain to < 3 or stated comfort level of pain time frame of over 2 months was not individualized to the patient's concern/wishes. This was discussed with the DON and QAPI RN.

Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that the plan of care was incomplete. For example in RRHV#1 the foley catheter order was Continue Foley Catheter Management: French 16 - change foley catheter every month and as needed. with no balloon size or amount to fill balloon and no reason for as needed foley catheter change. In record RRHV#2 the POC included integumentary/skin however the wound care order was not included. In record RRNHV#3 the plan of care order set did not include hospice aide visit frequency although the aide was visiting the patient. This was discussed with the DON and QAPI RN present.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the comprehensive assessment was not completed. For example, in records RRNHV#1 and RRNHV#6 there was no documentation of the patient's and family spiritual needs. This was confirmed with the DON and QAPI RN present.

Observed in Record Review. In 4 of 7 patient records reviewed, that included hospice aide services it was noted that the registered nurse did not supervise the hospice aide. For example, in records RRHV#1, RRHV#3, RRNHV#3, and RRNHV#5 it was noted that the supervisory visits were not documented no less frequently than every 14 days; RRHV#1 had 17 day gaps (3 days late), RRHV#3 and RRNHV#5 had 15 day gaps (1 day late), and RRNHV#3 had 16 day gaps (2 days late). Also, records RRHV#1, RRHV#3 and RRNHV#3 the supervising nurse did not recognize inconsistencies with the aide documentation, for example in record RRHV#3 the aide documentation not being completed for over 5 weeks. This was discussed with the DON and QAPI RN present.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that there was no documented orientation. For example, in the volunteer's file there was no documentation of orientation to the agency's policy and procedures or their specific job duties. This was confirmed with the DON present.

Observed in HR File Review. In 3 of 9 HR files reviewed, it was noted that skills and competence were not completed annually as required by the organization's policy. For example, in HR record's for the volunteer and the social worker there were no documented annual competencies after the initial competency. In the spiritual counselor/bereavement coordinator's file there was no documentation of competencies for his bereavement coordinator role. This was confirmed with the DON present.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that there was incomplete documentation. For example, in record RRHV#1 the nurse had documented the foley catheter change Change FC done., noted draining to yellow, colored urine, no s/s of infection. with no indication of the removal of old catheter and no indication of the type, catheter size, balloon size and amount the balloon was filled. Also, in RRHV#1 the bereavement assessment was incomplete, the bereaved was not identified. In record RRHV#2 the nurse had documented the wound care Wound treatment provided on pt's left occipito-parietal wound with no description of the wound or care provided. In the same record the nurse also documented it was noted that pt`s resolved sacrococcyx wound has reopened. MD was notified and obtained new order for wound treatment. Wound care was provided on new wound with no further description such as size of the wound and no documentation of the wound care ordered or provided. Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that there was no documentation of aide visits in clinical record RRHV#3 for the previous 5 weeks. The organization's policy required notes to be in the record by 5pm the Monday following the visit. This was confirmed with the DON present.