Every finding on record at Sarah Bush Lincoln Health Center

Observed in Record Review. The organization had not included volunteer staff in its emergency management training. In 2 of 2 volunteer records reviewed, the organization had not documented emergency management training consistent with their roles and responsibilities in an emergency. This finding was discussed with the volunteer coordinator.

Observed in Record Review. In 12 of 14 active patient records reviewed, .it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. Upon review of the records, multiple PRN pain medication ordered to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example, in HOSRRHV#1 Morphine concentrate 20 mg/ml 0.25 ml PO as needed every 2 hours for pain; Norco 5-325 mg 1 tablet PO as needed every 4 hours for pain. Also noted in record HOSRRHV#2 Acetaminophen 325 mg 2 tablets PO every 6 hours for pain ; Tramadol 50 mg 1 tablet PO PRN every 6 hours for breakthrough pain. In addition, oxygen was ordered to be administered at 2 LPM via NC, however, it did not specify if it is for PRN or continuous. HHRRHV#3, Morphine Sulphate 20 mg/ml 0.25 ml PRN every 2 hours for pain and Norco 5 mg-325 mg tablet oral 1-2 tablet PRN every 4 hours for pain. HOSRRNHV#1; Acetaminophen 325 mg 2 tablet PRN every 4 hours for pain; Morphine Concentrate 20mg/dl 0.25 ml every 2 hours PRN for pain. HOSRRNHV#2- Acetaminophen 500 mg 2 capsule PRN every 6 hours PRN Morphine Concentrate 20mg/ml 0.25 ml every 2 hours PRN for pain; HOSRRNHV#3- Acetaminophen 325 mg 2 tablet PRN every 4 hours for pain; Morphine Concentrate 20mg/dl 0.25 ml every 2 hours PRN for pain. HOSRRNHV#4- Acetaminophen 325 mg 2 tablet PRN every 4 hours for pain; Morphine Concentrate 20mg/dl 0.25 ml every 2 hours PRN for pain. HOSRRNHV#6 - Morphine Concentrate 20 mg/ml oral PRN every 2 hours for pain Lidocaine 4% topical patch PRN every 12 hours for mild pain. HOSRRNHV#7- morphine concentrate 20 mg/ml 0ral 0.25 ml- 1ml every 2 hours PRN for pain , Tylenol 325 mg every 4 hour PRN for pain. HOSRRNHV#8-Morphine Concentrate Tramadol 50 mg 1 tablet PO PRN every 6 hours for pain, Hydrocodone 10 mg-Acetaminophen 325 mg 1 tablet PRN every 4 hours for pain. Lastly, HOSRRNHV#9 - Tylenol 325 mg 2 tab PRN every 4 hours for mild pain, Morphine Concentrate 20 mg/ml oral PRN every 2 hours for pain. This finding was discussed and validated by the hospice Director.

Observed in Record Review. In 1 of 4 bereavement records reviewed, the organization was not able to validate that bereavement services were offered and provided to or declined by the bereaved. This was evidenced by the lack of a bereavement care plan. This finding was discussed with hospice leadership.

Observed in Record Review. In 9 of 9 active patient records with hospice aide services, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HOSRRHV#1, HOSRRHV#3,HOSRRHV#4, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#8, Aide was assigned to monitor pulse, respiration, and blood pressure on every visit. However, the hospice aide care plan did not include written instructions specifying when the aide should report abnormal vital sign readings to the RN based on established parameters. Lastly, HOSRRNHV#9, patient was placed on oxygen continuously. Upon review of the aide care plan, the box where it says may remove oxygen while having personal care, was not marked off. This finding was discussed and validated by the hospice Director.

Observed in Record Review. In 3 of 9 active patient records reviewed with hospice aide services, it was noted the organization failed to provide services that are included in the plan of care. For example, in review of record HOSRRNHV#1, the Aide failed to provide incontinence care and toilet assist as instructed in the POC. No explanation or reason documented in the clinical record. Another example in HOSRRNHV#3, the hospice aide did not perform respiration and pulse. No explanation was documented. HOSRRNHV#8, Aide did not provide nail cleaning and filing as per aide care plan. No explanation documented. This finding was discussed and validated by the Hospice Director.This finding was discussed and validated by the hospice Director.

Observed in Record Review. In 1 of 2 live discharge records reviewed, it was noted the organization failed to ensure that the hospice agency provides the patient’s attending physician with a copy of the hospice discharge summary. For example, upon review of record HOSRRDC#1, the patient had been discharged from hospice services due to extended prognosis; however, there was no evidence documented that hospice discharge summary was sent to the physician. This finding was discussed and validated by the Clinical Supervisor.

Observed in Patient Home. In 1 of 3 patients with home oxygen therapy, it was noted the organization failed to ensure that the patient/family member receives instruction in the safe use of durable medical equipment and supplies. For example during home visit conducted (HOSRRHV#4) multiple oxygen tanks stored in closet with empty boxes, 2 folded wheelchairs and 1 pillow on top of the cylinders. The clinical staff was informed of the issue; however, the nurse did not take any action , such as reinforce education/teaching, by the staff. This finding was discussed and validated by the Clinical Supervisor who was present during the visit.

Observed in Document Review. During document review it was determined that annual fire door inspections had not been performed as required. This was verified by the maintenance team during document review.

Observed in Document Review. During review of documents including the admission packet for hospice both in office and in patient home visits it was noted that the organization had not informed the patient of and provided the patient with written information about its policies on advance directives, including a description of any state law concerning advance directives. This was confirmed with the hospice manager

Observed in Record Review. In 7 of 13 patient records reviewed, it was noted that there was no documentation of a bereavement risk assessment for record reviews of home visit #1 and #3 and record review #1, #5, #2, #3, #4, #8, #9 and #10. This was confirmed by the hospice manager.

Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that for the hospice records reviewed the goals on the plan of care were not individualized, measurable and not all were timed. For example, the following goals were noted in record review for home visit #1, maintain urinary function without complications within limits of disease process and caregiver verbalized understanding of skin breakdown prevention measures. In record review for home visit #2 the following goals were noted, maintain adequate airway and respiratory function within limits of the disease process and identify feelings of spiritual support. Pt. seizure activity is controlled within limits of disease process. In record review #1 there was no goal for respiratory issues. In record review #3 there were no goals for the following issues identified, Medication Management, Genitourinary issues and foley management and Musculoskeletal issues. In record review for home visit #1 there was no goal for the problem of agitation/anxiety. In record review #5 there was no goal for identified sleep issues. In record review #7 there was no goal for nausea/vomiting and Gastrointestinal issues. This was confirmed by the hospice manager.

Observed in Record Review. In 4 of 13 patient records reviewed, it was noted that the plan of care in record review for home visit #2 did not identify the balloon size for the foley catheter. In record review for home visit #3 it was noted that there was no frequency ordered for Inventys eye drops. The order simply stated as needed. In another example, in record review #5 the nurse documented that the patient was taking Aspirin for pain however there was no order on the plan of care for this medication. In record review #6 the nurse documented that the patient was taking Zyprexa however there was no order on the plan of care for this medication. This was confirmed by the hospice manager.

Observed in Record Review. In 4 of 13 patient records reviewed, it was noted that the hospice plan of care was not updated or revised. For example, in record review #1 it was noted that the care plan was not revised when the patient developed a new infection and was placed on antibiotics. In record review #3 the plan of care was not revised to include a new issue of rash and new medication Benadryl or a new cough and development of wheezing. In record review #5 it was noted that the plan of care was not revised to reflect a new upper respiratory infection and sore throat for which the patient was placed on antibiotics. In record review #8 it was noted that the patient developed dizziness and was started on Meclizine however this problem and intervention were not added to the plan of care as a revision. This was confirmed with the hospice manager.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted in review of hospice record review #1 that the patient developed an infection and was treated with an antibiotic however no surveillance data/infection report had been documented. This was confirmed by the hospice manager.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted in review of record for home visit #3 that the aide plan of care listed turn and reposition, reposition for comfort, shower, bed bath, emptying bedpan. The plan of care was not specific for the needs of the patient as she was noted to be fully ambulatory during the home visit and was assessed upon admission as fully functional by the RN.

Observed in Record Review. In 4 of 4 patient records reviewed, with hospice aide services provided it was noted that the aide care plan stated that vital signs including temperature were to be taken however in home visit #1 the aide was observed not taking a temperature. Discussion with the hospice manager indicated that temperatures were not taken and thermometers were not provided either to the employee or the patient. This was observed in record review #2, #3, and record review for home visit #1 and #3.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.100

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the medication list for the ALF did not match the hospice medication list. For example, Aspercreme with Lidocaine lotion was used by the patient but not on the hospice list. Inveltys eye drops were on the list but not in the home or on the ALF medication list, the ALF medication listed Prednisolone eye drops but these were not on the hospice list. Lastly, the hospice list had Tylenol Arthritis listed but was not being taken nor was it on the ALF medication list. This was observed by the hospice manager present on the visit.

Observed in Document Review. in review of the contract for the Skilled Nursing Facility it was noted that the contract did not contain a provision that the hospice may use the SNF, NF, or ICF/IID nursing staff when permitted by state law and only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care. This was discussed with the hospice manager.

Observed in Document Review. in review of contract for Skilled Nursing Facility it was noted that there was no stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the hospice manager.