Every finding on record at Scott & White Memorial Hospital

Observed in Individual Tracer. In review of 4 of 4 individual tracers, it was noted that the organization did not ensure that plan of care goals include outcome measures for specific care activities. For example, during a review of the medical record for RRHV#1, the following problem statement was identified: “Dying Process”. The plan of care did not include a goal statement to evaluate interventions related to care, treatment and services of the problem “Dying Process”. In addition, the following goal statement(s) were noted: “Patient will remain as independent as possible and/or remain safe in their environment” and “Patient’s anxiety/agitation will be treated throughout hospice care”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for RRHV#2, the following problem statement(s) were identified: “Dying Process” and “Altered Nutrition”. The plan of care did not include a goal statement to evaluate interventions related to care, treatment, and services of the problems “Dying Process” and “Altered Nutrition”. In addition, the following goal statement was noted: “Patient’s anxiety/agitation will be treated throughout hospice care”. 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 RRHV#3, the following problem statement was identified: “Altered Nutrition”. The plan of care did not include a goal statement to evaluate interventions related to care, treatment, and services of the problem “Altered Nutrition”. In addition, the following goal statement were noted: “Patient’s anxiety/agitation will be treated throughout hospice care”. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #4: During a review of the medical record for RRHV#4, the following problem statement(s) were identified: “Dying Process” and “Altered Nutrition”. The plan of care did not include a goal statement to evaluate interventions related to care, treatment, and services of the problems “Dying Process” and “Altered Nutrition”. In addition, the following goal statement(s) were noted: “Patient will remain as independent as possible and/or remain safe in their environment” and “Patient’s anxiety/agitation will be treated throughout hospice care”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with agency leadership.

Observed in Individual Tracer. In 3 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RRHV#1, it was noted that the patient experienced a fall during week 7 of hospice services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example #2: During week 8 of services for RRHV#2, the clinician documented a change in condition related to the patient’s cardiovascular status. The documentation described the following: “Fatigues easily, palpitation, hypertension and 2 plus bilateral lower extremity edema. New medication treatment started: Lasix 40mg, take 1 tablet daily. The plan of care was not updated with a problem related to cardiovascular status and a goal statement to measure the effectiveness of problem interventions. Example #3: During week 3 of the present hospice benefit period for RRHV#4, the clinician documented an exacerbation of the patient's nausea and vomiting symptoms. Patient experienced difficulty swallowing, and inability to retain food after eating. New medication treatment started: Lorazepam 1mg, diphenhydramine 25mg haloperidol 1mg gel - apply 1 {packet} application topically every 6 hours as needed for nausea/vomiting. The plan of care problem Altered Nutrition was not updated with interventions to address the change in the patient's condition. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the organization did not ensure the requirement to maintain accurate patient medication information was implemented. For example, a review of the medical record for RRHV#1, revealed that the first update to the plan of care [2nd benefit period] included documentation by the Registered Nurse that the patient was currently taking “Ex-lax”. The current medication list did not include “Ex-lax”. This observation was reviewed with agency leadership.

Observed in Record Review. A review of 1 of 17 patient records revealed that the organization did not ensure that care, treatment, or services were provided in accordance with the plan of care. For example, during a review of the medical record for RRBR#2, it was noted that the bereavement plan of care included an intervention for a 2 month contact call. There was no documentation that this contact call was completed. This observation was reviewed with agency leadership.

Observed in HR File Review. In 2 of 8 Human Resource files reviewed, it was noted that competence was not initially assessed and documented as a part of orientation for the Chaplain and Volunteer Coordinator. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, for patients discharged or transferred from the organization, it was noted that the discharge summary did not include all required information. For example, a review of the medical record for RRDC#1, revealed that the discharge summary did not include a summary of care, treatment, and services provided during the course of the patients stay with the agency. The discharge summary did not include a description of the patient's progress towards goals. Example #2: A review of the medical record for RRDC#2, revealed that the discharge summary did not include discharge instructions. The discharge summary did not include a summary of care, treatment, and services provided during the course of the patients stay with the agency. The discharge summary did not include a description of the patient's progress towards goals. This observation was reviewed with the agency leadership.