Every finding on record at Scott & White Memorial Hospital

Observed in Record Review. In 1 of 20 patient records reviewed, the hospice did not conduct and document a patient-specific comprehensive assessment and reassessment including all areas of hospice care related to the palliation and management of the terminal illness and related conditions. In RRNHV#9, it was noted the patient was treated with oral antibiotics for an infected laceration to the lower extremity. There was no assessments of the laceration/wound performed and documented by the registered nurse per organizational standards/policy. This was reviewed and verified with the Hospice Manager.

Observed in Record Review. In 2 of 20 patient records reviewed, the written plan of care was not based on the patient's goals and the timeframes, settings, and services required to meet those goals. In RRHV#1, the patient was admitted to hospice general in-patient care for pain/symptom management with an assessed pain rating of 5. The plan of care goals did not include the patient's pain goal(s) and the timeframe to meet the goal(s). In RRHV#2, the goal for the patient's anxiety/agitation was documented as: Patient's anxiety/agitation will be treated throughout hospice care. This plan of care goal was not patient-specific, with no short/long-term timeframe(s) noted. This was reveiwed and verified with the Hospice Manager.

Observed in Record Review. In 3 of 20 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. In RRHV#4 and RRNHV#2, the most recent Certificate of Terminal Illness (CTI) documented by the hospice medical director indicated the patient had difficulty swallowing. The swallowing difficulties and related precautions were not included on the patient's plan of care. In RRNHV#4, the RN assessed the patient had difficulty swallowing at the initial assessment, but this was not included in the hospice plan of care. This was reveiwed and verified with the Hospice Manager.

Observed in Record Review. In 6 of 20 patient records reviewed, the plan of care did not include 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. In RRHV#4, the patient's plan of care included medication orders for Ondansetron and Prochlorperazine as needed for nausea with no clear indications for use (which prn medication to take when). The plan of care also included prn orders for Lorazepam 0.5mg tablet, Lorazepam 2 mg/ml concentrate, and Lorazepam topical for anxiety/agitation with no clear indications for use. In RRNHV#2, the plan of care included prn Lorazepam oral tablets and Lorazepam topical for anxiety/agitation with no clear indications for use. RRNHV#3, the patient's plan of care included multiple prn pain medication orders, including two (2) orders for Dilaudid (tablets and solution), Acetaminophen, and Norco with no clear indications for use. In RRNHV#4, the plan of care included three (3) orders for Lorazepam (SL tablet, tablet, and concentrated solution) with no clear indications for use. In RRNHV#5, prn pain medication orders for Tylenol oral tablet, Tylenol Suppository, Ibuprofen, and Morphine Sulfate concentrated solution were included in the patient's plan of care with no clear indications for use. In RRNHV#8, the plan of care included prn orders for Dilaudid liquid and tablets with no clear indications for use. The patient's order for Methadone (2.5mg by mouth twice a day and 5 mg once a day) was also noted to be incomplete/unclear. This was reveiwed and verified with the Hospice Clinical Manager.

Observed in Record Review. In 5 of 15 patient records reviewed, the registered nurse responsible for hospice aide supervision did not prepare written patient care instructions for the hospice aide. In RRNHV#2, RRNHV#6, RRNHV#7, RRNHV#8, and RRNHV#9, the patient was on home oxygen. The aide plan of care did not provide instructions as to whether the oxygen could be removed for the bath and personal care/services provided by the hospice aide. This was reviewed and verified with the Hospice Manager.

Observed in Record Review. In 5 of 15 patient records reviewed, the hospice aide did not provide services that were ordered in the plan of care. In RRHV#2, the aide plan of care included a shampoo and oral care to be provided every visit. It was noted in the most recent aide visit note that the shampoo and oral care were not marked as completed on the aide visit note, with no documented explanation as to why these tasks were not performed by the aide. In RRNHV#3, the hospice aide did not complete assigned tasks on the aide plan of care including changing bed linens, assist with toileting, and shaving. The aide also documented the patient's face and hands were washed during the visit, but the care plan indicated a shower was to be provided. In RRNHV#7 the aide did not change bed linens, assist with oral care, and assist with shampoo as outlined on the hospice aide plan of care. In RRNHV#8, the hospice aide documented on the visit report that the patient was transported to the bathroom per wheelchair and a shower was provided. The aide care plan indicated the patient was to be receive a bed bath. RRNHV#13, the hospice aide did not perform/document tasks included in the aide plan of care, including apply lotion, change adult brief, clean perineal area, assist with transfers using walker, and assist with repositioning. This was reveiwed and verified with the Hospice Manager.

Observed in Record Review. In 2 of 3 patient records reviewed, the hospice discharge summary did not include a summary of the patient's treatments, symptoms, and pain management. In RRDC#2 and RRDC#3, it was noted in the patient's discharge summary that the section for the summary of hospice care/services was not completed. This was reveiwed and verified with the Hospice Manager.

Observed in Patient Home. In 1 of 6 home visits conducted, the organization did not provide education and training based on each patient's needs and abilities, including procedures to follow if care, treatment, or services were disrupted by a disaster or an emergency. In RRHV#2, the patient was cared for by 24/7 caregivers in the home, with no family in the area. It was noted the individual evacuation plan in the home folder was incomplete and did not outline a plan for evacuating the bedbound patient in the event of a emergency/disaster. This was reveiwed and verified with the Hospice Manager.