Every finding on record at Seasons Hospice & Palliative Care of Ca-San Bernardino LLC

Observed in Patient Home. In 4 of 4 home visits conducted, the organization did not ensure that the patient was involved in making decisions about their care, treatment, or services. At every visit there was a copy of the plan of care in the patient's folder, however none were current. At home visits RRHV#1, RRHV#2, and RRHV#3 plans of care had not been current since the interdisciplinary meeting 10 weeks ago. And at home visit RRHV#4 the plan of care was created in the first interdisciplinary meeting five weeks prior to this survey. Protocol 2076a entitled Home Chart requires that a current plan of care be provided to the patient after each interdisciplinary meeting. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 13 of 14 active patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. For example, in records RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, and RRNHV#10 the interdisciplinary group did not document patient decline, progress towards desired outcomes and goals, and plans for the next two weeks in meeting notes. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 14 of 14 active patient records reviewed, the organization did not ensure that the plan of care included measurable goals. In all records the goals were generic. For example: Patient will have safety needs met; anxiety/agitation will be minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment; patent will exhibit reduction/relief of any cardiopulmonary symptoms; patient will verbalize effects of pain medication on bowel function; pain will be managed at a level acceptable to the patient. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 3 of 14 active patient records reviewed, the organization did not ensure that the plan of care included interventions to manage pain and symptoms. For example, in record RRHV#3 a nurse documented in the initial comprehensive assessment and a visit note that the patient was having black, tarry stools. In record RRNHV#1 a nurse documented that the patient was taking an anti-coagulant drug. In record RRNHV#4 a nurse documented that the patient was experiencing significant pain and nausea after eating. These assessed risks and problems were not addressed in the plans of care. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 1 of 14 active patient records reviewed, the organization did not ensure that the plan of care included medications to meet the patient’s needs. In the record of RRNHV#7 Cipro 500 mg twice a day for seven days was noted on the medication list, however there was no order documented for the antibiotic in the plan of care. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 2 of 14 active patient records reviewed, the organization did not ensure that the scope and frequency of services identified in the plan of care were provided as ordered. In the record of RRHV#3 the social work visit frequency was once a month, but there were no visits documented in two of three months prior to this survey. In the record of RRNHV#6 the social work frequency was also once a month, but the visit documented two months prior to this survey was done by telephone. Spiritual counseling visits were also ordered once a month, but none had been documented in the two months prior to this survey. And in record RRNHV#7 the initial psychosocial assessment was completed virtually. This RFI was reviewed with the Executive Director and Director of Clinical Services. Observed in Patient Home. In 1 of 1 home visits where medications were reconciled, the organization did not ensure that treatment was provided according to the plan of care. At home visit RRHV#2 the caregiver stated that the patient “ran out” of Acetaminophen 500 mg, Claritin 10 mg and Hydrocodone 10mg/Acetaminophen 325 mg. These medications were all scheduled to be given once a day. As well, Hyoscyamine 0.125 mg Disintegrating Tablets were to be given every four hours but none were available. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Competency Session. In 1 of 12 HR files reviewed, the organization did not ensure that staff competence was assessed as required by policy. In personnel file HR#11 for a patient volunteer, hand hygiene competence was not assessed annually as required by Hand Hygiene Protocol 4003. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Record Review. In 2 of 3 bereavement records reviewed, the organization did not ensure that documentation in patient records contained information required by organization policy, in accordance with law and regulation. In records RRBR#2 and RRBR#3 LVNs made visits when these patients died but failed to document in the record that the Medical Director was contacted to pronounce the deaths. The Director of Clinical Services was able to validate with the Medical Director that she was contacted by the LVNs to pronounce the deaths. This RFI was reviewed with the Executive Director and Director of Clinical Services.

Observed in Patient Home. In 1 of 4 home visits conducted where oxygen was present, the organization did not reinforce education on the correct storage of medical gases. For example, during home visit RRHV#2 it was observed that four of five full M-24 oxygen cylinders were standing unsecured against a wall next to the patient's bed. The registered nurse did not re-instruct the caregiver on how to safely store cylinders not secured in a holder, nor take action to mitigate risk. This RFI was reviewed with the Executive Director and Director of Clinical Services.