Every finding on record at Serenity and Grace Hospice Care, LLC

Observed in Record Review. In 4 of 10 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 necessary to meet the patient’s needs. Upon review of the records, several PRN pain medication ordered to be given for pain without specifying which PRN medication should be administered based on defined parameters. For example, in RRNHV#1: Oxycodone -Acetaminophen 5mg-325 mg 1 tablet PO every 8 hours as needed for pain; Ibuprofen 200 mg 1-2 tablet PO every 4-6 hours as needed daily for pain; Salonpas 3.1%-6% topical patch 1 patch to affected areas 1-4 times daily a needed for pain. In record RRNHV#4: :Ibuprofen 200 mg 2 tablets every 406 hours for pain; Acetaminophen 500 mg 2 tablets every 6-8 hours for pain/fever; Oxycodone 10 mg 1 tablet every 4-6 hours PRN for pain. In record RRNHV#5: Lidocaine pain relief 4% topical patch to affected area as needed for pain; Motrin IB 200 mg 1 caplet by mouth every 4-6 hours as needed for pain; Hydrocodone 10 mg-Acetaminophen 325 mg 1 tablet every 4-6 hours for pain; Tylenol Arthritic pain 650 mg tablet extended release 2 caplets by mouth every 8 hours as needed for pain. In RRNHV#6: Ibuprofen200 mg 2 tablets every 4-6 hours as needed for pain or fever; Acetaminophen 500 mg 2 tablets evry 6-8 hours as needed for pain/fever. This finding was discussed and validated by the agency leadership team.

Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted the organization failed to ensure that the care are provided in accordance with the plan of care. For example, during home visit (RRHV#2) conducted, the hospice nurse (LVN) had performed wound care treatment on the sacral area and right lower extremity. According to the hospice plan of care, the nurse was instructed to apply zinc oxide cream, However, the LVN did not carry out this treatment. This finding was discussed and validated by the agency leadership team.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted the organization had failed to follow its organization policy, INPT.13 Hand Hygiene and accepted standards of practice to prevent the transmission of infection and communicable diseases, including the use of standard precautions. For example, at home visit RRHV#1:the registered nurse (RN) was observed wearing double gloves while removing the old dressing from the left lower leg. The dressing was soaked with drainage from a weeping wound and had a scant amount of blood. The nurse did not change gloves before proceeding with wound care on the same leg. A few minutes later, the nurse removed the gloves without sanitizing hands, attempted to dry sweaty hands by blowing air from her mouth and waving them in front of an electric fan, then proceeded to perform wound care on the right lower leg. Also observe in RRHV#2:, the LVN did not sanitize hands before accessing the nursing bag and immediately donned gloves to remove the old dressing from the sacral area. After completing wound care, the nurse removed the gloves, put on a new pair without hand sanitizing, and proceeded to perform wound care on the right lower extremity as ordered. This finding was discussed and validated by the agency leadership team.

Observed in Record Review. In 5 of 6 active patient records with hospice aide services, it was noted the organization 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. Based on a review of records and hospice aide care plan, it was noted that some patients were on anticoagulant medications such as Plavix or Eliquis, or a patient receiving continuous oxygen therapy, or aide to check vital signs and pulse oximetry. However, no specific additional instructions were provided by the RN for the hospice aide to follow. For example, RRNHV#6, hospice aide was checking vital signs (T,P,R,BP) and pulse oximetry. Similarly in RRHV#2, hospice aide assessed vital signs and pulse oximetry, RRHV#3, patient was receiving continuous oxygen. Hospice aide stated at time she would have remove the cannula while undressing and putting on new clothes. RRNHV#5, patient takes anticoagulant medications and no instruction what to report. RRNHV#6, hospice aide was also checking vital signs and pulse oximetry with no defined/specific parameters. This finding was discussed and validated by the agency leadership team.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted the organization had failed to ensure that the patient record contains information pertaining to a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example at home visit RRHV#2, this was identified during medication reconciliation conducted by the nurse at the boarding care facility. The medication bottle was labeled Senna Plus - generic name for Senokot, 50 mg/8.6 mg oral tablet, 1-2 tablets as needed. However, the medication list provided by the agency indicated Dulcolax 50 mg/8.6 mg. The nurse state that the two medications were the same, which is incorrect. This finding was discussed with and validated by the agency leadership team.

Observed in Emergency Management Session. The organization did not train staff for their assigned emergency response roles. During the Emergency Management System tracer, the surveyor learned that the organization did not train staff, volunteers, contracted employees, and the medical director on their specific emergency response roles. This was confirmed during the competence session with one of the executive leaders.

Observed in Record Review. In 11 of 11 patient records reviewed, where the interdisciplinary group had met more than twice, the organization did not update comprehensive assessments based on changes that had occurred since the initial assessment. The surveyor found that notes did not document on-going patient decline, new or revised goals, and updated plans for the next two weeks. This was reviewed with the executive leaders.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that goals established in patients’ plans of care evaluated progress. In every record reviewed it was noted that most goals were generic and did not include measurements to indicate progress or decline. Most did not include completion dates however a few were to be met in two weeks. When those deadlines were not met, the timelines for completion were not revised. This was reviewed with the executive leaders.

Observed in Patient Home. In 1 of 2 home visits conducted, where medications were reconciled, information was inconsistent. At HV#1 the surveyor observed that the medication list directed acetaminophen 650 mgs rectal suppository to be given every four to six hours as needed for an elevated temperature or pain. The frequency specified on the label was every two to four hours. This was reviewed with the executive leaders and the DON.