Every finding on record at Sheldon Hospice

Observed in Record Review. In 3 of 3 patient records reviewed, for all active records, the nurse surveyor noted that the goals were not measurable or individualized. For example, “Patient will verbalize having urinary elimination at an acceptable level and maintain blood sugar levels within target.There were no short-term goals at the start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety. Finding was verified by the Administrator and the DPCS (Director of Patient Care Services).

Observed in Record Review. In 3 of 3 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies for the skilled nurse, medical social worker, and spiritual counselor did not have a reason for when to make the as needed PRN visits (they were not qualified). For RRHV#1, RRHV#2, RRHV#3, all PRN visit frequencies were quantified for a number of how many visits could be made, but not for the reason in which the visits would be made.. Finding was verified by the Administrator and DPCS (Director of Patient Care Services).

Observed in Record Review. In 2 of 5 patient records reviewed, The HCO did not ensure the initial spiritual care assessment was completed within five days of the patient electing the hospice benefit. For example, the surveyor noted on patient HV #2/RR #2, and HV #3/RR #3, it was documented the patient/family refused spiritual care services; however, there was no documentation that initial spiritual care assessments were completed as a part of the initial comprehensive assessment. Standards require a comprehensive assessment, including psychosocial and spiritual care be completed within five days of a patient electing hospice care. These findings were reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 5 of 5 patient records reviewed, The HCO did not ensure patient care plan goals were attainable, measurable, realistic, and appropriately timed. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, HV #3/RR 3, RR #4, and RR #5, the patient’s care plan goals included statements such as: “Pt will have no hypo/glycemic episodes within 30 days, Patient/PCG will be able to verbalize/demonstrate safety during syncopial episodes within 2 weeks. Patient's oxygen saturation on room air will remain >90% during care. Patient will bilateral lower ext edema will decrease to <+1 within 4 weeks. Patient and wife will verbalize/demonstrate ways to reduce presence of BM within 1 week. CNA notes not signed by pt/pcg. Patient will be able to effectively communicate with her family and staff within 1 week, Pt's daughter will be able to identify signs of developing pressure ulcers, be able to demonstrate safe positioning in bend and recliner and be able to demonstrate proper hygiene within 2 weeks. Pt will be able to identify and express feelings appropriately within 2 weeks, patient's oxygen saturation on oxygen will remain >90% within 30 days. CNA notes not signed by Pt/CG.” These stated goals are not realistic, and do not contain information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Tracer Activities. The organization failed to ensure there was 24-hour service availability during afterhours. For example, on February 21, 2023, the surveyor made several telephone calls to the organization prior to 9:00 a.m. There was no answer and no response to the request for a return call. Standards require the hospice organization make covered services available 24-hours a day, to meet the needs of the patient and family. The findings were discussed and acknowledged by the Administrator/DCPS designee.