Every finding on record at St. Elizabeth Hospice Care, Inc.

Observed in Record Review. In 4 of 12 patient records reviewed, the Surveyor noted an RN had not visited the hospice patient every 15 days to conduct a comprehensive assessment. In RRNHV#4, the patient had the DOPCS Nurse Practitioner (NP) visiting the patient but only to complete the Hospice Aide supervisory visits. The NP had documented the supervisory note only, and had not documented any comprehensive assessment elements. All other patient visits had been completed by the LVN using a 'short' form and did not include a full patient assessment. The patient had been on service for 84 days. In RRBR#2, the patient had been on service for 52 days without a nursing comprehensive visit documented. The LVN completed 'short' visit notes and the NP documented HA supervisory visits only. In RRDC#1 There had been no RN comprehensive visits documented in the 36 days patient was on service. In RRDC#2, there had been no RN comprehensive visits in the 83 days patient had been on service. This was validated with the Administrator and DOPCS.

Observed in Record Review. In 3 of 12 patient records reviewed, the Surveyor noted orders for wound care and or medications had been incomplete. For example, in RRNHV#4, the patient had Hydrocodone Bitartrate/Acetaminophen 5mg-325mg Tablet and Acetaminophen 325mg both ordered every 6 hours as needed for pain. In RRHV#2, the patient had wound care being provided to right heel. The order had been missing what the wound was to be cleansed with and the type of wrap to secure it. In RRNHV#5, the patient had Clotrimazole/Betamethasone Dipropionate 1%-0.05% Topical Cream ordered to apply to affected area. This was validated with the DOPCS. Observed in Record Review. In 2 of 12 patient records reviewed, the Surveyor noted not all patient identified care needs had been included on the plan of care (POC). For example, in RRHV#2, the patient had been bedbound and a high risk for skin breakdown; however this had not been included on the POC. In RRHV#3, the patient had been a high falls risk and at risk for skin breakdown, but these had not been on the POC. This was validated with the DOPCS. Observed in Record Review. In 1 of 12 patient records reviewed, the Surveyor noted a patient with visits but there had been no orders for the visits. For example, in RRBR#1, the patient had a Hospice Aide care plan written and the HA had made visits to the patient; however there had been no frequency orders present in the patient record. This was validated with the DOPCS. Observed in Record Review. In 1 of 12 patient records reviewed, the Surveyor noted the plan of care (POC) had not been updated as the patient condition had changed. For example, in RRHV#2, the patient had a documented UTI and started on antibiotics; however, this had not been discussed at IDG and added to the POC with prevention interventions. This was validated with the DOPCS.

Observed in Record Review. In 3 of 12 patient records reviewed, the Surveyor noted care not provided according to the patient plan of care (POC). For example, in RRHV#3, the patient had orders for nursing visits 2 times per week; however, there had only been 1 visits per week documented over the past 9 weeks. In RRNHV#4, the POC had orders for an RN to visit 2 times per week; however, there had not been an RN visit documented during the patients time on service from March. All visits made had been completed by the LVN. In RRNHV#5, there had been no visit documented by the LVN or RN in the 2nd week of February even though visits had been ordered. This was validated with the DOPCS.

Observed in Tracer Activities. The Surveyor had been unable to validate that recruitment activities had been completed as this information had not been available during the survey. The Administrator reports that he had completed recruitment, but could not locate the documentation.

Observed in Record Review. In 8 of 9 patient records reviewed, The surveyor noted no recorded patient education related to death and dying nor the use of comfort medications to alleviate symptoms associated with death and dying. The organization was also not following their police named 'End of Life Care' which states: Provides education and instruction to the family or other caregivers in preparation for the patient’s death, including: what to expect regarding physical and/or symptom changes. Review of the patient’s advance directives and wishes, including any related state or local requirements. What will happen after the patient dies, including the process for following the patients wishes regarding organ or body donation'. For example, during HV RR #1 the patient was actively dying, there was no documentation that the family had been educated on what to expect during the dying process and the patient had been started on comfort medications Morphine and Atropine, but no documentation related to the care giver education on the use of the medications and indications for use. This was found in each record reviewed except for RR #8 where the patient revoked hospice. This was validated with the Nursing Director and the Administrator.

Observed in Record Review. In 2 of 9 patient records reviewed, the Surveyor noted that the patients had a Hospice Aide (HA) providing care to the patient 2 times per week; however, there had been no frequency orders for ongoing services nor a signed physician order. This had been identified in in HV #2 RR and RR #5. This was validated with the Administrator.

Observed in Record Review. In 6 of 9 patient records reviewed, the medication orders had not specified the indications for use of 'as needed' medications. For example, HV RR #1, HV RR #2, RR #4, RR #6, and RR #9 the patients had Morphine Sulfate 20mg/ml ordered for pain management as a 2nd medication without assessment administration parameters (i.e. for severe pain 5 -10 out of 10). RR #7, patient had Norco ordered as needed for pain and no indications for use. HV RR #2 and RR #9, the patients had multiple different as needed medications for use for constipation (Bisacodyl, Colace, fleets enema, MOM); however, there were no orders for which to use first, second, nor what was considered constipation for the patient. This was validated with the Administrator and the Director of Patient Care Services Observed in Record Review. In 5 of 9 patient records reviewed, the surveyor noted that the patients had been experiencing significant pain, anxiety and/or agitation during death and dying; however, there had been no interventions to meet the patient needs to achieve comfort. For example: during HV RR #1 the patient was observed to be experiencing pain with any touch and movement, and was holding herself rigid, but there was no medication ordered to treat this symptom. This was also noted in RR #4 where the patient had been experiencing anxiety and increased shortness of breath. The prescribed Morphine had not met the needs of the patient as the patient continued to experience pain and anxiety without relief. RR #6, the patient had 4-6/10 agitation and severe pain at 8/10 and the prescribed treatment and medication did not provide patient relief as the patient continued to experience the symptoms. This was validated with the Nursing Director.

Observed in Patient Home. In 2 of 2 home visits conducted, The organization had not implemented infection prevention and control activities to reduce the transmission of infection between patients according to the agency policy and CDC guidelines. The LVN providing patient care was observed to set equipment and note taking materials down in the patient area and then without disinfection, take them to another patient room, as well as the nursing station and medication room. The LVN was also observed going into a patient room to provide care without observing isolation precautions in place, set patient care materials down on bedside table, and then did not disinfect the supplies after use and prior to placing back in his nursing bag, and transporting them to other areas of the Skilled facility. This was validated with the Director of Patient Care Services present during the visit. Observed in Patient Home. In 2 of 2 home visits conducted, The organization had not implemented infection prevention and control activities according to their policy: Hand Hygiene Policy and Compliance Program, which states: hands will be disinfected after any contact with contaminated materials, before re-entering nursing bag or patient's clean supplies and between glove changes. During HV #1 and HV #2, The LVN was observed donning gloves without first disinfecting his hands, and then touching the patient, going in and out of his nursing bag and touching contaminated materials without changing gloves nor disinfecting his hands. Of note, the patient seen for HV #2 was on isolation for 'Droplet Precautions'. This was validated with the Director of Patient Care Services present during the visit.