Every finding on record at St. Joseph?S Hospital of the Hospital Sisters of the Third O

Observed in Individual Tracer. In 1 of 13 Hospice Medical Records reviewed, an Initial bereavement assessment had not been completed. During review of Hospice home visit #1, the patient had not had an Initial Bereavement Risk assessment completed and no available bereavement documentation identified in the patient record. This was validated with the Hospice Director and the Chaplain.

Observed in Record Review. In 6 of 13 patient records reviewed, it was noted that the hospice plan of care was not individualized and did not contain timed or measurable goals. This was noted in record review for hospice home visit #1, with a goal to promote comfort. In record review #2 the goal for the MSW was stated as Pt receives appropriate emotional support with a time frame ending at the certification period. In record review #3 the goal for SN was stated as maintain safe environment with a time frame ending at the certification period. In record review #6 the goals for SN were stated as Edema is decreased or stabilized and Understanding of Medication regime. In another example in record review #1 the patient had significant weight loss however the generic care plan for Nutritional Status was the only problem related to nutrition on the care plan. In review of record #10 it was noted that all goals were to be achieved at the end of the certification period. This was confirmed by and discussed with the Quality Nurse.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the plan of care did not contain a specific frequency and duration. For example, in hospice record review #5 the frequency for MSW was stated as 1-12 visits in 90 days. In another example in hospice record review #1 the MSW frequency was stated as 1-8 visits in 90 days. This was confirmed by and discussed with the Quality Nurse.

Observed in Record Review. In 5 of 13 patient records reviewed, it was noted by the hospice surveyor that the plan of care had not been revised. For example, in record review for hospice visit #2 the SN visit notes described an URI with antibiotic ordered, a pannus rash and other skin irritation, and the development of ascites however none of these issues were added to the plan of care with interventions or goals. Additionally, the Chaplain visits had been declined by the patient however the plan of care was not updated and still reflected the interventions of the Chaplain. In record review #2 the plan of care did not address and issues related to nutrition however SN documentation stated gum issues and loss of appetite and no issues related to skin integrity however the patient had skin issues/rash with three different creams ordered. In another example in record review #1 it was noted that the plan of care had not been updated to include a new wound with staples following a fall, nor were there any interventions or problems or goals related to behavior issues including hallucinations and inappropriate behaviors. In another example, in record review #4 the plan of care was not updated by the MSW when the patient's wife had died and he was experiencing grief. The plan of care goal simply stated, appropriate emotional support. In review of record #10 it was noted that for this patient who was admitted 9 months prior there was no updated issues or problems added to the plan of care. This was confirmed by and discussed with the Quality Nurse. Observed in Record Review. During record review of Hospice patient #1, it was noted that the plan of care, goals and interventions had not been updated with new goals and interventions. The original goals from 2.5 years ago still reflected on the plan of care did not include interventions related to the patients decline in self care, increase in dementia symptoms as well as admission to a skilled nursing facility. This was validated with the Nursing Director assisting with record review.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted by the hospice surveyor in record review for hospice home visit #2 that the orders for oxygen were for 2L/nc as needed however on 4 of 4 SN notes reviewed the nurse documented that oxygen was in use at 3L/nc. In record review #3 it was noted that the massage therapist was ordered weekly however for the first 5 weeks the therapist did not make a visit and although there were missed visits documented there was no reason documented for the missed visits. This was confirmed by and discussed with the Quality Nurse.

Observed in Patient Home. the clinician did not follow the agency policy 'Infection Prevention/Blood-Borne pathogen exposure policy guidelines for disinfection from table 1, CDC guidelines for disinfection and sterilization in healthcare stating 'after handling contaminated or soiled supplies/equipment use antibacterial/antimicrobial soap and water or alcohol based hand sanitizer'. During Hospice Home Visit #1, the clinician was observed to drop a bottle of hand sanitizer from his pocket to the floor, step on it, then pick it up and put it back into his pocket without disinfecting his hands. The policy also stated that 'Non-critical items will include a blood pressure cuff, laptop computer., . [etc.] will be cleaned using a low level disinfectant (alcohol or germicidal wipe). The clinician utilized his phone and watch during patient care, and handled the dropped hand sanitizer bottle without disinfecting the devices after the visit was completed. This was validated with the Intake Nurse onsite observing the visit and the Nursing Director.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted by the hospice surveyor in review of record for hospice home visit #2 that the patient developed an URI however there was no infection report documentation. This was confirmed by and discussed with the Quality Nurse.

Observed in Record Review. In 5 of 13 patient records reviewed, it was noted that in record review #1 and #7 a spiritual assessment was not documented and in record review #1 and #6 an MSW initial evaluation was not documented. While extensive MSW notes from phone calls were documented they did not contain all of the elements required in the MSW initial evaluation assessment. This was discussed with and confirmed by the Quality Nurse. Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that in hospice record review for hospice visit #1 the SN notes state that the patient is taking Acetaminophen for pain however this medication was not on the medication sheet or physician orders. This was confirmed by and discussed with the Quality Nurse.