Every finding on record at St. Luke's Hospital of Duluth

Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to ensure the comprehensive assessment and reassessment identifies the patient's need for hospice care and services. For example: on review of RRHV#1 the documentation noted 2 open wounds on the patient's buttocks yet there were no measurements noted in the clinical documentation as required by policy upon initial discovery and first visit of the calendar week. In RRHV#4 the patient had a stage 4 wound to the coccyx that there was not documentation noted that the wound been fully assessed each week per the policy. RRNHV#11 had wounds with dressing changes and the wound assessment was not documented weekly per organization policy. This observation was reviewed with the Hospice Manager.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to assess potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. On home observation for RRHV#2 the RN was observed to perform a medication reconciliation, yet failed to effectively assess the medications in the patient home, as she reviewed the medication profile and reviewed with high risk medications with the patient, yet did not review the medications in the home nor discuss the medications listed on the profile with the patient. This observation was reviewed with the RN and the Hospice Manager.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect the patient and family goals based on problems identified in the comprehensive assessment that were specific, measurable, and time-bound. In review of RRHV#1 the goals were noted to not be specific, measurable, nor time-bound such as urinary catheter irrigation completed per orders and patient is responding appropriately to current meds. In RRHV#2 a goal was noted to be patient verbalize symptom control of sleep disturbance. In RRHV#3 there were examples such as facility staff is knowledgeable and involved in hospice plan of care for patient and continuity of care is achieved. There were no achieve by dates for the goals. Throughout all records reviewed there was a noted disconnect between the goals established on the plan of care updates and the plan of care report. On the plan of care report all goals have no achieve by dates and were noted to not be specific, individualized, and measurable. In RRHV#4 the goals established on the recent update all had the same achieve by date set for the end of the benefit period. In RRNHV#5 all goals in the update were noted to have an achieve by date of the end of benefit period 1 or 2. The goals that achieve by dates ended at BP1 were continued with and throughout hospice care. In RRNHV#6 an example of updated goal that was non-specific to the patients dyspnea was (pt, sister and niece) will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease by 9/4/23 and throughout episode of care. Another goal was decision has been made to deactivation of pacemaker/internal defibrillator but no achieve by date. In RRNHV#8 an example of a goals was (Pt) will receive assistance with personal care and hygiene and other activities as needed. In RRNHV# 10 all goals on the most recent update were to be achieved by the end of the benefit period. Throughout all records reviewed there was a trend of goals that were non-specific, not measurable and/or appropriately time-bound. These observations were reviewed with the Hospice Manager and Home Care Services Leadership.

Observed in Record Review. In 7 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient had wounds documented and dressing change orders, however there was no skin integrity care plan to guide the care. Further, there was documentation of starting antibiotics in October but the infection was not reflected in the plan of care. There was an order to change the frequency of the suprapubic catheter changes, yet the change was not reflected in the care plan. On Review of RRHV#4 the caregiver noted on home observation of a Volunteer visiting her regularly, but the volunteer was not reflected on the plan of care. On RRNHV#5 the patient was transitioned to GIP level of care for 4 days in September yet the GIP stay was not reflected in the plan of care. In RRNHV#6 there was documentation of a patient fall, yet the fall was not reflected in the plan of care. There was documentation of issues with dyspnea and education on pursed lip breathing but the issue was not specifically reflected in the care plan. In RRNHV#7 there was documentation of a UTI with antibiotics without a care plan to guide the care. Further, there were multiple medication changes for increased pain, wound odor, and constipation yet the changes in patient status were not reflected in the plan of care. RRNHV#8 also had documentation of increased pain requiring increase in morphine and fentanyl, but the change in status was not reflected in the care plan. In RRNHV#13 the patient was evaluated by the Chaplain and orders noted to develop a spiritual plan of care yet no spiritual care plan was noted in the record. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 there was a physicians order that stated suprapubic catheter changes every 3 weeks. The order was incomplete and did not specify a catheter/balloon size. In RRHV#2 an order on the medication profile for oxygen stated O2 2 liters per NC continuously may increase O2 to get sats greater than 90% PRN activity. The order did not give specific instruction on how much to increase the oxygen nor did it specify how often to monitor O2 saturation during activity. During the home observation for RRHV#2 the RN and patient discussed usage of Bipap yet there were no orders for Bipap with settings noted on the clinical record. In review of RRNHV#11 there was an order for wound treatments in September that was incomplete as it did not include the location of the wound. These observations were reviewed with the Hospice Manager.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to ensure the hospice conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services that included patient and family spiritual orientation, including their desire for the involvement of a religious group - Spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. On review of RRHV#1 it was noted there was no spiritual assessment conducted at admission. On the RN initial comprehensive assess under the question was psychosocial/spiritual status assessed the answer no was documented along with not appropriate at the time of evaluation. On review of RRNHV#12 the current update to the POC completed at recert for 3rd BP noted Chaplain to evaluate and develop a plan of care, with a goal that Chaplain will develop a POC however there was no documentation of a Chaplain assessment completed. In RRNHV#14 had similar update to the poc that noted Chaplain to assess and develop a plan of care and no assessment was documented. This observation was reviewed with the Hospice Manager.

Observed in Tracer Activities. During the volunteer program tracer, the Volunteer Coordinator discussed many volunteer recruitment and retainment effort but was unable to show any documentation of the efforts as required per policy. This observation was reviewed with the Volunteer Coordinator, and Hospice Manager.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to ensure staff competence was initially assessed and documented as part of orientation. For example: on review of HR#4 for the VC, there was no documentation that skills and competency was assessed as part of orientation. These observations were reviewed with the HR Team and Hospice Leadership. Observed in HR File Review. In 1 of 8 HR files reviewed, the organization failed to ensure the staff competence was assessed and documented once every three years, or more frequently as required by organization policy. For example: on review of HR#1 for the MSW there was no documentation of competency assessment at least once every three years. This observation was reviewed with the HR team and Home Care Leadership.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the patient record contains information that reflects the patient's care, treatment, or services. For example: on review of RRHV#2 during the home observation the patient discussed congestion with the RN and noted the CG had gotten Mucinex for the patient, then further the patient presented a prescription bottle of guaifenesin that she noted she had for some time, however the medication was not listed on the medication profile. This observation was reviewed with the Hospice Manager.

Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to ensure that complete and accurate clinical records were maintained. For example: On review of RRHV#2 the RN documentation of medication reconciliation stated yes that expiration dates were reviewed and medication reconciliation was conducted per policy, however on home observation of the medication reconciliation process it was not observed that the expiration dates of medications were checked, nor was the reconciliation carried out per policy. In RRNHV#6 there were three RN visit notes with aide supervisory visits documented in October and November. The RN documented that the aide had not been to the home yet but continued to complete the aide supervisory with documentation that yes the aide follows the plan of care, and yes aide notifies of issues, and that no changes to the POC were indicated at the time. These observations were reviewed with the Hospice Manager. Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to ensure that complete and accurate clinical records were maintained. For example On review of RRHV#2 the RN documentation of medication reconciliation was stated yes to expiration dates were reviewed and medication reconciliation was conducted per policy, however on home observation of the medication reconciliation process it was not observed that the expiration dates of medications were checked, nor was the reconciliation carried out per policy. In RRNHV#6 there were three RN visit notes with aide supervisory visits documented in October and November. The RN documented that the aide had not been to the home yet but continued to complete the aide supervisory with documentation that yes the aide follows the plan of care, and yes aide notifies of issues, and that no changes to the POC were indicated at the time. These observations were reviewed with the Hospice Manager.