Every finding on record at St. Luke's Regional Medical Center

Observed in Record Review. In 3 of 19 patient records reviewed, the Hospice Nurse surveyor noted the goals in patient records were not specific and individualized to the intervention and care needs of the patient. For example, in S2RRHV2, the patient was using oxygen and had changes in oxygen usage that was not reflected on the patient's plan of care. On review of S2RRHV3, the patient had tubi-grips ordered and the goals did not reflect the care and teaching needs of the patient's condition. Also, oxygen use had been changed and the care plan did not reflect the increases in oxygen rate increase or the usage to the patient. On review of S2RRNHV4, it was noted that the patient had a urine catheter and the care plan did not reflect individualized goals for the care of the urine catheter for caretakers. This was finding was reviewed with the Hospice Supervisor who was present for all shared visits and chart reviews.

Observed in Record Review. On 1 of 19 Hospice Patient Records reviewed, it was noted by the Hospice Nurse Surveyor that the care plan had not been revised with updated information. On review of S2RRNHV7, it was noted that the patient had goals for teaching for constipation and skin pressure prevention for the caregivers on admission to hospice but that had not been resolved or updated since admission 4 months ago. This finding was reviewed and validated with the Hospice Supervisor who was present for chart reviews.

Observed in Regulatory Review. During the volunteer session Hospice Surveyor 1 noted that Volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. The rate for 2022-2023 was 3.2%. This was validated in a discussion with and observation by the Director of Home Health and Hospice and the Area manager.

Observed in Patient Home. In 1 of 4 hospice home visit conducted, Hospice Nurse Surveyor #2 noted that the organization had not reassessed medications of the patient. On HSRRHV #2, a patient had orders for Melat-Gaba-5htp-thean-mag-hrbs tab to be taken every night at bedtime and Lorazapem PRN, on pill box fill with the RN it was noted that the nurse was giving Lorazapam every night in the pill box and that Melat-Gaba-5htp-thean-mag-hrbs tab was not even present or being put in the pill box. On interview with the patient the patient stated daughter bought one bottle of the Melat-Gaba-5htp-thean-mag-hrbs tab and had not been taking it for awhile now because she didn't need it now because of the Lorazapam she takes nightly works. The Melat-Gaba-5htp-thean-mag-hrbs tab has a start date 6 months ago and had not been updated on the medication record. In addition, the Lorazapam dosing had not been updated on the medication record to reflect the current frequency of nightly administration. This finding was reviewed with the organization leadership.