Every finding on record at Stonewood Hospice Inc

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions identified in the initial and updated comprehensive assessments. Agency policy Plan of Care [reviewed and adopted 07/31/2022] stated in part, The written plan of care will include...problems and interventions. Agency policy Interdisciplinary Group [reviewed and adopted 07/31/2022] stated in part, “The meetings [IDG] will include a report on all care, treatment, and services provided including but not limited to problems, goals, interventions...discussions and updates will be documented on the Plan of Care." Clinical Record 6: The patient elected the hospice benefit on 5/10/2023, with a terminal diagnosis of lung cancer. The physician documented on the Physician's Certification of Terminal Illness for the benefit period 05/10/2023 through 08/07/2023, that the patient "has a chest tube in place to right chest wall, [the chest tube is] drained 2x weekly via PleurX drain 500ml every Tuesday and Thursday, hospice will continue with draining twice weekly." The skilled nurse documented on the 05/11/2023 nursing visit that 500cc of fluid was removed from the patient via the PleurX drain. The Plan of Care dated 05/10/2023 through 08/07/2023 did not include interventions for the care/maintenance of the PleurX drain. During an interview on 10/25/2023, the Director of Nursing confirmed the plan of care did not include planned interventions to address the PleurX catheter draining parameters or frequency and no planned interventions to address the PleurX catheter dressing or frequency of dressing changes.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders. Agency policy Clinical Record [reviewed and adopted 07/31/2022] stated in part, "The hospice must establish and maintain a clinical record system to ensure the care and services provided to each patient are completely and accurately documented. Each clinical record will include the following...physician orders." Agency policy Durable Medical Equipment (DME) and Medical Supplies [reviewed and adopted 07/31/2022] stated in part, "The following will be documented/filed in the Clinical Record...physician orders." Clinical Record 6: The patient elected the hospice benefit on 5/10/2023, with a terminal diagnosis of lung cancer. The physician documented on the Physician's Certification of Terminal Illness for the benefit period 05/10/2023 through 08/07/2023, that the patient "has a chest tube in place to right chest wall, [the chest tube is] drained 2x weekly via PleurX drain 500ml every Tuesday and Thursday, hospice will continue with draining twice weekly." Skilled nurse documentation on the 05/11/2023 nursing visit stated that 500cc of fluid was removed from the patient via the PleurX drain. The Plan of Care dated 05/10/2023 through 08/07/2023 did not include a physician order for the PleurX drain assessment /maintenance and did not include the dressing to be used or the frequency of dressing changes. During an interview on 10/25/2023, the Director of Nursing confirmed the plan of care did not include physician orders for the PleurX drain.