Every finding on record at Summerlin Healthcare, Inc.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization did not assess the patient according to defined time frames. In HV#1, HV#3, and RR#8, the psychosocial assessment was not completed by the MSW within five (5) days of the patient's election of hospice care. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Document Review. In 1 of 13 patient records reviewed, the organization did not maintain complete and accurate patient records. In RR#3, the documentation of medications on the patient's medication profile in the hospice plan of care was inaccurate, incomplete, and/or unclear. The Fentanyl patch order was documented incorrectly. The patch was noted to be prn on the medication profile, but it was confirmed by the Clinical Supervisor the correct order was for Fentanyl 75mcg/hr transdermal patch 1 patch to be applied every 72 hours. The order for ABH topical cream on the medication profile indicated the cream was to be given subcutaneously. The Ativan injection did not indicate the specific type of injection administration (subcutaneously, intramuscular) and dosage was documented to give 1-2mg every four (4) hours. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Record Review. In 6 of 13 patient records reviewed, the plan of care did not include interventions to manage the patient's pain and symptoms. In HV#1, the patient was on Methadone, with continued needs related to pain management and caregiver education. Pain/symptom management was not included in patient's plan of care. In HV#3, RR#5, and RR#7, the patient was assessed at high risk for falls,, but fall prevention/safety was not included in the patient's plan of care. In RR#3, the patient's symptom management related to agitation and pain was not included in the hospice plan of care. In RR#4, the patient with a primary hospice diagnosis of Amyloidosis with multiple comorbidities was assessed at high risk for falls and skin breakdown. The patient's plan of care only included interventions/goals related to respiratory status. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization did not plan the patient's care/services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient's needs. In RR#3, the patient had two (2) prn medication ordered for constipation and three (3) prn medications ordered for agitation, with no clear indications for use (when to take which prn medication). In RR#10, it was documented in the skilled nursing assessment and physician CTI that the patient was on Oxygen 2 liters per nasal cannula for shortness of breath, had an indwelling Foley, and an ileostomy. There were no specific orders in the hospice plan of care for the Oxygen, Foley catheter care/changes, or for care to be provided related to the patient's ostomy. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not manage safety risks by taking action to minimize the identified risk. In HV#2, there were multiple portable oxygen tanks standing up-right on the floor unsecured near the front door of the patient's home. Staff did not identify this risk and take action to assure proper/safe storage of the oxygen cylinders in the home as required by policy. This was reveiwed and verified with the Director of Patient Care Services.