Every finding on record at Superior Hospice of NW Louisiana

Observed in Record Review. In 2 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#3) that the nursing assessment indicated that the patient was receiving G-tube feedings; however, there was no evidence that the G-tube insertion site had been assessed. In (ARR#7), the nursing assessment indicated that the patient had a wound; however, there was no indication that the wound was assessed by a hospice nurse when admitted or since (24 days ago). The only information was that the facility staff had reported the wound. This was confirmed with director of nursing.

Observed in Record Review. In 6 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#3) that the nursing assessment indicated that the patient had a G-Tube; however, there were no orders or interventions on the plan of care for site care. In (ARR#4) the orders for wound care for wounds # 2, #3, and #4, did not indicate how often the wound care was to be done or who would perform the care when the nurse did not visit. In (DRR#2), the assessment indicated that the patient had a wound; however, there were no goals, interventions or wound care orders and the plan of care did not indicate who was to assess and/or perform the care of the wound for this patient in a SNF. I (DRR#3) there were no goals, interventions or wound care orders for a wound to the left toe and the plan of care did not indicate who was to perform wound care for this patient in a SNF. In (ARR#6), the surveyor noted that the plan of care and physician orders did not include goals or interventions for managing a non-stageable tunneling wound of the sacrum and there were no orders for the care of the wound. In (ARR#7) there were no goals, interventions or orders for wound care to a stage 2 wound to her thigh and it did not indicate who was responsible to perform the care for this patient in a skilled. This was confirmed with the director of nursing. Observed in Record Review. In 4 of 10 patient records reviewed, The hospice nurse surveyor noted (ARR#1) that the medication orders included Acetaminophen, Norco and Morphine as needed for pain and did not indicate the order in which the medications were to be given or for what level of pain the medications were to be used. In (ARR#4), (ARR#6) and (DRR#2) both Tylenol and Morphine were ordered as needed for pain and did not indicate the type of pain or the order to use the medication. This was confirmed with the director of nursing. Observed in Record Review. In 10 of 10 patient records reviewed, The hospice nurse surveyor noted in ten of ten records reviewed that the plan of care and physician orders did not include oral diet orders for all 10 patients. In (ARR#3) the surveyor noted that the patient assessment indicated that the patient was NPO and receiving Jevity via G-tube. The plan of care did not include the NPO order. Also, the surveyor noted in (DRR#1), (DRR#2), (DRR#3), (ARR#6) and (ARR#7), the patient's were at risk for aspiration; however, the plan of care did not include orders for pureed or thickened liquids were indicated. The surveyor noted that the EMR did not include a locator for diets. This was confirmed with the director of nursing.

Observed in HR File Review. In 2 of 7 HR files reviewed, of employees hired within the past 12 months, there had been no initial emergency management training. HR #3 and HR #7 had both been hired within the past 5 months and had not received initial emergency management training. This was validated with the Office Manager and the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, of a live planned discharge, the NOMNC had not been in the patient record so the Surveyor had been unable to validate whether it had been signed 2 days prior to discharge or even discussed with the patient. This was validated with the DON/Administrator.

Observed in Record Review. In 9 of 14 patient records reviewed, of active patient records, the Surveyor noted the Chaplain and/or Medical Social Worker (MSW) had not completed an initial or ongoing assessment of the patient. For example, In RRNHV #3, no SC services had been documented since the patient came on service. In RRNHV #5, the initial SC visit occurred 30 days post EOHB and not further visits had been documented. In RRNHV #6, RRNHV #7, RRNHV # 10, RRNHV # 12, RRNHV # 13, and RRNHV # 14 there had been no SC contact documented in the clinical record. In RRNHV #10 and RRNHV #14, there had been no MSW visits documented in the patient record, including initial evaluations. This was validated with the DON/Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, of active patient records, The Surveyor noted the Chaplain and/or Medical Social Worker (MSW) had not completed an initial assessment within five days after the election of hospice benefit (EOHB). For example, In RRNHV #5, the initial SC visit occurred 30 days post EOHB. This was validated with the DON/Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, of active patients,the Surveyor noted the Initial bereavement assessment had not been completed. For example, RRNHV #5, the Medical Social Worker had documented that the patient had not allowed the MSW to contact any family members, so no bereavement assessment had been completed. In RRNHV #9, RRNHV #10, and RRNHV #14, the patient had no documented initial bereavement assessment. This was validated with the DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, where the patient had wound care or device in use, the Surveyor noted no education of care and infection control for patient/family, nor that they had been deemed competent to provide the care. For example, RRHV #3, the CG was to be performing wound care when agency staff present; however, there is no documentation that the CG had been educated on the wound care and infection control, nor that he had been competent to perform. In RRHV #4, there had not been any documented education on wound care and infection control though the care giver was to perform the care in the absence of hospice Nurse. In RRNHV #8, the patient had an indwelling urinary catheter and was experiencing frequent urinary tract infections. There had been no documentation that education was provided to care givers on infection control, catheter care and UTI prevention. RRNHV #10, the patient had a wound with dressing changes; however there had been no documented education and validation that the care giver was competent to perform the care. This was validated with the DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, the Surveyor noted patient plan of care (POC) goals not patient specific, measurable and all with a time frame of 'the benefit period'. Examples include: Skin will remain intact during this benefit period. Cardiovascular status will remain within the limits of the disease process through the benefit period. Patient/CG verbalizes/demonstrates ways to decrease edema by end of the benefit period; Patient will maintain adequate airway and respiratory function within the limits of their terminal disease process; Patient's neurological status will stay within the expectations of their terminal disease process; Wound care will be performed per MD orders (of note, patient did not have a wound). Patient/CG maintains adequate nutrition and hydration within the disease limitations; This had been demonstrated in each patient record and validated with the DPCS and Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, the Surveyor noted incomplete patient care orders. For example, RRHV #3, the patient had wound care orders that did not indicate who was to complete the care nor the frequency of the care. RRHV #4 the orders for wound care had not specified who was to perform the wound care. RRNHV #8 the orders for wound care had not specified who was to complete the wound care and what were the indications for a ‘prn’ dressing change. The same patient also had orders for an indwelling foley catheter that had not specified the size and type of catheter, who was to change, and indications for ‘prn’ changes. In RRNHV #10, the patient had wound care orders without specifying who was to complete the care and what the indications for a prn dressing change would be. This was validated with the DON/Administrator. Observed in Record Review. In 6 of 14 patient records reviewed, the Surveyor noted the patient Plan of Care (POC) had not addressed all patient specific needs related to diagnosis and/or identified problems. For example, in RRHV #2, the patient POC had not addressed patients risk for falls and constipation. RRHV #3 the patient had recurrent urinary tract infections; however, this had not been on the POC with infection prevention. Of note, the patient had just completed antibiotics for another UTI. RRNHV #5 the POC had not addressed: constipation, aspiration, falls prevention, skin care, respiratory symptoms that had been identified on the initial evaluation. In RRNHV #10 the patient had a urinary tract infection shortly after starting on service, but this had not been captured on the plan of care. Pt also had a rash from an abo reaction and interventions had not been addressed on the POC. In RRNHV #11 the POC had been missing respiratory symptoms, falls, and constipation, and RRNHV #13 that patient had issues with constipation and was identified as a high falls risk, but this had not been included on the POC. This was validated with the DON/Administrator. Observed in Record Review. In 7 of 14 patient records reviewed, the Surveyor noted as needed medications without specific indications for use or a specific site of application. For example, in RRHV #3, the patient had: HYDROcodone-Acetaminophen and Morphine Sulfate; however there had not been specific instructions on which to use first and the type of pain to treat. The same patient also had Miralax and Dulcolax ordered for constipation also without specific instructions for use. RRNHV #5 the patient had been prescribed Morphine Sulfate, OxyCODONE and Acetaminophen as needed for pain without specific clinical symptoms for use. RRNHV #7 the patient had Voltaren External Gel 1 % Apply liberally to affected areas three times daily as needed without specifying the site of application. In RRNHV #9, the patient had Morphine and Lorazepam ordered for restlessness and Morphine and Tylenol ordered for patient without specific clinical indications for use. In RRNHV #10 the patient had Tylenol, Naprosyn, and Morphine all ordered for pain without specific indications for use and severity of symptoms. RRNHV #12 had Senna and another stool softner ordered without specific indications for use. RRNHV #13 had , the patient had Morphine and Lorazepam ordered for restlessness and Morphine and Hydrocodone-Acetaminophen ordered for patient without specific clinical indications for use. This was validated with the DON/Administrator.

Observed in Record Review. In 14 of 14 patient records reviewed, the Surveyor noted that there had been nothing in the record to indicate an interdisciplinary group (IDG) had occurred or that the members of the IDG had communicated with each other. The patient records had been lacking updates to the plan of care (POC) as patient needs and condition changed. There had been nothing in the record to indicate the members of the IDG communicated with each other regarding patient clinical, psychosocial, and spiritual needs. In discussion with Leadership, they were aware of the issue. They had the abrupt departure of the DPCS early in the year and had been without clinical oversight that pulled all the care together for 6 months. The new Don/administrator has yet to be educated on the process of the IDG documentation. The records contain no evidence that the POC had been discussed and changed in collaboration with all IDG. Observed in Record Review. In 14 of 14 patient records reviewed, the Hospice Surveyor noted no documentation to support collaboration between disciplines during the IDG meetings. There had been no sign-in sheet, and no evidence of discussion and or collaboration. This was discussed with the Don/Administrator. The HCO had been without a DPCS for 6 months and no one understood the process for IDG documentation. The new DPCS hired (4 months ago) is new to hospice and has been taking nursing notes, but had not captured discussions, so the Surveyor had been unable to validate collaboration and POC updates.

Observed in Record Review. In 2 of 14 patient records reviewed, of active patients, the Surveyor noted care was not provided according to hospice plan of care (POC). For example, in RRHV #2, Spiritual Care (SC) had orders to visit the patient 2 times every month, but did not document 1 visit in August and no visits in September. The Medical Social Worker (MSW) also had orders to visit the patient 2 times per month, but had also not documented a 2nd visit in August or September. In RRNHV #13, the SC had orders to see the patient monthly; however no visits had been documented. This was validated with the DON/Administrator.

Observed in Patient Home. In 3 of 4 home visits conducted, the Surveyor noted the clinicians had not followed the organization's bag technique policy. In RRHV #2, the clinician had been observed entering her bag 3 times without first disinfecting her hands, and entered her bag x1 wearing dirty gloves. The clinician also had a single compartment bag without an identified clean and dirty area. In RRHV #3, and RRHV #4, the clinician had cleansed her equipment and put into her clinical bag without performing hand disinfection and while wearing dirty gloves. This was validated with the DON/Administrator present during the visits.

Observed in Record Review. In 8 of 14 patient records reviewed, the comprehensive assessment did not include a spiritual assessment performed by the chaplain and/or psychosocial assessment performed by MSW. For example, in RRNHV #3, no SC services had been documented since the patient came on service.In RRNHV #6, RRNHV #7, RRNHV # 10, RRNHV # 12, RRNHV # 13, and RRNHV # 14 there had been no SC contact documented in the clinical record. In RRNHV #10 and RRNHV #14, there had been no MSW visits documented in the patient record, including initial evaluations. This was validated with the DON/Administrator.

Observed in Record Review. In 3 of 12 patient records reviewed, of active patients with Hospice Aide (HA) services, the Surveyor noted the HA had not followed the plan of care (POC). For example, in RRNHV #7, RRNHV #8 and RRNHV #9, the HA documented vital signs outside the RN written parameters, but had not documented any follow up, such as who it was communicated to. In RRNHV #8, the HA had orders to record the foley catheter output every visit, yet this had not been documented, and several visits the vital signs had been outside the established parameters, but there had been no documentation that the deviation from normal had been called to the RN case manager. This was validated with the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level Deficiencies at 418. 104, 418.110 and 418.56. Policies are in place, however, they have not been implemented and staff have not been held accountable.

Observed in Record Review. In 3 of 8 patient records reviewed, where the patient had been recertified for ongoing hospice services, the Surveyor had been unable to validate that the Medical Director had reviewed the clinical information, discussed the patient with the interdisciplinary group and signed the CTI prior to recertification. In RRHV #1 the patient had been recertified for services in early September; however there had been no CTI signed. RRHV #4, the patient had been recertified in late April but the CTI had not been signed until early May. RRNHV #7 the patient had multiple recertifications with the CTI signed 5-6 days post recertification. This was validated with the DON/Administrator.

Observed in Record Review. In 5 of 14 patient records reviewed, of active patients, The Surveyor noted the HCO had not followed their policy on timeliness of documentation. For example, the RN comprehensive visit for RRHV #1 for the beginning of October had been blank. In RRNHV #5, the RN clinical documentation had been incomplete for 4 comprehensive visits in September and 1 in October. In RRNHV #6, the RN visit note from the 3rd week of October had been incomplete. In RRNHV #7, the comprehensive visit note for the 3rd week of October had been incomplete, and in RRNHV #8 Nursing documentation for the 1st, 2nd, and 3rd week of October had been incomplete including the 15 day re- assessment. This was validated with the DPCS.

Observed in Patient Home. In 1 of 4 home visits conducted, the Surveyor noted the medication list in the HCO electronic medical record (EMR) had not contained all the medications the patient was being administered. For example, in RRHV #4, the patient had just completed an antibiotic Ciprofloxacin for a Urinary Tract Infection; however this had not been included on the medication profile in the EMR. The same patient had been administered Magnesium Citrate for constipation the day of the visit. This was validated with the DPCS present for the visit.

Observed in Record Review. In 12 of 14 patient records reviewed, the Surveyor had been unable to locate documentation that the patient & family had been educated on home oxygen use, cleaning, storage, and safety. This was found in RRHV #3, RRHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8 and RRNHV #9, RRNHV #10, RRNHV #11, RRNHV #12, RRNHV #13, and RRNHV #14. There had also been no documentation in RRHV #3 on the proper use of a Hoyer lift. This was validated with the DPCS.