Every finding on record at Sutter Visiting Nurse Association and Hospice

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the organization did not ensure that a revised plan of care included information from the patient's updated comprehensive assessment. Clinical Record 9: The patient elected hospice care on 08/17/2024 with a primary terminal diagnosis of cerebral atherosclerosis and co-morbidities that included dementia, chronic kidney disease, a history of urinary tract infections (UTI), and a Foley catheter. The patient resided in an adult living facility (ALF). The initial plan of care dated 08/17/2024 ordered: "Instruct on the care of the urinary catheter and when to contact hospice. Instruct on signs and symptoms of urinary tract infections." The RN comprehensive assessment dated 09/07/2024 documented that an "18FR, 10ml bulb Foley catheter" was replaced for the patient after it was reported by facility staff that the patient had a decrease in urine output and a possible clogged Foley catheter. The RN comprehensive assessment dated 09/20/2024 documented that the patient’s catheter was "clogged"... “attempted to be flushed with (normal saline) NS”... was "sluggish," and the catheter was replaced with an "18 Fr, 10ml bulb Foley catheter." The RN comprehensive assessment dated 10/03/2024 documented that the Foley catheter was reported by facility staff as “likely clogged due to no urine output.” On 10/03/2024; the RN obtained the physician's order: “Change urinary catheter indwelling coude 18FR, 10ml. May irrigate with 30ML of sterile water or NSS each visit and as needed for obstruction. Change as needed for signs/symptoms of infection, occlusion, or sluggishness.” The RN changed the catheter per the physician's order. During an interview and joint record review, the Clinical Manager and Administrator confirmed that the plan of care effective 08/17/2024 and the plan of care updates dated 08/21/2024 and 09/04/2024 did not include Skilled Nursing interventions for catheter replacement that specified catheter size and balloon size or irrigation of the catheter. The Administrator confirmed, “Yes, we have our plans of care updated now, and we have a Performance Improvement Project to ensure that Foley catheter size, replacement, and flushing interventions are not missing from our urinary catheter plans of care and our revised as appropriate going forward.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the organization did not ensure that the patient's clinical record contained the physician's order for care and services. Clinical Record 9: The patient elected hospice care on 08/17/2024 with a primary terminal diagnosis of cerebral atherosclerosis and co-morbidities that included dementia, chronic kidney disease, a history of urinary tract infections (UTI), and a Foley catheter. The patient resided in an adult living facility (ALF). The initial plan of care dated 08/17/2024 ordered: "Instruct on the care of the urinary catheter and when to contact hospice. Instruct on signs and symptoms of urinary tract infections." The RN comprehensive assessment dated 09/07/2024 documented that an "18FR, 10ml bulb Foley catheter" was replaced for the patient after it was reported by facility staff that the patient had a decrease in urine output and a possible clogged Foley catheter. The RN comprehensive assessment dated 09/20/2024 documented that the patient’s catheter was "clogged"... “attempted to be flushed with (normal saline) NS”... was "sluggish," and the catheter was replaced with an "18 Fr, 10ml bulb Foley catheter." The RN comprehensive assessment dated 10/03/2024 documented that the Foley catheter was reported by facility staff as “likely clogged due to no urine output.” On 10/03/2024; the RN obtained the physician's order: “Change urinary catheter indwelling coude 18FR, 10ml. May irrigate with 30ML of sterile water or NSS each visit and as needed for obstruction. Change as needed for signs/symptoms of infection, occlusion, or sluggishness.” The RN changed the catheter per the physician's order. During interviews and a joint record review on 10/03/2024 and 10/04/2024, the Clinical Manager and Administrator confirmed that the record did not contain documented physician orders for catheter replacement, including catheter size or balloon size, and did not include instructions for flushing the Foley catheter if it became sluggish or clogged. The Administrator confirmed that a physician's order for the Foley catheter size, bulb capacity, and flushing were in the patient record before the exit conference.