Every finding on record at Sutter Visiting Nurse Association and Hospice

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals that were measurable. CLINICAL RECORD 4: The initial nursing assessment dated 01/07/2025 stated in the narrative that the patient was receiving oxygen at 2-5 liters per min continuous via nasal cannula for shortness of breath. A physician order dated 01/08/2025 stated "DC routine oxygen order: Start oxygen, as needed at: 2 L for comfort/mild shortness of breath; 3 L for moderate shortness of breath; 4 L for severe shortness of breath; and 5 L for extreme shortness of breath. via nasal cannula". The interdisciplinary group (IDG) POC dated 01/08/2025 included the intervention for oxygen therapy, however, the goal for this intervention was “"Oxygen per physician order". There was no documented evidence that the goals included on the plan of care were measurable. CLINICAL RECORD 17: The initial nursing assessment dated 07/18/2024 included that the patient had a physician order for wound care to the coccyx that stated, "Stage II Pressure Ulcer to Coccyx: cleanse with mild soap and water, pat dry, apply zinc oxide to wound bed and peri wound". The IDG POC dated 07/18/2024 included the physician order, “Stage II Pressure Ulcer to Coccyx: cleanse with mild soap and water, pat dry, apply zinc oxide to wound bed and peri wound" The goal for the wound care intervention stated, "Provide wound care per physician order." There was no documented evidence that the goals included on the plan of care were measurable. The Administrator/Alternate Director of Patient Care Services (DPCS) and DPCS/Alternate Administrator stated in an interview on 02/14/2025 that the agency did not ensure the plan POC reflected patient and family goals and interventions that include specific detail based on problems identified in the initial and updated comprehensive assessments.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the Registered Nurse (RN) provided the aide with clear and accurate patient-specific written care instructions on the aide care plan. CLINICAL RECORD 17: The interdisciplinary group (IDG) plan of care (POC) dated 07/18/2024 included a nursing order for wound care to the "Stage II Pressure Ulcer to Coccyx: cleanse with mild soap and water, pat dry, apply zinc oxide to wound bed and peri wound". The aide care plan dated 07/18/2024 lacked evidence of clear patient-specific written instructions for how the aide was to manage and what to report related to the wound area on the patient's "Coccyx" while providing the assigned task: "Bed bath". The aide care plan ordered the task "Bed bath" every visit. The aide visit frequency ordered was 2 times per week. The aide visit notes dated 07/22/2024 and 07/25/2024 lacked evidence of how the aide managed and what to report related to the wound area on the patient's "Coccyx" while providing the assigned task: "Bed bath". The Administrator/Alternate Director of Patient Care Services (DPCS) and DPCS/Alternate Administrator stated in an interview on 02/14/2025 that the agency did not ensure the hospice RN provided the aide with clear patient-specific written care instructions on the aide care plan related to how to manage and what to report related to the "Coccyx" wound while performing the ordered task: "Bed bath".

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of the document, clinical records, and interview. 13 of 13 (100%) records reviewed revealed the IDG did not document measurable outcomes that could be anticipated from the implementation and coordination of patient-specific, individualized goals of care. Record #33117: Start of Care 1/8/2021, Date of Live DC for Extended Prognosis 4/29/2022, Diagnosis Cerebrovascular Disease. The patient’s Plan of Care included the following: ADLs: Need for skilled teaching related to self-care deficits. Intervention: Instruct how to assist patient with activities of daily living. Goal: Caregiver/Family verbalizes/demonstrates how to assist patient with activities of daily living. The plan of care does not include specific activities of daily living that require assistance (i.e. dressing, eating, etc.) or strategies to be taught to caregivers/family to assist the patient with specific ADLs requiring assistance. Record #55081: Start of Care 3/14/2022, Date of Death 3/17/2022, Diagnosis Hypertensive Heart Disease and Chronic Kidney Disease Stage 3 with Heart Failure. The patient’s Plan of Care included the following: Problem: Pain. Intervention: Skilled nurse to instruct on the use of appropriate pain scale and administration/side effects of pain medications. Goal: Patient/Caregiver/Family to use appropriate pain scale and verbalizes understanding of administration/side effects of pain medications. The plan of care does not specify what pain scale is to be used/taught, does not specify patient/family pain/comfort goals or acceptable level of pain, and does not specify specific pain medications to be used/taught in the palliation of pain. Record #14031: Start of Care 6/4/2021, Diagnosis COPD. The patient’s Plan of Care included the following: Problem: Respiratory status, altered. Intervention: Instruct on measures to promote respiratory comfort. Goal: Patient/Family/Caregiver verbalizes/demonstrates measures to promote respiratory comfort. The plan of care does not specify the patient’s definition of respiratory “comfort” and does not include specific strategies that the patient/family/caregiver will be taught to achieve patient goals (i.e. anti-anxiety medications, pursed-lip breathing, increased oxygen flow before exertion, etc.). Record #79095: Start of Care 11/8/2021, Date of Discharge for Extended Prognosis 1/27/2022, Diagnosis CA Lung. The patient’s Plan of Care included the following: Problem: Anxiety: Need for Skilled teaching related to anxiety. Intervention: Instruct on measures to decrease anxiety. Goal: Pt/Caregiver/family verbalizes understanding of measures to decrease anxiety. Patient signs/symptoms of anxiety and individualized interventions used to decrease these signs/symptoms for this patient are not included in the plan of care to determine if interventions have been successful in alleviating anxiety and if/when goals have been met. Record #47627: Start of Care 4/11/2022, Diagnosis Acute Kidney Failure. The patient’s Plan of Care included the following: Problem: GU: Need for skilled teaching related to the care of urinary catheter. Intervention: Instruct on irrigation of indwelling catheter. Goal: Patient/Caregiver/Family demonstrates irrigation of indwelling catheter. The catheter remains patent. The patient’s plan of care did not include the type of solution to be used for “10ml” of irrigation and how often the patient’s urinary catheter should be irrigated by the caregiver/family. Record #82898: Start of Care 5/1/2022, Diagnosis Intra-abdominal and pelvic mass. The patient’s Plan of Care included the following: Problem: Pain. Intervention: Skilled nurse to instruct on the use of appropriate pain scale and administration/side effects of pain medications. Goal: Patient/Caregiver/Family to use appropriate pain scale and verbalizes understanding of administration/side effects of pain medications. The plan of care does not specify what pain scale is to be used/taught, does not specify patient/family pain/comfort goals or acceptable level of pain, and does not specify specific pain medications to be used/taught in the palliation of pain. Record #11249: Start of Care 3/7/2022, Date of Live Discharge/Transfer to Home Health 3/23/2022, Diagnosis Hypertensive Heart Disease and Chronic Kidney Disease Stage 2 with Heart Failure. The patient’s Plan of Care included the following: Problem: Respiratory status, altered. Intervention: Instruct on measures to promote respiratory comfort. Goal: Patient/Family/Caregiver verbalizes/demonstrates measures to promote respiratory comfort. The plan of care does not specify the patient’s definition of respiratory “comfort” and does not include specific strategies that the patient/family/caregiver will be taught to achieve patient goals (i.e. anti-anxiety medications, pursed-lip breathing, increased oxygen flow before exertion, etc.). Record #98602: Start of Care 6/20/2020, Diagnosis Progressive Supranuclear Ophthalmoplegia. The patient’s Plan of Care included the following: ADLs: Need for skilled teaching related to self-care deficits. Intervention: Instruct how to assist patient with activities of daily living using the equipment. Goal: Caregiver/Family verbalizes/demonstrates safe use of equipment in activities of daily living. The plan of care does not include specific activities of daily living that require assistance using equipment (i.e. ambulation, transfer, etc.) the type of equipment to be used/taught (i.e. Hoyer lift) or safe strategies to be taught to caregivers/family in the use of the equipment. Record #41653: Start of Care 5/23/2020, Diagnosis Dementia with Lewy Bodies. The patient’s Plan of Care included the following: Problem: Skin: Need for wound care. Intervention: Coordinate care with wound care nurse. Goal: Patient receives optimal wound care. The plan of care does not define the goals for wound care as established by the IDG or patient/family (i.e. relief of pain, prevention of infection, healing, etc.). Record #72067: Start of Care 4/2/2022, Diagnosis CVA/Stroke. The patient’s Plan of Care included the following: Problem: Seizures. Intervention: Skilled nurse to instruct on seizure management. Goal: Patient/Family/Caregiver verbalizes understanding of the management of seizures. The plan of care does not define the goals established by the IDG or patient/family regarding seizure “management” (i.e. prevention, after-care, etc.). Record #88161: Start of Care 3/30/3033, Date of Live Discharge/Revocation 4/12/2022, Diagnosis CA Colo-rectal. The patient’s Plan of Care included the following: Problem: ADLs: Need for skilled teaching related to self-care deficits. Intervention: Instruct how to assist patient with activities of daily living. Goal: Caregiver/Family verbalizes/demonstrates how to assist patient with activities of daily living. The plan of care does not include specific activities of daily living that require assistance (i.e. dressing, eating, etc.) or strategies to be taught to caregivers/family to assist the patient with specific ADLs requiring assistance. Record #52723: Start of Care 4/21/2022, Diagnosis CA Malignant Neoplasm. The patient’s Plan of Care included the following: Problem: Safety, Altered Home Safety. Intervention: Instruct Caregivers/Family on how to prevent falls. Goals: Caregiver/Family verbalizes/demonstrates how to prevent patient falls. At SOC, the patient was documented as falling 5-7 times/day, some with injury. The plan of care does not include specific strategies taught to reduce or prevent falls. Record #34144: Start of Care 12/16/2021, Date of Death 12/20/2021, Diagnosis Follicular Lymphoma. The patient’s Plan of Care included the following: Problem: Nausea/Vomiting. Intervention: Instruct on how to monitor nausea/vomiting using a numeric scale. Goal: Patient/Caregiver/Family verbalize understanding of nausea/vomiting numerical scale. The plan of care does not include the numeric scale with parameters to be considered and does not include the patient’s stated level of acceptable nausea/vomiting according to the specific scale. Agency policy titled The Plan of Care states in part, "This plan will focus on identified problems, goals, and interventions and include all services necessary for the palliation and management of the terminal illness and related conditions. …Each patient will be monitored for his/her response to care or services provided against patient goals and patient outcomes to evaluate progress toward goals. …The written plan of care will contain but will not be limited to the following: …individualized interventions to assist with end-of-life care. …Measurable outcomes are anticipated from implementing and coordinating the plan of care. Care provided to the patient will be in accordance with the plan of care. …” The agency Administrator, who also oversees the corporate organization’s home health agency, stated that implementing measurable outcomes into individual patient plans of care will be “modeled” after the home health process when educating the IDG.