Every finding on record at Sutter Visiting Nurse Association and Hospice

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure the drug profile contained the patient's current medications to identify actual or potential drug interactions and duplicate drug therapy. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/04/2024 with a diagnosis of Alzheimer's disease. The patient resided in a board and care facility. During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 12/10/2024, the hospice medication profile (printed on 12/09/2024) was compared to the facility medication profile (printed on 12/10/2024). The hospice medication profile documented the following medications not documented on the facility medication profile: Senna 8.8mg/5ml, take 26.4 mg=15 ml by mouth daily at bedtime, and Thick-It 3-4 tsp, follow package directions to make fluid nectar thick consistency. In addition, the hospice medication profile documented Acetaminophen 500 mg tablet, take two tablets every 6 hours as needed for pain. The facility medication profile documented Acetaminophen 325 mg tablets. There was also observed to be Zinc Remedy cream being utilized by hospice and facility staff in the patient's room that was not documented on either medication profile. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 11/14/2024 with a diagnosis of malignant neoplasm of the rectum. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN)[Personnel Record 4] on 12/10/2024, the hospice medication profile (printed on 12/09/2024) was compared to the SNF medication profile (printed on 12/10/2024). The SNF medication profile documented the following medications that were not documented on the hospice medication profile: Boost supplement one can daily (ordered 11/06/2024); Zofran 8 mg one tablet every 12 hours as needed for nausea/vomiting; witch hazel external pad, apply to rectum every 4 hours as needed for rectal pain ordered 11/18/2024; and ferrous gluconate 324 mg 1 tablet by mouth 2 times daily (ordered 11/22/2024). The Director of Patient Care Services, who was present during the home visits on 12/10/2024, confirmed the medication differences between the hospice and facility lists.

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 the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure the patient's plan of care included drugs and treatments necessary to meet the patient's needs. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 04/04/2024 with a diagnosis of Alzheimer's disease. The patient resided in a board and care facility. During the home visit on 12/10/2024, Zinc Remedy cream was being utilized by hospice and facility staff in the patient's room, which was not documented in the patient's plan of care. Clinical Record 4/Home Visit 4: The patient elected the hospice benefit on 11/14/2024 with a diagnosis of malignant neoplasm of the rectum. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 12/10/2024, the SNF medication profile (printed on 12/10/2024) documented the following medications that were not documented on the patient's plan of care: Boost supplement one can daily (ordered 11/06/2024); Zofran 8 mg one tablet every 12 hours as needed for nausea/vomiting; witch hazel external pad, apply to rectum every 4 hours as needed for rectal pain ordered 11/18/2024; and ferrous gluconate 324 mg 1 tablet by mouth 2 times daily (ordered 11/22/2024). The Director of Patient Care Services, who was present during the home visits on 12/10/2024, confirmed the medication differences between the hospice and facility lists.

It is required that 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 4 of 14 (29%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the Hospice Aide (HHA). Clinical Record 1/Home Visit 1: The patient elected hospice care on 04/04/2024 and resided in a group home. The plan of care ordered HHA services twice weekly. The HHA care plan dated 04/08/2024 assigned the HHA the relevant tasks: bed bath, dressing, skincare, lotion, turn, and position in bed every visit. This HHA care plan has not been updated since 04/08/2024. On 12/10/2024, during the home visit with the Hospice Aide (HHA) [Personnel Record 7], the HHA removed the heel protectors from the patient. There were no written instructions for removing the heel protectors on the HHA care plan. Clinical Record 2: The patient elected hospice care on 08/17/2024 and resided in an assisted living facility (ALF). The plan of care ordered HHA services twice weekly. The HHA care plans dated 08/17/2024, 09/09/2024, and 09/17/2024 assigned the HHA the relevant tasks: bed bath, dressing, hair care, peri care, skin care, transfer client from bed/chair, and change linens every visit. A nursing visit note dated 08/19/2024 documented, "left heel diabetic ulcer left heel covered with foam dressing." A nursing visit note dated 09/16/2024 documented, "heel protectors were added to the patient." A nursing visit note dated 11/04/2024 documented an emergency room visit and "4th right toe sutures and dressing." The HHA care plan was not updated to inform or provide the HHA with instructions for the wound dressing or sutures during personal care or the heel protectors. The HHA care plan was updated on 12/10/2024 (during the site visit) to add heel protectors. Clinical Record 13: The patient elected hospice care on 03/14/2024 and resided in an ALF. The plan of care ordered HHA services twice weekly until 05/08/2024 when HHA services were increased to five times weekly. The HHA care plan dated 03/15/2024 assigned the HHA the relevant tasks: showering, assisting with toilet dressing, hair care, nail care, oral care, peri care, shampoo, shaving, skincare/may apply to lotion to unbroken skin, and changing linens every visit. A nursing visit note dated 05/30/2024 documented, "wound on peri covered with foam dressing." The HHA care plan was not updated to provide the HHA with notification of the wound or specific instructions for the foam dressing during tasks. Clinical Record 17: The patient elected hospice care on 07/20/2024 and resided at home. The plan of care ordered HHA services twice weekly. The HHA care plan dated 07/24/2024 and revised on 08/12/2024 assigned the HHA the relevant tasks: stand-by assistance with ambulation, changing linens, washing linens, tidying patient area, bed bath, dressing, hair care, peri care, shampoo, and skin care every visit. A nursing visit note dated 08/14/2024 documented "three (3) scabbed areas to patient neck." A nursing visit note dated 08/14/2024 documented wound care ordered: "after scab accidentally dislodged during personal care (by an aide)." There were six (6) more HHA visits after this wound care order was written in which specific instructions were not provided for the HHA to use caution during baths or skincare or given specific instructions regarding the lesions on the neck. During an interview and a joint record review on 12/10/2024, the Director of Patient Care Services (DPCS), Administrator, and Director of Quality agreed the wounds, heel protectors, and "scabs" should have been added to the HHA care plans.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed of patients with Hospice Aide services, the agency did not ensure the Hospice Aide (HHA) provided services included in the plan of care. Clinical Record 1/Home Visit 1: The patient elected hospice care on 04/04/2024 and resided in a group home. The plan of care ordered HHA services twice weekly. The HHA care plan dated 04/08/2024 assigned the HHA the relevant tasks: bed bath, dressing, skincare, lotion, turn, and position in bed every visit. This HHA care plan has not been updated since 04/08/2024. On 12/10/2024, during the home visit with the Hospice Aide (HHA) [Personnel Record 7], the HHA removed the heel protectors from the patient. The HHA care plan did not assign the task of removing the heel protectors. During a joint review of the record and observation during the home visit on 12/10/2024, the Director of Patient Care Services, who was present during the home visit, confirmed that the task was not listed on the HHA care plan.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Home Health and Hospice Clinical Documentation" (revised 06/11/2024) stated in part: "All home care personnel shall compose clinical notes on the day that they provide care to the patient... All electronic and paper notes should be made during the time service is being provided, to the extent possible, and will be completed and submitted within 24 hours of the visit." In 1 of 14 (7%) clinical records reviewed of patients that received Hospice Aide (HHA) services, the agency did not ensure the HHA documented reporting changes in the patient's needs to the Registered Nurse. Clinical Record 17: The patient elected hospice care on 07/20/2024 and resided at home. The plan of care ordered HHA services twice weekly. The HHA care plan dated 07/24/2024 and revised on 08/12/2024 assigned the HHA the relevant tasks: stand-by assistance with ambulation, changing linens, washing linens, tidying patient area, bed bath, dressing, hair care, peri care, shampoo, and skin care every visit. A nursing visit on 08/14/2024 at 10 AM documented "three (3) scabbed areas to patient neck." The HHA visit occurred around 4 PM on 08/14/2024. The patient's son called the on-call nurse on 08/14/2024 at approximately 7 PM, and a note documented that the "patient has sores on her neck that frequently bleed. He (son) stated the patient told him that the aide knocked one of the sores and it dislodged the scab and began bleeding, and he needed assistance with wound care." A nursing visit on 08/14/2024 at around 7:38 PM documented wound care ordered "after scab accidentally dislodged during personal care (by aide)." There was no evidence that the HHA reported the scab was knocked loose to the Registered Nurse (RN). During an interview and a joint record review on 12/10/2024 with the Director of Patient Care Services (DPCS) and Administrator, the DPCS advised she had "spoken to the aide about remembering to document reporting changes to the nurse" and confirmed the changes and report of bleeding had not been noted in the clinical record. During an interview on 12/12/2024 with the Administrator and the Hospice Aide, the HHA advised she "thought she had reported the bleeding to the nurse but did not document it in the chart." This is not in accordance with Agency Policy.