Every finding on record at Talbot Hospice Foundation, Inc

Based on direct observation on 09/10/2024, a Registered Nurse (RN) providing care to Patient #14 in the hospice house failed to follow infection control protocols, resulting in cross-contamination (when germs or dirt from something dirty get on something clean, spreading germs). --- The findings include: During direct observation of the RNs care for Patient #14 on 09/10/2024, it was noted that two barriers were placed on a table during the patient assessment. However, clean and dirty equipment were co-mingled (when two or more things get mixed together and are no longer separate) on these barriers, violating infection control standards that require separating clean and contaminated items.

A review of the medical record for Patient #2 on 09/09/2024 revealed that there were two referral requests from volunteer services for companionship visits on 08/26/2024 and 09/05/2024. However, no documented activities or services from volunteer visits were found in the patients record. --- The findings include: A review of Patient #2s medical record on 09/09/2024 revealed a referral from volunteer services for companionship visits on 08/26/2024 and 09/05/2024. No documentation was found indicating that the visits occurred or that any volunteer services were provided. An interview was conducted with the Director of Volunteer Services on 09/10/2024, during which the director stated that there was no documentation of companionship visits being done. A review of the hospices volunteer documentation policy confirmed that documentation of volunteer visits must be completed within 72 hours and included in the patients clinical record, which was not done in this instance.

A review of the personnel file for the Clinical Manager on 09/10/2024 revealed that no competency skills evaluation was completed upon hire, as required, for clinical roles that involve direct patient care, case management, and caregiver supervision. Competency evaluations allow the agency to check if employees have the right skills to do their job safely and correctly and identify areas for improvement. Failure to complete competency evaluations increases the risk of patients receiving care from unqualified or untrained staff. --- The findings include: A review of the Clinical Manager's personnel file on 09/10/2024 showed no documentation of a competency skills evaluation at the time of hire. The job description for the Clinical Manager states: "May include responsibility for direct patient care as RN case manager and caregiver supervisor, including admission, ongoing assessment, and treatments, etc., for patients admitted to home health (HH)."