Every finding on record at Tenderly Hospice

Upon patient record review 9 of 23 (Patient #1, 4, 7, 8, 9, 12, 14, 15, 18) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #1, 4, 7, 8, 9, 12, 14, 15, 18: There is no evidence of an initial spiritual care assessment, completed by the spiritual care provider or the nurse that included a history of any religious affiliation and support, spiritual beliefs, traditions and rituals.

Upon patient record review, 11 of 23 (Patient #2, 3, 4, 6, 9, 11, 12, 13, 16, 17, 18) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The patient is taking Eliquis. There are no interventions in the plan of care for bleeding and use of anticoagulant use. Hospice is providing the patient Trazadone and Melatonin for difficulty sleeping, there are no interventions or goals related to insomnia/sleep. The Hospice has ordered Seroquel for symptoms of anxiety and agitation, there are no interventions or goals related to anxiety or agitation. Patient #3: The patient is taking Coumadin. There are no interventions in the plan of care for bleeding and use of anticoagulant use. The hospice is providing Duoneb as well as Guaifenesin. There are no interventions or goals related to the nebulizer or cough on the plan of care. Patient #4: The patient is taking Guaifenesin/Dextromethorphan as well as Flonase, however there is no evidence of interventions or goals related to cough or respiratory needs. Patient #6: There is a plan of care for risk of infection related to wound on coccyx, however, there is no evidence of interventions or goals related to wound care and treatment of wound on coccyx. Patient #9: Patient is admitted with lung cancer with metastasis. There is a plan of care for weakness related to risk of falls due to SOB. The patient is on oxygen and albuterol for respiratory symptoms. There is no evidence of a plan of care with interventions or goals related to respiratory needs. The patient is taking Eliquis. There are no interventions in the plan of care for bleeding and use of anticoagulant use. Patient #11: The patient is on hospice for COPD. She is taking daily Oxycodone for pain. There are no interventions or goals related to pain and use of narcotics. Patient #12: The patient is admitted with right lung cancer with metastasis. There is a plan of care for weakness related to risk of falls due to SOB. The patient is on 6 liters of oxygen as well as Duoneb and Guaifenesin. There are no interventions and goals related to oxygen, nebulizer and respiratory distress. The patient is taking Eliquis. There are no interventions in the plan of care for bleeding and use of anticoagulant use. Patient #13: The patient is admitted with liver cancer. They also have history of seizures. They are using Reglan, Zofran for nausea and vomiting. There are no interventions or goals related to seizure precautions, nausea and vomiting. Patient #16: Patient has a suprapubic catheter. The plan of care does not specify that the patient has a suprapubic catheter. The patient has a history of seizures and is on Keppra and Primadone. There are no interventions or goals for seizure. Patient #17: The patient has a history of seizures and is on Keppra and Gabapentin. There are no interventions or goals for seizure. Patient #18: There is a plan of care for risk of falls due to weakness and SOB. The patient is on oxygen and Tessalon, and oxygen for respiratory symptoms. There is no evidence of interventions and goals related to respiratory distress.

Upon patient record review, 3 of 23 (Patient #9, 16, 18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #9: Patient has an indwelling foley catheter. There are orders in the record for flushing the catheter as needed, however, there are no orders for the foley itself, nor the size of the foley with balloon size and frequency of foley change. Patient #16: The patient has a suprapubic catheter, there is no order for the suprapubic catheter and instructions for size or replacement as needed. Patient #18: Patient has an order for wound care to wound, though does not specify the location of the wound.

Upon patient record review, 1 of 23 (Patient #16) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #16: Patient was prescribed Cipro for a UTI. There was no update to the plan of care to include new infection.

Upon patient client record review, 4 of 23 (Patient #5, 15, 17, 18) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5: Patient has an order for wound care to wound on sacral, coccygeal area, though does not specify the type of wound. Patient has an order for wound care to wound on right knee, though does not specify the type of wound. Patient has an order for wound care to wound on bilateral groin folds, though does not specify the type of wound. Patient #15: Patient has an order for wound care to wound on coccyx, though does not specify the type of wound. Patient #17: Patient has an order for wound care to wound on the right ball of foot, though does not specify the type of wound. Patient has an order for wound care to wound on right posterior thigh, though does not specify the type of wound Patient #18: Patient has an order for wound care to wound, though does not specify the type of wound.

Upon patient record review, 1 of 13 (Patient #9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #9: The medical record indicated the patient had a problem with constipation. The medical record did not indicate evidence of any nursing problem statements with goals, interventions and progress toward outcomes related to constipation on the plan of care.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Patient #11 The medical record contained documentation the patient had an adverse reaction to albuterol inhaler which including swelling of the lips. The hospice nurse notified the physician and provided treatment and an incident report was written however the incident was not analyzed, tracked and reported in QAPI.

Upon patient record review 3 of 13 (Patient #3,#4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3: The medical record contained an aide plan of care indicating perform oral care, denture care, change linens, shampoo hair, incontinence care, document output, document last bm, use barrier cream, and reposition at each visit. The record indicated that these task were not performed on 2/14/23. Patient #4: The medical record contained an aide plan of care indicating task to perform nail care, shave, denture, foley catheter care, linen change, output, and assist to chair to be completed at each visit. There was no evidence that these task were performed on 1/20/23. Patient #5: The medical record contained an aide plan of care indicating task to perform foot care, denture care, shave and shampoo to be completed at each visit. There was no evidence that these task were performed on 1/11/23 and 1/18/23.

Upon patient record review 1 of 13 (Patient #10) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #10: The aide documented on 1/30/23 that the patient was unresponsive. There was no evidence in the medical record that the RN was notified of the change in patient's condition.

Upon patient client record review, 1 of 13 (Patient #8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #8: The medical record contained a discrepancy in documentation on the hospice aide visit note dated 2/13/23. The hospice aide marked all tasked complete but the narrative indicates the patient refused all task.