Every finding on record at The Hospice of Martin & St. Lucie, Inc.

Observed in Record Review. A review of 3 of 26 patient records revealed that the organization did not ensure initial assessments by members of the interdisciplinary group included all required information. For example a review of the medical record(s) for HV#3, and HV#5, revealed that the form Home Environmental Safety Evaluation was not completed. Example #2: A review of the medical record for RR#9, revealed that the comprehensive assessment documented the presence of a pressure ulcer at the buttocks area. The wound assessment did not include the wound size measurements, condition of the wound bed, and the condition of the surrounding tissue. This observation was reviewed with the Director of Quality and Education.

Observed in Record Review. A review of 1 of 26 patient records revealed the organization did not ensure the plan of care specified the care and services necessary to meet the needs identified in the comprehensive assessment. For example, during a review of the medical record for HV#6, it was noted that the patient’s falls risk assessment indicated the patient was at risk for fall. In addition, the patient had a recent fall during the week preceding week 1 of hospice services. The patient’s plan of care did not include interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Director of Quality and Education.

Observed in Record Review. In 1 of 26 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RR#7, it was noted that during week 12 of the 1st benefit period, the clinician documented that the patient had experienced multiple falls since the start of care, increased weakness, the need for ambulation with assistive devices, and required additional assistance to complete activities of daily living. In addition, the patient experienced a recent fall during week 11 of the first benefit period. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and the goal statement to evaluate response to care, treatment and services related to fall prevention interventions was not revised. This observation was reviewed with the Director of Quality and Education.

Observed in Record Review. A review of 1 of 3 patient closed records, revealed the organization did not implement all requirements related to revocation of the hospice benefit. For example, during a review of the medical record for RR#3, it was noted that there was no documented evidence the attending physician was notified of the patient's intent to revoke the hospice benefit. This observation was reviewed with the Director of Quality and Education.

Observed in Record Review. A review of 1 of 3 patient closed records, revealed that the organization did not implement all requirements related to completion of a discharge summary. For example, a review of the medical record for RR#3, revealed that the discharge summary did not include: 1) A summary of the patient's stay, including treatments, symptoms, and pain management, 2) The patient's current plan of care, and 3) The patient's latest physician's orders. This observation was reviewed with the Director of Quality and Education.