Every finding on record at Toluca Hospice Care, Inc

Observed in Record Review. In 2 of 5 patient records reviewed, the nurse surveyor noted that more than one medication for pain control were ordered without direction on when to take the different pain medications. For example during HOSRR#3, patient had orders for Tylenol and Tramadol both are ordered every 6 hrs prn. Additionally, In HOV#1, patient noted to be on Tylenol and oxycontin every 6 hrs. prn. Qualifiers were not documented for both. These findings were discussed with Director of Nursing and Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the initial bereavement risk assessment was not completed. In HOSRR #4, the Surveyor noted the initial bereavement risk assessment was not completed. This was confirmed with the Director Nursing and Administrator

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor noted there was no documentation of the IDT reviewing the plan of care at least every 15 days. For example, in HOSRR#4 there was no documentation that shows that the plan care was reviewed during IDT meetings for the 1st cert period. This was discuss with the Director of Nursing and Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the surveyor noted that the hospice aide plan of care did not specify the type of bath to be provided by the aide. For example, in HOSRR#1, HOSV#1, HOSRR#2, HOSRR# 5, HOSRR#6 bath was marked as a task but the type of bath was not specified. This finding was discuss with the Director of Nursing and Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the hospice aide did not provide care as assigned. Upon review of the record for HOSRR#3, it was noted on multiple visit notes the aide documented a shower was given; however, a shower was not ordered. Aide documentation indicated assistance with bath chair; however, this task were not ordered on the aide plan of care. This finding was discuss with the Director of Nursing and Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, the surveyor found that that the staff member had not appropriately authenticated, dated and timed the notes in the electronic medical record. For example, in HOSV#1, HOSRR#1, HOSRR#2, HOSRR#3, HOSRR#4, HOSRR# 5 there were multiple notes which were not electronically signed or dated by the staff member. This finding was discuss with the Director of Nursing and Administrator.