Every finding on record at Tomah Memorial Hospital

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to assess potential medication-related problems. The RN did not comply with the organization's policy Medication Reconciliation which states that with weekly RN visits, the RN will verify the accuracy of the patient's medication list in the home and the hospice medication profile by visually checking the medications and asking about changes. For RRHV #1 the hospice nurse conducted a medication assessment however did not visually check the medications until prompted by the surveyor at which time it the RN discovered that Prochlorperazine Maleate 10 mg tablets, Prochlorperazine 25 mg rectal suppositories and Loperamide 2 mg capsules were not in the home and that the patient had not taken them for the past 4 months. This was validated with the Hospice Clinical Coordinator.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not provided care and treatment according to the patient's individualized plan of care. For RRHV #1 the patient was oxygen dependent and the oxygen was listed on the medication list 1-3 liters continuously however the patient was using the oxygen 3-4 liters continuously as she had been instructed by the RN. This was validated with the Hospice and Palliative Care Coordinator.

Observed in HR File Review. In 3 of 9 HR files reviewed, the organization had not defined competencies. In review of the personnel file for the Hospice Medical Director HR #7 and the Volunteer files for HR # 8 and HR #9 the organization had not identified competencies. This was validated with the Hospice and Palliative Care Coordinator and the Volunteer Coordinator. Observed in HR File Review. In 3 of 9 HR files reviewed, Staff competency was not assessed as part of orientation. In review of the personnel files for HR #7 the Hospice Medical Director, HR #8 and HR #9 of volunteer files there was no evidence that competence was initially assessed and documented as part of orientation. This was validated by the Hospice and Palliative Care Coordinator and the Volunteer Coordinator.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to conduct an accurate assessment of the patient's medications.. The patient medication list for RRHV #4 who had been admitted to the Hospice program 3 weeks ago included Tiotropium Bromide 2.5 mcg 2 puffs daily, however the patient reported he had not taken the medication for quite a while and was not taking it at the time of admission to the Hospice program. This was validated with the Hospice and Palliative Care Coordinator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization had not provided education to the patient and primary caregiver based on the patient's assessed needs. In review of the medical record for RRHV #1 who was oxygen dependent the skilled nursing visit notes documented that the patient/family had refused delivery of back up oxygen however there was no evidence in the medical record that the patient/caregiver was educated about what to do in the event that the oxygen concentrator fails. This was validated with the Hospice and Palliative Care Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the surveyor found that the organization had not performed a comprehensive assessment of the patient's severity of symptoms. For example, I review of the medical record of HV2, the patient was noted to have a coccyx wound on admission. There was no comprehensive assessment of this wound on admission and for greater than 14 days after adission. In discussion with the Hospice Quality and Informatics nurse, she stated that it was an expectation of the organization that wounds are assessed at least weekly. Lack of this assessment was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Record Review. In 1 of 13 patient records reviewed, the surveyor found that the organization had not consistently specified measurable outcomes for problems identified in the assessment. For example, in review of the medical record for HV1, the surveyor found that the organization had identified the problem of constipation but the outcome was not measurable, only specifying that the patient will not have constipation while on Hospice. This was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not identified specific interventions to manage the patient's symptoms. For example, in review of the medical record for HV1, the surveyor found that the organization had initially identified the patient was at increased risk for falls on the comprehensive plan of care but had not identified specific interventions to address the risk. In HV3, the patient was identified at risk for falls and the only intervention identified, required the caregiver to report increased weakness. This was verified by the Hospice Quality and Informatics nurse assisting with record review

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not identified specific treatment necessary to meet the needs of the patient. For example, in review of the medical record for HV1, the surveyor found that the organization had initiated an original foley catheter order which did not include the French or balloon size. The follow-up catheter order did not specify the frequency of PRN flushes or the indications for when 30cc of flush verses 60cc of flush would be used. In review of the medical record for HV2, the surveyor found that the organization did not have an order for the specific wound care that had been completed. These findings were verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Patient Home. During the home visit for HV1, the surveyor observed the staff member clean the pulse oximeter with a sanicloth. In review of the manufacturer's instruction for use, the device was to be cleaned with alcohol or a 1:10 bleach solution. This was discussed with the Hospice Quality and Informatics nurse.

Observed in Record Review. In 4 of 10 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on all safety precautions to implement or when to notify the nurse. For example, in review of the medical record for RR2, the patient was on an anticoagulant. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. In RR5 and RR6, the patient was on oxygen and was at risk for falls. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these issues. In review of the medical record for RR8 the patient had a PleurX drain and was at risk for falls. The home plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these issues. This was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Record Review. In 2 of 10 patient records reviewed, where the patient had hospice aide services ordered, the surveyor noted that the organization had not completed aide supervisory visits at least every 14 days. For example, in review of the medical record for HV1, a supervisory visit was not documented for at least the first 19 days the patient was receiving aide services. In review of the medical record for RR5, a supervisory visit was not documented at least every 14 days on one occasion. This was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Record Review. In 3 of 13 patient records reviewed, the surveyor found that the record did not contain specific notes on the care, treatment, or services being provided. For example, in review of the medical record for RR2 the surveyor noted that nursing documentation included flushing the patient's portacath but did not include accessing the portacath, type of flush used, amount of flush used, etc. In review of the medical record for RR4 and RR8, nursing documentation included that the PleuriX catheter was drained but it did not include the dressing change and the drainage procedure. Assessment of the site was also not consistently documented. This was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Record Review. In 4 of 7 patient records reviewed, where the patient had oxygen ordered, the hospice surveyor found that the organization had not informed and educated the patient, family, and/or caregiver about the following: - The findings of the safety risk assessment - The causes of fire - Fire risks for neighboring residences and buildings - Precautions that can prevent fire-related injuries - Recommendations to address the specific identified risk(s). In review of the medical record for RR4, RR5, RR9 and RR10, this education was not found. The sheet where this education would have been documented as provided had been left blank. This was verified by the Hospice Quality and Informatics nurse assisting with record review.

Observed in Building Tour. During the building tour of the hospice facility, the surveyor observed two penetrations of the 2 hour rated fire wall above the ceiling over the main fire door. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.