Every finding on record at Traditions Hospice of Biloxi, LLC

Observed in Record Review. In 1 of 2 patient records reviewed, for discharged patients, it was noted by the surveyor that for RRDC#1 the Notice of Medicare Non-coverage (NOMNC) was not provided to or signed as required by the patient’s Power of Attorney when it was determined that the patient was going to be discharged for extended prognosis. Findings were discussed and verified with the RN Branch Manager, VP of Quality and Standards, and Regional Clinical Director.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the bereavement risk assessment was not completed as part of the comprehensive assessment. For RRHV#3, the Bereavement Risk Assessment was completed two months after the patient was admitted. For RRNHV#5 there was no documented Bereavement Risk Assessment by any member of the Interdisciplinary Team as required since admission three months ago.. Findings were discussed and verified with the RN Branch Manager, VP of Quality and Standards, and Regional Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that orders were not clear or complete. For RRHV#2 the patient had Metoprolol on his medication profile, however, the patient did not have any in the home. It was unclear at the time of the visit if the patient was to be taking the medication or not. The patient was also taking Tamsulosin 0.4mg, the EMR medication profile instructions said take 2 tabs po every night, the bottle said to take one table twice a day. The patient's wife said he was taking it twice a day. Additionally, the patient's EMR stated he had Ativan 1mg tab ordered PRN anxiety. there was no time frame between doses or maximum dose noted. Also the patient only had liquid Ativan in the home, 2mg/ml, 1/2ml was to be given (1mg) every four hours PRN anxiety. He was also getting a Dobutamine Drip, the instructions were to inject 332 mcgg/min into the vein continuously for 5 days, the five days were up and he was still receiving the medication and there were no instructions for pump settings in the order/instructions. Findings were verified by the Branch Director who was present on the visit.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that the staff failed to follow infection control practices and agency policy when performing patient care. During RRHV#2, During the home visit, the RN placed used equipment (blood pressure cuff and stethoscope) back onto the barrier alongside clean items. She completed vital signs, assessed the PICC line dressing, and applied barrier cream to the patient’s buttock—all without changing gloves. Without performing hand hygiene or changing gloves after handling supplies, she opened the PICC line dressing kit and donned sterile gloves over her existing gloves before completing the dressing change. After the procedure and tidying the area, she removed both pairs of gloves and sanitized her hands. Findings were verified by the Branch Director who was present on the visit.

Observed in Record Review. In 7 of 7 patient records reviewed, for patients with a hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not include the information necessary for the hospice aide to effectively care for the patients. For RRHV#2, the patient had a PICC line, chest tube, skin breakdown, and continuous oxygen, yet the hospice aide are plan did not mention or address what the hospice aide's responsibility should be in response to these. RRHV#3, the hospice aide care plan did not inform the hospice aide that the patient had toe to knee dressings on his legs nor what to do/report if they were soiled or dislodged. Also, the patient had left side hemiplegia with contractures that the hospice aide care plan did not mention. Additionally, for all patients with a Hospice Aide, there also were no instructions to notify the skilled nurse if there was a change in the patient’s condition. Findings were discussed and verified with the RN Branch Manager, VP of Quality and Standards, and Regional Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that the medication profile was inaccurate. During RRHV#2, it was noted during the medication reconciliation by the skilled nurse, that the patient had been taking Jardiance, Atorvastatin, and Empaghflozoin since admission, however, they had never been added to the patient’s medication profile. Additionally, the patient’s wife was applying Calmoseptine Cream topically to the patient’s raw buttocks area, which had not been added to the medication profile. The patient had been on service over one week. Findings were verified by the Branch Manager who was present during the visit.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#2 five small backup oxygen tanks were stored standing up unsecured on a tile floor in a warm side room off of the kitchen. The tanks were immediately laid on their side. Finding was verified by the Branch Director who was present on the visit.

Observed in Patient Home. In 1 of 1 home visits conducted, to patients in a facility, it was noted by the nurse surveyor that for RRHV#3, the patient’s Facility binder did not contain, the patient’s most recent updated plan of care, or the physician's recertification of illness. Finding was verified by the Branch Director who was present on the visit.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the patient and/or primary caregiver receive education and training provided by the hospice to their responsibilities for the care and services identified in the plan of care. For example: upon review of HV#1 and HV#2 the patient had wounds with wound treatment orders. There was no indication in the documentation the caregiver was given instruction on wound care, nor documentation that the caregiver demonstrated proficiency in providing wound care as ordered. In review of RR#8 the patient had a g-tube and was receiving tube feedings. There was no documentation noted in the record that the caregiver was given instruction and training on safely using the g-tube, nor was documentation noting the caregiver's proficiency at providing the care related to the g-tube noted in the record. These observations were reviewed with the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflected the patient and family goals and interventions based on the assessed needs of the patient, nor were the plan of care goals noted to be individualized, specific, measurable, and time bound. For example: In HV#1 the patient had wound care ordered yet there were no goals and interventions established for skin integrity. There was also an order for antibiotics yet no goals and interventions to guide care for the infection. The goal for cardiopulmonary stated patient exhibits reduction/relief of any cardiopulmonary symptoms this goal lacked being individualized, specific, measurable, or time bound. In HV#2 the patient also was ordered wound care but there were no goals and interventions for skin integrity. In HV#3 there was documentation of concerns for patient falls and DME ordered for safety yet no goals and interventions for fall safety established. Further, in HV#3 all goals were marked met and therefore, no goals remained to guide patient's care. Similar observations for a lack of goals and interventions based on issues identified in the comprehensive assessments were noted throughout all records reviewed. Further, throughout records reviewed there was a noted disconnect between the goals established and the interventions, as the interventions do not address meeting the goals. Such as: in RR#4 the goal stated patient/caregiver verbalize understanding to report any altered mental status the only intervention stated assessed sensory/neurological status and did not address the established goal. These observations were reviewed with the Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the established plan of care failed to include all services needed for the palliation and management of the terminal illness and related conditions, including the drugs and treatments necessary to meet the needs of the patient. For example: upon review of HV#1 the patient had an order that stated turn q2 hours and apply barrier 3 times a day and as needed. The order failed to specify where to apply barrier cream and what situation to institute the as needed order such as as needed after incontinence episode. Another order for HV#1 noted staff to clean and apply Cloroplast Triad to the buttocks twice daily and as needed. The order failed to specify the type of wound, what to clean with, how to dry, if to cover or leave open to air, nor when to use the as needed order. Further there were two wounds documented but only one wound care order. In review of HV#2 the documentation notes a wound care order that stated staff to clean every 3 days with soap and water, apply xeroform, and dry dressing. The order lacks the wound type, location, where to apply the xeroform and dry dressing, and whether to cover and/or what to secure with. Further with all wound orders it was not specified who was to perform the wound care, the hospice staff or the personal care home staff. Example 2: In review of HV#1 the documentation noted morphine in narcotic counts, yet morphine was not listed on the medication profile. Example 3: In RR#8 the patient had a peg tube and was receiving tube feedings of Nutren 3 bottles per day per nursing documentation, however there were no physicians orders for the tube feedings, nor any orders for peg tube maintenance noted in the record. These observations were reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the hospice followed accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions per organization policy. For example: during the home observation for HV#1 while performing the comprehensive assessment which included wound care the RN, on several occasions while providing care removed and replaced gloves but failed to sanitize hands in between glove changes as required by policy. Further, at the conclusion of the assessment the RN washed hands in the common shared bathroom and dried hands using a bath towel that was hanging in the shared space, and did not utilize disposable towels as noted in organization policy. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 9 patient records reviewed, where hospice aide services were being provided, the organization failed to ensure that he the registered nurse provided specific written patient care instructions for the hospice aide. For example: on review of HV#1 the aide assigned tasks were limited to a bed bath, dress patient, and check for skin breakdown and report. Further, the patient had wounds, yet there were no instructions on how the aide was to handle the wounds during the bath. In RR#7 the aide also had minimal tasks assigned as the patient was a bed bath, and required assist with all adl's yet there was no task to assist with dressing after the bath. Further, the patient had a wound and there were also no instructions on how the aide was to handle the dressings. This observation was reviewed with the Administrator.

Observed in Record Review. In 5 of 9 patient records reviewed, where hospice services were being provided, the organization failed to ensure that the RN provide an on-site visit supervisory visit for the hospice aide to ensure the quality of care and that services ordered meet the patient's needs no less frequently than every 14 days. For example: upon review of HV#1 the last documented hospice aide supervisory was 21 days prior to date of survey. In HV#2 there was a noted 28 day gap in documented on-site supervisory visit between June and July. Gaps in aide supervision greater than 14 days as required can also be seen in RR#4, RR#6, and RR#10. These observations were reviewed with the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure that the plan patient record included all of the care, treatment and services necessary. For example: upon review of HV#3 the patient was noted in documentation to be a concern for falls and side rails for the bed and floor mats were ordered for safety however the DME was not reflected on the patient's plan of care. Upon further review the DME, for each patient record reviewed, did not appear on the patient's plan of care. In discussion with the Administrator, the DME is noted on the Admission Comprehensive Assessment and should flow per the EMR to the plan of care yet the DME portion of the assessment was currently not appearing on the plan of care.