Every finding on record at Traditions Hospice of Ridgeland, LLC

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, it was noted by the nurse surveyor that the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. All IDG notes included the “IDG Documentation Template”, in which staff documented a minimal amount of information. Overall, the IDG notes do not reflect the patient’s current condition or response to care provided. For example, HOSHV#1/RR#1 was due for a recert, the IDG note did not reflect the decline of the patient or the decision of the IDG to recertify the patient. For HOSRR#8, the patient had an increase in pain with medication changes, response to the medication changes were not documented in the IDG notes. All findings were verified by the Branch Director.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not measurable. For example, “Pain will be managed at level acceptable to patient,” “Patient/Caregiver verbalize and demonstrate understanding of skin breakdown,” and “Patient/Caregiver will understand how psychosocial/spiritual factors influence pain.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, most goals did not have a timeframe for completion. Findings were verified by the Branch Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy, “Bag Technique - IC60 Policy and Procedure”. For HOSHV#2/RR#2 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Clorox wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time. Finding was verified by the Branch Director who was present during the home visit.