Every finding on record at Trinity Health Services

Observed in Record Review. In 2 of 3 discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) at least 2 days prior to discharging patient from service. On review of RRDC #1 and RRDC #3 it was noted that the NOMNC was signed on day of discharge. This finding was reviewed and validated with Hospice leadership.

Observed in Patient Home. On 1 of 3 home visits conducted, the hospice nurse surveyor observed unsafe oxygen cylinder storage on home visit. On RRHV #3, it was noted upon entering the patient's room that the oxygen tank was being stored upright without being secured and this was issue was not identified by organization staff. This finding was reviewed and validated with the DCPS who was present for the visit.

Observed in Patient Home. in 1 of 3 home visits conducted, the organization did not provide a comprehensive pain assessment. Organization's policy Pain Assessment 2-032 stated that when pain was identified an in-depth pain assessment would be obtained and include pain intensity using a rating scale, pain location, quality, alleviating and aggravating factors and pain management regimen and effectiveness. On RRHV #2, the patient had complaints of pain but the nurse did not assess pain using a pain intensity scale as per policy. This finding was reviewed and validated with DCPS who was present for the visit.

Observed in Record Review. In 7 of 9 active patient records reviewed, the Hospice surveyor noted the goals in patient records were not measurable and/or specific to the intervention and care needs of the patient. On RRHV #1, goals were not specific with examples of Patient will maintain optimal comfort and safety with home oxygen and Patient will maintain optimal comfort and skin integrity. On RRHV #2 goals were not specific with examples of Pt/family/PCG will verbalize that there will be sufficient care at home setting till the end of life and Patient will maintain optimal comfort with minimized dyspnea On RRNHV #1 it was noted that goals were not measurable and specific to the patient with examples of Optimum bowel elimination and comfort and Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. On RRNHV #2, goals were not measurable and specific to the patient with examples of Pt will maintain optimum peripheral circulation and Optimal bowel elimination and comfort. On review of RRNHV #3, RRNHV 4, and RRNHV #6 the goals were not measurable and specific with examples that mirror the previous charts reviews. This finding was reviewed and validated with hospice leadership.

Observed in Record Review. In 8 of 9 active patient records reviewed, the organization failed to update goals and document progress towards goals. On RRHV #1, it was noted that patient has been on service for 7 months and goals had not been updated with progress toward the goal with example of teaching goals Patient/family/caregiver will verbalize understanding of oxygen safety precautions and demonstrate safe equipment set-up and Pt/Family/PCG will verbalize understanding of safety intervention On RRHV #2 it was noted that patient has been on service for 3 months and goals had not been updated to reflect changes or updates in those goals including teaching goal of Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects and Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. On RRHV #3 it was noted that patient has been on service for 2 months and goals had not been updated to reflect changes or updates in those goals including teaching goal of Pt/Family/PCG will verbalize understanding of oxygen safety measures throughout the episode of care. On review RRNHV #1, it was noted that patient has been on service for 7 months and goals had not been updated to reflect changes or updates in those goals including teaching goal of Pt/pcg will verbalize/express understanding of treatment orders that has been on the plan of care over 6 months with no update. On RRNHV #2, it was noted that patient had multiple teaching goals that had not been revised or updated since patient was admitted 4 years ago with examples of Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects and Family/PCG will verbalize understanding of non-verbal signs of pain. On review of RRNHV #3, RRNHV 4, and RRNHV #6 the goals were not updated to reflect changes in care or updates with examples that mirror the previous charts reviews. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 2 bereavement charts reviewed, the organization did not plan bereavement care. Agency Policy 2-010 states that each patient chart will have a bereavement plan of care. On RRBR #1 it was noted that the organization had not created a bereavement plan of care. This finding was reviewed and validated with Agency leaders.

Observed in Patient Home. In 1 out of 3 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. During the home observation for RRHV #2, the nurse surveyor noted that patient had a tube of Bengay topical cream at her side that the nurse did not address during the visit and was not on the medication list. At the end of the visit the nurse surveyor asked the patient if she uses the cream and she says when she has a headache she puts it on her neck to help the headache. These observation were reviewed and validated with the DPCS who was present for the home visit.

Observed in Record Review. In 8 of 9 active records reviewed, documentation was not authenticated with electronic signature per agency policy. Policy 5-006 states that entries in the clinical record will be turned in by end of workday and it will include signature. In RRNHV #1, it was noted by the Hospice surveyor that visit notes had not been authenticated with electronic signature dating back up to 3 months. On RRHV #1, RRHV #1, RRHV #3, RRNHV #2, RRNHV #3, RRNHV #4, and RRNHV #6 it was noted that visit notes had not been authenticated with electronic signature for visit notes over several months old. This finding was reviewed and validated with hospice leadership. Observed in Record Review. On 6 of 9 active patient records review, all members of the Interdisciplinary Team did not authenticate attendance in the IDG. On RRHV #1, RRHV #2 and RRHV #3, RRNHV #2, RRNHV #3 and RRNHV #4, it was noted that both the chaplain and social worker had no signature of attendance to the meetings over the last month. This finding was reviewed and validated with hospice leadership.

Observed in Patient Home. It was noted in one hospice medical record the assessment was not updated. The patient developed a lesion on her shin, however this lesion was not documented in the patient's medical record

Observed in Patient Home. It was noted on one home visit that the nurse did use the correct cleaning agent/ wipes to clean her blood pressure cuff, thermometer and pulse oximetry device. There were no manufacturer guidelines for sanitizing or disinfecting equipment noted with these wipes that the nurse used to clean the equipment. Observed in Patient Home. It was noted that the Aide performed mouth care with a toothbrush that was soaking in previously used glass , the glass had dried stains from a previous use on arrival to the patient room on the inside of the glass where the tooth brush was soaking. The Aide used to perform this toothbrush to perform the patient's mouth care.

Observed in Record Review. In 2 of 6 patient records reviewed, It was noted that that the wound care documentation was missing or incorrect .On one record the nurse recorded other treatments for the patient but did not document the wound care for one day - nor did the nurse document why the wound care was not completed. On a second patient the wound care completed on the right leg was documented as the left legs. Both of these patients were being treated with saline and triple antibiotic cream. These documentation errors were discussed with the Quality Manager and the DCPS.