Every finding on record at Visiting Nurse and Hospice Home Inc

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 27 (7%) clinical records reviewed revealed that the agency did not ensure hospice protocol for wound monitoring was followed for weekly wound measurement. Hospice Home Care Measurement Protocol stated in part, "This protocol is meant to be a guideline for patient assessment at the minimum required frequency. If a patient requires monitoring outside of these parameters, ensure there is a physician order and care plan to do so." Wounds weekly Clinical Record 7: The patient elected the hospice benefit on 05/28/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in an assisted living facility (ALF). The wound was identified and care of the wound was ordered to start on 09/05/2024 for a wound on the middle back - no measurements documented. On 09//12/2024 wound care changed from a kerlix dressing to a foam dressing 2 x week. There was no document evidence of measurements or wound description. The assessments documented wound care porivided:09/12/2024, 09/18/2024 and 09/26/2024. Measurements were documented on 09/26/2024, 10/03/2024, and then weekly. But in the first 20 days, no measurements were documented. The wound did improve with no infections documented. Clinical Record 13: The patient elected the hospice benefit on 09/14/2024 with a diagnosis of Pancreatic CA. A wound was identified and care started on the coccyx wound identified on 09/04/2024 with a Medihoney, foam dressing wound care. The wound was not measured weekly. Wound measurement was documented 10/08/2024 then not until 10/24/2024 which was two weeks. The wound was documented as improved and no deterioration in that time. During an interview with the Chief Nursing Officer who reviewed the clinical records stated that the measurements were not documented weekly.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 27 (7%) clinical records reviewed revealed the agency did not ensure that the plan of care documented all individualized interventions for problems identified in the initial comprehensive assessment or the updated assessment. Care Coordination and Communication [revised 09/2022] stated in part, "Care and services provided are based on all assessments of the patient and family needs; sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under the arrangement." Clinical Record 21: The patient elected the hospice benefit on 10/11/2024 with a diagnosis of Parkinsons. The patient resided in a skilled nursing facility (SNF). The nursing assessment dated 11/6/2024 documented that the patient had a fall at the SNF. The patient got up unassisted and was on the floor in front of his recliner. As of 11/13 2024, there was no documented evidence of an update to the plan of care for fall interventions. Additionally, the nursing assessment documented a fall on 10/23/2024. The patient had been walking down the hall and fell backward witnessed by the facility CNA (certified nursing assistant). Fall interventions were documented on the coordination note that included clear pathways, non-skid footwear, and well-lit pathways with no added intervention after but the interventions were not documented on any of the updated plan of care as of review 11/14/2024. Clinical Record 22: The patient elected the hospice benefit on 02/08/2024 with a diagnosis of HTN. The nursing assessment documented on 04/17/2024 included that the patient had 2 falls without injury reported from the ALF (assisted living facility); had trouble with dizziness and stated should not have gotten up. There was no documented interventions updated to the plans of care for falls. An additional fall on 06/15/2024, the patient fell by the bed and said that she felt weak she had a skin tear that did heal but no other injuries There were Interventions documented on the coordination visit note that stated that clear pathways, non-skid footwear well-lit pathways, side rails, a fall mat, and a low bed were added as interventions to be started on this coordination note. There was an added recommendation for education to rise slowly was documented in the coordination note but none of the interventions were documented on any of the updated plans of care as of review 11/14/2024. During an interview with the Chief Nursing Officer who reviewed the records stated that the interventions were on the coordination notes but not on the plans of care for falls.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. Clinical Record 5: The patient elected the hospice benefit on 09/26/2024 with a diagnosis of Senile Degeneration and resided in a skilled nursing facility (SNF). The hospice aide frequency was ordered on 09/28/2024 for 2 times a week. The nursing assessment was documented on 11/04/2024 with the Foley catheter removed as the patient pulled it out. The assigned tasks for the aide included foley care and emptying the drainage bag at every visit. The aide plan of care was updated on 10/04/2024 with no further updates that included the removal of Foley catheter care and emptying of the drainage bag. The hospice aide documented in the 2 times a week visit that there was no catheter or drainage bag. Additionally, a foam dressing on the left arm was started on 10/31/2024. The aide plan was documented with no further updates on 10/04/2024 for the assigned bath every visit of a shower. As of 11/12/2024, the aide plan was not updated with any direction for what to do if the dressing is saturated or off or how to protect during the bath. Clinical Record 13: The patient elected the hospice benefit on 09/14/2024 with a diagnosis of Pancreatic CA. The hospice aide plan last updated on 09/17/2024 did not include direction for the aide. The bath task was ordered as a shower with a shower chair every visit. The patient had an identified coccyx wound on 09/14/2024 that had a foam dressing on it. There were no directions on the aide plan for what to do with the dressing if it became saturated or fell off during the shower. During an interview with the Chief Nursing Officer on 11/14/2024, who reviewed the clinical records stated that the aide plans should have been updated.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by documentation review and interview that fire drills were not conducted and documented quarterly for all shifts. Agency Policy: Life Safety (no date) stated in part, "The inpatient unit will conduct fire drills ...... Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift." Fire dills documented in 2019, with in-patient unit staffing for 3 shifts, 2nd quarter failed to document a drill on day shift (7am - 3pm). Third-quarter no night shift (11pm - 7 am), and fourth quarter no day shift (7am - 3pm) and no afternoon shift (3pm - 11pm). In 2020, first quarter no day shift (7am - 3pm), second-quarter no day shift (7am - 3pm), 3rd quarter no night shift (11pm-7am), fourth-quarter no night shift (11pm - 7am). All 2021 fire drills on all shifts are documented. Interview with Chief Nursing Officer stated that we did miss those fire drills.

It is required that the Interdisciplinary Group reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by record review and interview. In 1 of 20 (5%) clinical record reviews, it was revealed the documentation from comprehensive updates was not documented in the revised plans of care. Record# 73785: The initial and comprehensive assessment and plan of care were completed on the date of admission of 5/20/2021. An updated comprehensive assessment documented on 9/1/2021 included an order for wound care on ”right second toe – wash with wound cleanser, dry completely. Apply calcium alginate and band-aid every 3-4 days and PRN soliage or dislodgement. Pt only to wear socks and/or slippers at this time.” An updated comprehensive assessment documented on 10/1/2021 stated the wound healed. The plan of care was not updated with problems, interventions, and goals related to this wound. During an interview, the CNO confirmed these findings and agreed the plan of care was not updated.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records with aide services, it was revealed that the aide plan of care did not include patient-specific written instructions for the aide to follow based on problems identified in the initial and comprehensive plan of care. Record# 87024 The initial and comprehensive assessment completed on 10/1/21 documented the patient had a wound on the right hip as a result of surgery to repair a right hip fracture. A review of the HHA assignment, created on 10/5/2021, revealed instructions to provide a bed bath, turn and position in bed, transfer client from bed/chair and transfer client from chair/bed every visit. There was no indication within the assignment to notify the aide the patient had a surgical wound on the right hip. There were no instructions provided to the aide on any actions to be taken if the integrity of the wound/dressing was compromised during their assignment. Record# 91335: The clinical record included an order on 11/16/21 “to apply Lotrimin ointment to the rash on right outer foot BID x 7 days. Cover with gauze pad during the day.” A review of the HHA RN assignment, dated 11/11/2021, revealed instructions to provide a bed bath, routine catheter care, perineal care, shaving, and oral care every visit. There was no indication within the assignment to notify the aide the patient had a rash with a medicated bandage applied. There were no instructions provided to the aide on any actions to be taken if the integrity of the dressing was compromised during their assignment. Record# 80915: The clinical record includes the following orders. 9/21/2021, cleanse wound on left leg with soap and water apply a thin layer of vaseline. Cover with non-adherence dressing and secure with Coban daily. Orders dated 11/16/21 indicated to apply steri strips to skin tear right elbow, cleans skin tear on the right elbow with wound wash, pat dry, apply dry dressing daily. 10/5/21, dc ATB ointment may remove sutures 10/8/21. The HHA assignment dated 4/22/2020 was reviewed and did not provide information to ensure the aide had awareness the patient had a wound or provide any actions to be taken if the integrity of the dressing was compromised during their assignment. During an interview, the CNO confirmed these findings and agreed aide plans of care required updated patient-specific information related to care aides provide to patients.