Every finding on record at Visiting Nurse Association of Wisconsin, Inc.

Observed in Record Review. In 4 of 18 patient records reviewed, the Hospice Nurse Surveyor observed that Spiritual Care (SC) visits or contact had not occurred within 5 calendar days after the election of Hospice Benefits. For example, in HOSRRNHV2, HOSRRNHV7, HOSRRNHV9 and HOSRRNHV12, there had been no documented SC contact in the patient electronic medical record. This was validated with the Hospice Manager of Clinical Services.

Observed in Record Review. In 5 of 18 patient records reviewed, the Hospice Nurse Surveyor noted medication orders that had been incomplete. For example, in HOSRRNHV4, the patient had Diclofenac 1% ordered to apply 2 times daily, without a specific site of application. The same patient had an order for Epinephrine 0.3 injection with 'administer as directed' and no further clarification of administration. In HOSRRNHV6, the patient has MOM and MiraLAX both ordered as needed for constipation without specific indications of which medication to utilize first or second. HOSRRNHV7 patient had Tessalon Perles and Guaifenesin syrup both ordered as needed for cough without specific indications for which to use first, or second. In HOSRRNHV9 the patient had both MiraLAX and Sennosides ordered as needed for constipation, and in HOSRRNHV10, the patient had Nystatin ordered with instructions to 'apply to affected area twice daily without a specific site of application. This was validated with the Hospice Manager of Clinical Services.

Observed in Patient Home. In 1 of 6 home visits conducted, the Hospice Nurse Surveyor had observed a prescription label that had been modified by an RN from the HCO. For example, in HOSRRHV4, a nurse had added incorrect instructions to the Metoprolol label, stating 'Do Not Crush'. This was again modified by the RN during the observed home visit a the instructions were crossed out. This was validated with the Hospice Manager of Clinical Services.

Observed in Record Review. In 13 of 13 patient records reviewed, the plan of care did not include specific orders for the services needed to meet the specific patient and family needs. In all records reviewed the plan of care included an order to insert a Foley for comfort. The order did not include specifics such as the size of the catheter or balloon or any further orders on maintenance of a Foley once inserted. This was validated with the clinical manager. Observed in Record Review. In 2 of 13 patient records reviewed, the hospice plan of care did not address all patient needs In HOHV#2 the patient was admitted to hospice at the GIP level of care for behavioral issues including a suicide attempt prior to admission. In addition the intial comprehensive assessment identified high skin risk, altered mental status, pain, and fall risk. The plan of care did not address any of these issues. In HO RR#4 the record documented two wounds one on the buttocks and one on the coccyx. There were wound care orders on the plan of care for the buttocks but not the coccyx. This was validated with the clinical manager.

Observed in Patient Home. In 1 of 3 home visits conducted, and 3 of 13 additional records reviewed, the agency had multiple prn medications for the same indication without instructions in the home as to which medication to take when. Agency leadership indicated that comfort kits are delivered with instructions to only utilize those medications in the comfort kit when instructed by the hospice nurse. However in HOHV#1 for a patient in a group home the patient had Tylenol tablets, Tylenol suppositories and Roxanol all ordered prn for pain with no instructions in the home for the caregivers to differentiate between medication choices. The visit nurse indicated that in group homes the comfort kits are altered to meet the facilities policies and preferences. In HO RR#7 Colace suppository, Senna, Miralax, Fleets enema, and MOM were ordered for constipation. Differentiation between these medications was documented on a protocol for the nurse to use but there were no instructions for the caregiver as to when to give which medication or to call the hospice for direction. In HO RR#9 Colace tablets, Colace suppository and Miralax were all ordered for constipation with no further instructions. In HO RR#10 Hydrocodone and Tylenol were both ordered prn for pain with no differentiation. This was validated with the clinical manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the agency failed to document care provided in accordance with the plan of care. In HO RR#7 the plan of care for a right foot wound was to cleanse with soap and water, apply Santyl, and cover with a foam dressing. There was one instance of wound care where there was no documentation of Santyl applied to wound. This was validated by the Clinical Manager.

Observed in Record Review. In 1 of 6 patient records reviewed, for patients receiving oxygen therapy the agency failed to document education to insure safe use of oxygen equipment. During HO HV#3 the hospice surveyor noted an oxygen tank stored in an unventilated closet. There was no documentation of any education to the patient/family regarding the safe storage of oxygen equipment. This was validated with the clinical supervisor.