Every finding on record at Washington Regional Medical Center

Observed in HR File Review. In 2 of 2 volunteer files reviewed, the organization had not provided Emergency Management (EM) education and training. This finding was validated by the Hospice Educator, who stated that the volunteers had not completed the EM training provided by the system. Per the educator, the organization is in the process of developing a method to provide EM training to the volunteers.

Observed in Record Review. In 14 of 14 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not consistently measurable. None of the goals had a timeframe for completion. 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, or safety. Finding was verified by the Utilization Review Nurse and the V.P Innovation & Care Transitions.

Observed in Record Review. In 14 of 14 patient records reviewed, for active patients it was noted by the nurse surveyor that PRN visits were not quantified for skilled nurse visits, social work visits, or chaplain visits when ordered as part of the plan of care. Finding was verified by the Clinical Liaison for Hospice and the Utilization Review Nurse.

Observed in Patient Home. In 2 of 4 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy. For RRHV#1 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Sani wipes and immediately dropped the items into her bag without allowing them to dry per the recommended product dry time of two minutes. For RRHV#3 the nurse put her cleaned equipment partially on top of her nurse bag strap which was lying across her clean barrier. Additionally, the patient’s oxygen tubing was in the floor and she put it back on the patient without cleaning it. Findings were verified by the Clinical Liaison for Hospice who was present on the home visits. Observed in Patient Home. In 1 of 4 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene Policy #CS-IPC-H101” During RRHV#2 the hospice aide did not hand sanitize upon entry into the patient’s room or before and after assisting the Assisted Facility Staff to transfer the patient to her wheelchair and then her bed. She then washed her hands in the patient’s sink with soap and water, donned gloves and began setting up items needed for the bath. She filled the basins, touched the patient and surrounding area, all without performing hand hygiene. She did change her gloves one time without performing hand hygiene per policy. Finding was verified by the Clinical Liaison for Hospice who was present on the home visit.

Observed in Record Review. In 1 of 14 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice supervisory visits were not made every 14 days as required. For RRHV#2, the most recent hospice aide supervisory visits were completed 15 days apart. Finding was verified by the Utilization Review Nurse and the V.P Innovation & Care Transitions.

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted by the surveyor that for RRHV#3 and RRHV#4 the the facilities did not have all the required documents and information available. The process for getting documents to the facilities was not consistently followed. Finding was verified by the Clinical Liaison for Hospice who was present on the visits.