Every finding on record at Wellstar Community Hospice

Observed in Record Review. In 1 of 20 patient records reviewed, During RR#2 it was noted pressure ulcers on the patient's coccyx were listed as a related conditions in addition to the terminal dx. The RN initial assessment documented the presence of the pressure ulcer but lacked documentation of the description of the coccygeal pressure ulcers. This was reviewed with the organization leadership present during record reviews.

Observed in Record Review. In 2 of 20 patient records reviewed, During HV#1 record review and RR#7, it was noted lack of documentation of an initial bereavement assessment within 5 days of the date of the RN initial assessment . This was discussed with leadership during record reviews.

Observed in Record Review. In 6 of 20 patient records reviewed, During RR#8, it was noted the patient developed cellulitis of the RLE that was documented during an IDG meeting in March 2023. The care plan was not updated to include interventions and goals related to the cellulitis. During RR#7 it was noted aspiration precautions was documented by the RN during the initial assessment. The care plan was not updated to include interventions and goals related to aspiration precautions. During RR#6 it was noted the patient had a PEG tube for feeding and aspiration precautions was documented as a safety issue. The care plan lacked an order for PEG tube care, dressing changes and related goals and interventions. In addition, there was lack of documentation of interventions and goals related to aspiration precaution. During RR#3 it was noted pain was documented on the RN initial assessment. Pain was not added to the care plan that included assessment, interventions and goals. During RR#2 it was noted an order for wound care for a pressure ulcer on the coccyx. The wound care order did not include who would perform the wound care and the plan lacked other interventions and goals related to care of the pressure ulcer. In addition, diabetes was listed as part of the diagnosis, comorbidities and related conditions. The care plan lacked assessment, interventions and goals related to the patient's diabetic status. During RR#13 it was noted an order for 02 at 2L/min continuous. The RN documented the patient was also increasing the flow rate to 3-4 L with activity and sometimes using 5 L. The POC lacked an order to increase the oxygen flow rates. This was discussed with the leadership team during record review.

Observed in Record Review. In 20 of 20 patient records reviewed, During HV#1-5, and RR#1-15 it was noted although the POC listed the DME the patient required, the POCs lacked the inclusion of the medical supplies necessary to meet the needs of the patient. This was discussed with organization leadership during record reviews.

Observed in Record Review. In 1 of 20 patient records reviewed, During HV#3 record review it was noted lack of documentation that the physician was notified during the RN initial assessment that the patient blood pressure was 160/122. This was discussed with the organization leadership present during record review.

Observed in HR File Review. In 1 of 15 HR files reviewed, the surveyor noted that the most current annual job specific competency for a nurse providing patient care was not found for the last current competency assessment conducted in 2022. This omission was validated with the Director of Clinical services at the time of the survey.

Observed in Record Review. In 18 of 20 patient records reviewed, During HV#1-5 record review and RR#1-3, and 6-15 it was noted lack of a documented individualized emergency plans that were given to the patient and maintained in the clinical record. This was discussed with the leadership team during record reviews.

Observed in EOC Tracer. During building tour of Tranquility at Kennesaw Mountain it was noted lack of caulking around one pipe that penetrated the ceiling in the Fire Riser Room that is located on the floor below a family room area of the facility. The corrective action was taken within 10 minutes of the survey finding and observed by the hospice surveyor as corrected. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.