Every finding on record at West Tennessee Healthcare Henry County Hospital

Observed in Record Review. In 3 of 4 patient records reviewed, for active patient, it was noted by the nurse surveyor that the hospice aide care plans did not contain all the necessary information. In HosRRDC#1 the Aide plan of care as incomplete as it only addressed bath without a specific type, foot care, skin care and assist with transfers. Other services were being provide such as shampoo, dressing and nail care but were not address on the plan of care. For HosRRNHV#2 the patient was on Xarelto but no bleeding precautions on the aide plan of care. Further, on the current plan of care the interventions were found to not populate. For HosRRNHV#3 the patient was on oxygen, however, the care plans did not address what the aide should do regarding the oxygen while performing the patient’s activities of daily living. Additionally, the bath stated bath and did not specify the type and the patient was receiving linen change, dressing and positioning that was not addressed. These observations were discussed with the Hospice Supervisor.

Observed in Tracer Activities. During the review of the Volunteer Training Program, it was noted that education on their role during an Emergency was not included in the annual training for volunteers. Per policy, all volunteers receive annual training. Finding was verified by the Volunteer Coordinator.

Observed in Record Review. It was noted by the nurse surveyor that for RRDC#2 the patient/patient’s representative was not issued a Notice of Medicare Non-coverage (NOMNC) at least two days prior to of discharge as required. Finding was verified by the Hospice Supervisor.

Observed in Tracer Activities. It was noted by the nurse surveyor during the Leadership Session and review of documents that the organization did not compile and analyze data to identify improvement opportunities. It was noted the organization was reporting and collecting data on patient falls, medication errors/adverse events, and infections as part of the Quality Assurance Performance Improvement Program. There was, however, no documentation to support that data was being compiled and analyzed to identify opportunities for improvement. Finding was reviewed and discussed with the Director of Home Health and Hospice and the Hospice Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the nurse surveyor that clinical staff did not clean their equipment per agency policy, “Bag Technique Policy#9-014.1”. For RRHV#2 and for RRHV#3, the nurse and the hospice aide, both cleaned their equipment (BP cuff, stethoscope, thermometer, pulse oximeter) with Sani wipes. The policy states that equipment is to be cleaned with alcohol. Finding was discussed with the Director of Home Health and Hospice and the Hospice Supervisor. Observed in Patient Home. In 3 of 3 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 “Hand Hygiene Policy”. For example, during RRHV#1 the chaplain performed hand hygiene in the driveway before entering the patient’s home. He then opened the door and entered the home, touched the patient’s hands frequently during the visit, read his bible, then took out his computer to document, all without hand sanitizing. During RRHV#2 with a skilled nurse, she went back and forth from the patient to her tablet to document without performing hand hygiene. During RRHV#3, the hospice aide hand sanitized, then donned gloves. She then gathered the patient's bathing supplies and clean clothes, filled the wash basins, then proceeded to bathe the patient head to toe, to include his dirty bottom all with the same pair of gloves on. Additionally, she did not change the bath or rinse water after bathing his feet or dirty bottom and then went on to bathe his back. Findings were discussed with the Hospice Supervisor.

Observed in Record Review. In 5 of 10 patient records reviewed, for active patient, it was noted by the nurse surveyor that the hospice aide care plans did not contain all the necessary information. For RRHV#1, RRHV#3, RRNHV#1, and RRNHV#3 the patients were all on oxygen, however, the care plans did not address what the aide should do regarding the oxygen while performing the patient’s activities of daily living. Additionally, there were no instructions regarding when the aide should notify the nurse on any of the hospice aide care plans to include RRNHV#7. Findings were discussed with the Hospice Supervisor.

Observed in Tracer Activities. It was noted by the nurse surveyor that the organization did not have any documented cost savings achieved through the use of volunteers for the past two fiscal years. The hospice had six active volunteers, but cost savings had not been calculated or documented. Finding was verified by the Volunteer Coordinator.

Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for the last two and a half fiscal years. There are currently six active volunteers. Finding was verified by the Volunteer Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the surveyor that the medication profile was inaccurate. During RRHV#2, the skilled nurse performed a medication reconciliation with the full-time paid caregiver. All of the prescribed by mouth medications were identified, however, there were topical creams such as Aspercream, and Caleseptine, along with Nystatin powder at the bedside that were being used but were not on the medication profile. Finding was validated by the Hospice Supervisor who was present during the visit.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted by the nurse surveyor that the Admission Booklet for Hospice patients that was reviewed in the office contained a “Disaster Planning Form” which was designed to educate the family and assist in developing an individualized disaster plan. However, during RRHV#1, RRHV#2, and RRHV#3, it was noted that the “Disaster Planning Form” had been removed. After discussion with the Director of Home Health and Hospice and the Hospice Supervisor, it was noted that the forms were being filled out by the admission nurse and returned to the office to be put in the EMR. Additionally, for RRHV#1, when asked about an individualized disaster plan, the caregiver daughter stated that she could not remember any education or information provided.

Observed in Tracer Activities. It was noted by the nurse surveyor that criminal background checks were not performed per regulation. For VOL#1, the volunteer was onboarded and started volunteering with a patient in the field prior to having a background check, sex offender registry check, or an abuse registry check per Tennessee law. Additionally, there was no process in place to obtain the required background checks. Finding was verified by the Volunteer Coordinator.

Based on policy review, record review and interview, the facility failed to facilitate spiritual counseling by a local clergy or pastor for 1 of 1 (Patient #1) patients reviewed that requested spiritual counseling. The findings included: 1. Review of the facilitys ";SPIRITUAL CARE SERVICES" policy (approved 12/29/04) revealed, ";...Hospice provides spiritual support in keeping with the patients belief system and practice and as developed by the interdisciplinary teams plan of care...Hospice documents all referrals, assessments, clinical notes, intervention letters and phone calls in the patients clinical record..." 2. Medical record review for Patient #1 revealed an admission date of 11/10/2022 with diagnoses that included Sepsis and protein-calorie malnutrition. Review of the 11/10/2022 initial nursing assessment revealed Patient #1 stated she would be interested in chaplain visits to help her deal with her grief and loss. Review of the 11/14/2022 initial social work assessment and Bereavement assessment revealed Patient #1 stated she would like a pastor to visit with her. The social worker documented she would contact a pastor to make a visit to the patients home. There was no documentation a pastor was contacted to visit Patient #1 in her home and provide spiritual support. In an interview on 1/18/2023 at 2:15 PM, the facilitys clinical director verified the social worker did not document her attempts to contact pastors to provide spiritual support for Patient #1. The director verified Patient #1 did not receive spiritual support and visits as she requested.