Every finding on record at Westlake Villa Hospice, Inc.

Observed in Record Review. In 1 of 12 patient records reviewed, During RR#1 it was noted the patient signed and dated a Notice of Non Medicare Coverage (NOMNC) the same day as the discharge date.

Observed in Record Review. In 3 of 12 patient records reviewed, the organization did not document a patient-specific comprehensive assessment that included related conditions documented in the RN initial assessment. During RR#1 and RR#5, it was noted the RN documented diabetes mellitus as a related condition without further assessments of the patient's current diabetic status. During RR#8 it was noted the RN did not document diabetes as a related condition on the POC. In addition the RN initial comprehensive assessment lacked an assessment of the patient's diabetic status. The patient medication profile listed metformin 500 mg 2 in the AM and 1 in the PM and an order for Blood Sugar checks daily by the patient.

Observed in Record Review. In 1 of 12 patient records reviewed, During RR#1 it was noted multiple goals that were not measurable, and all had the same outcome date for all of the goal. For example: Optimal bowel elimination and comfort, facilitate optimum bowel movement, Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, optimal blood sugar management for pt. comfort and Pt will have optimum level of oxygen.

Observed in Record Review. In 2 of 12 patient records reviewed, During HV#1 record review it was noted the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. Listed as an order: facility staff to do BS [blood sugar] check on non SN visit. This order was not added to the POC as an intervention for the NIDDM issue listed in the endocrine section of the POC. There is no documentation of blood sugars done by the SN or documentation of readings done by the facility staff. During HV#2 record review it was noted the dressing change order to the coccyx pressure ulcer was not added to the POC under the integument system issues identified. The POC contained the following orders: educate Pt/family/PCG on proper techniques for wound/decubitis care and repositioning. Educate/assess/monitor Family/PCG ability to perform dressing changes as ordered. Family / PCG/Hospice nurse to perform wound care as needed. The SN discussed with the surveyor during the home visit that the staff change the dressing if needed between SN visits. There was lack of documentation in the patient record that education had been provided to the facility staff on the procedure.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV#1 it was noted the SN, after disinfecting the equipment used to assess vital signs and pulse oximeter, immediately placed the equipment back into a case used to store the items. The label on the disinfectant used had a 3 minute wet to dry disinfection time.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#1 and #3 it was noted in the patient rooms in a residential care facility unsecured E tank. In HV#1 room it was noted 2 E tanks standing upright not in a crate or cannister in the corner of the room. In HV#3 room it was noted one E tank standing upright in the patient room not secured in a cannister holder or crate. In discussion after the visit, the DPCS stated the equipment company delivered cannister holders for the auxiliary oxygen tanks for those patients. The SN present during the visit did not instruct the facility staff of the need for the auxiliary tanks to be in a crate or in cannister holders.