Every finding on record at Westminster-Canterbury on Chesapeake Bay

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records reviewed, the agency did not ensure the comprehensive assessment included the initial bereavement assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/05/2025 with a diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 03/05/2025, included documentation that the bereavement risk assessment was not completed during this visit was because the assessment would be "completed by the Social Worker." Clinical record review revealed the patient declined the social worker on admission. The patient accepted social work services on 04/16/2025 and the initial bereavement risk assessment was documented at that time. There was no documented evidence that the bereavement risk assessment was completed at the time of the comprehensive assessment. CLINICAL RECORD 4: The patient elected the hospice benefit on 07/25/2024 with a diagnosis of cerebral infarct. The initial nursing assessment dated 07/25/2024, included documentation that the bereavement risk assessment was not completed during this visit because the assessment would be "completed by the Social Worker." Clinical record review revealed the patient declined the social worker on admission. The patient accepted social work services on 09/66/2024 and the initial bereavement risk assessment was documented at that time. There was no documented evidence that the bereavement risk assessment was completed at the time of the comprehensive assessment. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/03/2025 with diagnoses of end stage renal disease and diabetes mellites type 2. The initial nursing assessment dated 03/03/2025, included documentation that the bereavement risk assessment was not completed during this visit because the assessment would be "completed by the Social Worker." Clinical record review revealed the patient declined the social worker on admission. As of the date of record review on 06/05/2025, there was no documented evidence in the clinical record that the initial bereavement risk assessment was completed. CLINICAL RECORD 7: The patient elected the hospice benefit on 05/28/2025 with a diagnosis of heart failure. The initial nursing assessment dated 05/28/2025, included documentation that the bereavement risk assessment was not completed during this visit because the assessment would be "completed by the Social Worker." Clinical record review revealed the patient declined the social worker on admission. As of the date of record review on 06/05/2025, there was no documented evidence in the clinical record that the initial bereavement risk assessment was completed. During the joint record reviews and interviews on 06/05/2025 and 06/06/2025, the Clinical Manager (Personnel Record 7) confirmed that the initial bereavement assessments were not completed as part of the initial comprehensive assessment and stated, "in our old EMR (electronic medical record) system the nurses were forced to complete the bereavement assessment but, in this system they (nurses) can bypass it for the social worker to complete it. In these records the social worker was declined on admission." The Clinical Manager said, "we didn't realize this was happening and hadn't been auditing for it, but we will now."