Every finding on record at Zentor Hospice, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, for active patient records, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that included the severity of symptoms. For example: on review of RRNHV#5 the initial nursing comprehensive assessment noted a stage 2 pressure injury that was described as a blister, however there were no specifics of the wound as required by policy such as size, color, and surrounding skin. This observation was reviewed with Administrator, and QAPI nurse.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the hospice plan of care was individualized with goals that were specific, measurable, and time-bound. In review of RRHV#3 there were goals that were not measurable such as patient will have no complications related to high blood pressure for the duration of hospice care. In RRNHV#5 an example of a goal that was not measurable was Patient will take medication as prescribed for the next 3 months to keep cholesterol levels down. Further in RRHV#3 the plan of care noted a stage 2 wound with a goal that stated Current stage II pressure ulcer will heal without complications or injection by 12/29/2023 however, documentation and discussion with patient caregiver and RN noted the wound had healed months prior to the current IDG. In RRNHV#4 and RRNHV#5 all goals established had achieve by dates of the end of the benefit period (BP), which was not until April. Many of the goals were short term goals such as Caregiver will understand Alzheimer's disease process and 2-3 signs and symptoms of expected decline by (end of BP) and Patient and caregiver will verbalize 3 interventions how to manage constipation with non-pharmacological techniques (diet, fluid intake, and exercise) by (end of BP). These observations were reviewed with the Administrator, DPCS Designee, and QAPI RN.

Observed in Record Review. In 1 of 5 patient records reviewed, for active patient records, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: In RRNHV#5 the patient was being seen by the social worker yet there was no psychosocial care plan opened to guide the care. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, the organization failed to provide patient with care, treatment, and services according to the patient's individualized plan of care. On review of RRBR#1 the plan of care ordered a frequency of skilled nurse 2 times a week, however the week prior to the patient death there was only one documented skilled nurse visit leaving a 7 day gap from nursing visit to the patient's death. This observation was reviewed with the RN QAPI nurse.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example: on home observation with the RN it was noted she was cleaning equipment with a purple top Santi-Wipe that has a manufacturers guideline of maintaining a contact (wet) time of 2 minutes, yet the RN was observed to wipe equipment and immediately return the equipment to the nursing bag. When asked what the guidelines for the wipe she was using were, the nurse replied that the contact time was about 20 seconds. This observation was reviewed with the RN and the administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, for active patient records, the organization failed to ensure that the written patient care instructions for a hospice aide were prepared by the RN and include all instructions necessary to provide care. For example: on review of RRHV#3 the patient was on O2 per nasal cannula as needed however the use of O2 and O2 precautions were not included on the Hospice Aide plan of care. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to maintain complete and accurate records. For example: on review of RRHV#2 there was documentation that was noted to be confusing as the narrative in the CTI for the 1st benefit period contained the phrase Patient has demon lord extremities. In RRHV#3 there was a goal that stated Current stage II pressure ulcer will heal without complications or injection yet the RN noted the goal should have stated without complications or infection. These observations were reviewed with the Administrator and the RN DPCS Designee.