Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 6
Jun 6, 2022
Visit Reason
An unannounced onsite visit was made to Weinstein Hospice from May 31, 2022 through June 7, 2022 to investigate complaint GA00223383.
Findings
The complaint was partially substantiated with multiple deficiencies found including incomplete human resource files, expired CPR certification for one employee, failure to document physician orders for an indwelling Foley catheter, failure to provide physical therapy services, and incomplete documentation of nursing visits and medical records.
Complaint Details
The complaint was partially substantiated as evidenced by multiple deficiencies found during the investigation.
Deficiencies (6)
| Description |
|---|
| Failed to maintain complete human resource file for 1 of 4 personnel files reviewed, specifically the Nurse Practitioner. |
| Failed to ensure current CPR certification for 1 of 4 personnel files reviewed; CPR card expired for employee #2. |
| Failed to document physician order for indwelling Foley catheter on patient #1. |
| Failed to provide physical therapy to 1 of 3 patients reviewed; no current contract for PT services. |
| Failed to document nursing visits from 12/31/2021 to 1/21/2022 for patient #1 as required. |
| Incomplete documentation in medical records for patient #1 including lack of details on Foley catheter insertion and other required documentation. |
Report Facts
Personnel files reviewed: 4
Patients reviewed: 3
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Employee whose human resource file was incomplete. | |
| Employee #2 | Employee whose CPR certification was expired. | |
| Administrator | Interviewed regarding deficiencies and acknowledged incomplete documentation and files. | |
| Director of Nursing (DON) | Interviewed regarding deficiencies and confirmed incomplete documentation and files. | |
| Human Resources Manager | Interviewed regarding deficiencies and confirmed incomplete personnel files. |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Jun 6, 2022
Visit Reason
An unannounced onsite visit was made to Weinstein Hospice from May 31, 2022 through June 7, 2022 to investigate complaint GA00223383.
Findings
The complaint was partially substantiated with deficiencies including incomplete documentation of nursing visits, failure to provide physical therapy services, missing physician orders for a Foley catheter, and incomplete personnel files for one employee.
Complaint Details
The complaint was partially substantiated based on clinical record review and interviews.
Deficiencies (4)
| Description |
|---|
| Failed to have complete documentation of nursing visits in the clinical record for 1 of 1 sampled patients. |
| Failed to provide physical therapy to 1 of 3 patients reviewed; no current contract for PT services. |
| Failed to document an order for Foley catheter on patient #1 despite visit note indicating order was obtained. |
| Failed to maintain complete human resource file for 1 of 4 personnel files reviewed, missing multiple required documents. |
Report Facts
Census: 44
Patients reviewed: 3
Personnel files reviewed: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 22, 2018
Visit Reason
The inspection was conducted as an onsite complaint investigation for complaint number GA00181806.
Findings
The complaint was unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with 42 CFR Part 418, Requirements for Hospices.
Complaint Details
Complaint number GA00181806 was investigated and found to be unsubstantiated.
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