ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 8 MD order by nursing home staff." SouthernCare’s failure to address patient wounds is a direct violation of Medicare/Medicaid conditions of participation 418.64 (b) (1), which states “A hospice must routinely provide substantially all core services directly by hospice employees.” ("Centers for Medicare & Medicaid Services, HH," 2010, p. 221) During our interview, the Director of Operations shared the results of her staff investigation after survey. These results showed a failure in the orientation/education process. Each nurse who was asked to describe the wound care process for patients residing in a nursing home stated they were to document that the nursing home staff was executing wound care per the physician order. Furthermore, the believed it was the responsibility of the nursing home staff to document the wound appearance and wound treatment. As a result, my recommended organizational changes are as follows: Review all policies and procedures to ensure they include very specific guidelines for wound care documentation for patients residing in a nursing home. Update orientation material to include very specific guidelines for wound care documentation for patients residing in a nursing home. Provide thorough education for all existing staff to include very specific guidelines for wound care documentation for patients residing in a nursing home. Chart audits to be completed on all active charts with wounds to verify compliance. Based on results of chart audits further education will be provided as needed. The Director of Operations will form a team to execute the above listed actions. This team will included the Director of Operations, the unit Clinical Nurse Educator, the unit Case Managers, and the Nurse Manager. This team will work together to complete the above listed actions to ensure complete compliance of the Medicare/Medicaid conditions of participation 418.64(b)(1).
ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 9 The proposed recommendation for change will strengthen this organizations weakness by educating all current and future staff the Medicare/Medicaid conditions of participation, and organizations expectations. This education will also include the consequences associated with failure to comply, both from a regulatory an organizational perspective. The proposed recommendation for change will serve the community as this organization further strengthens their ability to provide exceptional care to the hospice clients they serve. Ultimately, the proposed changes will ensure exceptional safe clinical care for the population they serve, while reducing unnecessary risk for the organization. SouthernCare Hospice Kokomo Branch currently utilizes Consumers Assessment of Healthcare Providers and Systems (CAHPS) for the purpose of national benchmarking. CAHPS utilizes internal benchmarking and competitive benchmarking, SouthernCare uses the data provided by CAHPS to benchmark for the following reasons: Ensure the organization is providing the highest quality of care Ensure the organization is focused on and utilizing best practice
- Spring '18
- Nursing, advanced nursing practice, Nursing Practice Field, SouthernCare Hospice