Stillwater Hospice

“Upon patient record review 10 of 23 (Patient #1,2,3,11,13,14,15,16,17,18) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 1: Initial RN assessment dated 03/29/23 does not show evidence of a comprehensive pain assessment. Patient 2: Initial RN assessment dated 01/03/24 does not show evidence of a comprehensive pain assessment. Patient 3: Initial RN assessment dated 05/06/25 does not show evidence of a comprehensive pain assessment. Patient11: Initial RN assessment dated 07/23/25 does not show evidence of a comprehensive pain assessment. Patient 13: Initial RN assessment dated 03/04/25 does not show evidence of a comprehensive pain assessment. Patient 14: Initial RN assessment dated 12/03/25 does not show evidence of a comprehensive pain assessment. Patient 15: Initial RN assessment dated 11/30/24 does not show evidence of a comprehensive pain assessment. Patient 16: Initial RN assessment dated 04/10/25 does not show evidence of a comprehensive pain assessment. Patient 17: Initial RN assessment dated 06/06/25 does not show evidence of a comprehensive pain assessment. Patient 18: Initial RN assessment dated 05/15/25 does not show evidence of a comprehensive pain assessment.”

“Upon patient record review, 3 of 23 (Patient #9,11,16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 9: The current medication record includes an order for MiraLax powder, order does not include diluent. Corrected on site, medication record updated. Patient 11: The current medication record includes an order for triamcinolone acetonide external cream 0.1%, order does not indicate a site of application. Corrected on site, medication record updated. Patient 16: The current medication record contains orders for acetaminophen 500 (2) tab(s) twice daily and acetaminophen 325mg 2 tab(s) every 6 hours prn for pain/fever. There is no directive for maximum daily limit of acetaminophen in all forms. Corrected on site, medication record updated.”

“Upon patient record review, 7 of 23 (Patient #2,4,7,9,10,14,17) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Coordination/Clinical Notes: Patient 2: The current POC includes orders for Plavix. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 4: The current POC includes orders for Eliquis. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions Patient 7:The current POC include(s) orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 9: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 10:The current POC include(s) orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 12: The current POC includes orders for Eliquis & Plavix. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 14: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions. Patient 17: The current POC includes orders for ASA. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions.”

“Upon patient record review, 3 of 23 (Patient #9,11,16) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 9: The current POC includes an order for MiraLax powder, order does not include diluent. Corrected on site, POC updated. Patient 11: The current POC includes an order for triamcinolone acetonide external cream 0.1%, order does not indicate a site of application. Corrected on site, POC updated. Patient 16: The current POC includes orders for acetaminophen 500 (2) tab(s) twice daily and acetaminophen 325mg 2 tab(s) every 6 hours prn for pain/fever. There is no directive for maximum daily limit of acetaminophen in all forms. Corrected on site, POC updated.”