Dignity Health Hospice

“Upon patient record review, 1 of 20 (Patient #5) 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 #5: Patient has Primidone prescribed. Medication profile identifies indicated for epilepsy. There is no reference to epilepsy in diagnoses. Upon interview, staff states the medication is prescribed for Parkinson’s related tremors.”

“Upon patient record review, 2 of 20 (Patient #14, 16) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #14, 16: No evidence of initial bereavement assessment within 5 days”

“Upon patient record review, 4 of 20 (Patient #2, 6, 7, 12) 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. Patient #2, 6, 7: Patients have Eliquis prescribed with no evidence of problems, goals interventions in care plan. Patient #12: Patient has oxygen prescribed with no related problems, goals, interventions. Patient has admitting diagnosis of Urosepsis (including hospitalization), but no problems, goals, interventions related to UTI/Infection.”

“Upon patient record review, 2 of 20 (Patient #16, 20) 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 #16. Initial orders include Monday lab draws from PICC line (related to TPN administration). The order does not include specifics of flushing. Upon interview, apparently, the labs were not actually obtained by hospice staff, but clinic. This is not clear in order as written. Patient #20: Plan of care includes order for: Hospice Nurse for insertion of indwelling urinary catheter using 16, 18, 20 (size) / 10 or 30 (balloon ml). Change every 6-8 weeks and prn dislodgement or stoppage. Catheter size prescribed is unclear.”

“Upon patient record review, 2 of 20 (Patient #1, 6) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #1: SN visit 5/6/26 documented pain/bruising right arm, status 4 days post fall per daughter. Did not note any communication/update to MD. Patient #6: PRN visit 3/7/26 following patient fall. Nurse documented contusion to back of head, abrasion to face, actively bleeding (on Eliquis). No indication physician was updated. SN visit 3/10/26 when SN documented bruising right side of neck and right hip due to previous fall. No documented evidence of update to physician.”

“Upon observation 1 of 20 records (Patient #3) have no evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family’s desires which include: Patient #3: SC service was accepted per initial RN assessment 2/20/26. SC called patient 2/6/26 but patient refused/does not need. MSW visit 4/29/26, social worked documented that daughter would also like spiritual support, preferably someone that is Spanish speaking. MSW documented will let chaplain know next week when he is back from time off. There is no documented evidence of follow up. No SC contact or visit documented.”

“Upon patient record review, 5 of 20 (Patient #2, 5, 6, 7, 10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2, 6, 7: Patients have Eliquis prescribed with no reference to bleeding precautions on the aide plan of care. Patient #5: On 4/25/26 the hospice aide care plan for SNF resident assigns prn task: change linens as needed. There is no related cognitive ability statement or reference to decision maker/coordination with facility staff. Patient #10: Patient has Xarelto prescribed with no reference to bleeding precautions on the aide plan of care.”

“Upon patient client record review, 3 of 20 (Patient #6, 12, 20) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #6: PRN visit 3/7/26 following patient fall. Nurse documented contusion to back of head, abrasion to face, actively bleeding (on Eliquis). Nurse documented wound cleaned and dried. No specifics of how wound cleaned, but documented that patient refused dressing, ice or bandage. SN visit 3/10/26 when SN documented bruising right side of neck and right hip due to previous fall. Unclear if referring to 3/7/26 fall or an additional fall. Patient #12: PRN SN visit 3/16/26 to perform wound care to LLE. SN documented performed wound care to LLE - assessed and dressing applied. Healing hematoma noted with slight drainage - care provided. No specifics of wound care documented. Patient #20: Foley catheter changed 4/13/26, SN documented inserted 16 Fr. No reference to balloon size or other specifics of procedure.”