Destiny Hospice Care Inc.

“Observed in Record Review. In 2 of 14 patient records reviewed, During HOSRR#2 it was noted the initial RN evaluation did not include an assessment of the patient’s diabetic status that was documented as a comorbidity with 2 types of insulins prescribed. In addition, the patient was treated in a hospital ER for a chemical burn of his eyes caused by a ruptured battery and returned home with bandages to his eyes as documented in a communication note in March 2025. There was lack of an SN assessment of the injury post ER visit. During HOSHV#3 it was noted lack of an assessment of the patient’s diabetic status during the initial RN evaluation with glipizide and Jardiance prescribed. This was discussed with the organization leadership.”

“Observed in Record Review. In 6 of 14 patient records reviewed, During HOSRR#1 the RN, during the initial evaluation, documented the patient’s secondary diagnosis was cachexia, dysphagia and abnormal weight loss, however, the POC lacked nutritional assessment and interventions. The patient had a new order for oxygen therapy and nebulizer treatments as needed for SOB. The POC lacked interventions on use and safety of oxygen therapy and use of the nebulizer. The patient was assessed by the RN during the initial visit to have a high risk for skin breakdown identified on the Braden assessment however there were no interventions on the POC related to prevention of skin breakdown. During HOSRR#2 it was noted the patient developed a UTI, however the POC lacked assessment of the GU status and interventions related to the patient’s UTI. During HOSRR#2 it was noted the patient was admitted to a hospital emergency department after a bilateral eye chemical burn in March 2025 and returned home with ointment and cream and instructions to keep eye covered per communication log documentation. There was lack of an update to the POC for assessment, treatment and interventions related to the chemical burn. During HOSHV#4 it was noted a circulatory deficit on the POC however there were no interventions documented. During RR#4 it was noted a deficit of anxiety on the POC with the following goal: pt/pcg will be able to manage anxiety with interventions in place within the next IDG meeting however the POC lacked interventions with only assessments documented to accomplish the goal. During HOSRR#9 it was noted the patient had a UTI with antibiotics prescribed. The POC lacked interventions related to assessment of the UTI, instruction on perineal care, hydration, and s/s UTI. During HOSRR#8 it was noted in April 2025 during an IDG meeting, the RN documented a stage 1 pressure area to the patient’s left elbow. The POC was not updated to include interventions for the newly identified left elbow pressure area. This was discussed with the organization leadership.”

“Based on observation, interview, and record review, the agency failed to ensure the medications listed in the patient’s current medication profile and the Plan of Care (POC) were updated, accurate, and complete for one of four patients reviewed (Patient 7) when: Two medications Acarbose (a medication used for diabetes- a condition when there is too much sugar in the blood) 25 milligram (mg - a unit of measurement) one tablet oral (by mouth) three times a day, and Singulair (medication used to prevent asthma and breathing problem) 10 mg one tablet oral daily were not available for use and were still listed in Patient 7’s current POC and current medication profile; Two medications Thera Tears eye drop for extra dry eye therapy and Safe Tussin DM (for cough and congestion) were available for use but the medications were not listed in Patient 7’s current POC and medication Profile. This failure had the potential for Patient 7’s primary caregiver (PCG) and the agency not to be able to identify the significant side effects, drug interactions, duplicate drug therapy, and patient’s noncompliance with prescribed medications and administration of medications not currently prescribed by the physician. Findings: On October 9, 2024, Patient 7’s record was reviewed. Patient 7 was admitted to the agency with the Start of Care (SOC) date of September 20, 2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a lung disease). The physician Certification of Terminal Illness (CTI) for the certification period from September 20, 2024 to December 18, 2024, indicated Patient 7 was dependent on oxygen at three liters per minute through nasal cannula (a small tube that provides oxygen with two prongs through the nose). Patient 7 had a weight loss of eight to 10 pounds within two months, poor mentation, and short of breath on exertion. The POC/IDG (Interdisciplinary Group - a team responsible for the care of the patient) dated September 20, 2024 and October 2, 2024, indicated Patient 7 was on medications Acarbose 25 mg one tablet three times a day, and Singulair 10 mg one tablet oral daily. The frequency of Skilled Nurse (SN) visit indicated two times a week and three visits as needed. On October 10, 2024, at 9 a.m., a home visit was conducted with the Licensed Vocational Nurse (LVN) for Patient 7. Patient 7’s PCG was present during the visit. Patient 7 was observed awake, lying in bed with oxygen on at three liters per minute through nasal cannula. Patient 7 was verbally responsive in short words. The PCG/DPOC (Durable Power of Attorney - a person who was given the power to make decisions on behalf of the patient) signed the consent for the home visit. On October 10, 2024, at 9:53 a.m., a concurrent interview and medication review was conducted with the LVN and the PCG. The PCG stated she managed and administered Patient 7’s daily medications. During the medication reconciliation (a process of comparing a patient’s current medications to the medication orders to identify and resolve discrepancies) the following were observed: - The two medications Acarbose 25 mg one tablet oral 3x a day and Singulair 10 mg tablet oral one tablet daily were not available for use. The medications were listed in Patient 7’s current medication profile and current POC; and The PCG stated the two medications had been discontinued by Patient 7’s primary care physician prior to the SOC. - The two medications Thera Tears eye drop and Safe Tussin DM were available for use but the medications were not listed in Patient 7’s current medication profile and current POC. The PCG stated the medication Thera eye drops had been prescribed by Patient 7’s primary care physician since last year. She stated she had been giving Patient 7 the Thera eye drops one eye drop to each eye every three to four hours as needed for dry eyes. The PCG stated the medication Safe Tussin for cough and congestion was bought over the counter. She had been giving Patient 7 two table spoon every four hours as needed for her cough. The LVN stated she was not aware the medications Acarbose and Singulair were discontinued and were not available. She stated she did not know Patient 7 was using the Thera Tears eye drop and the Safe Tussin cough syrup as needed. She stated she had not conducted the medication reconciliation during her visits on October 1, 2024 and October 3, 2024. The LVN acknowledged the medications Acarbose and Singulair were still listed in Patient 7’s current medication profile and current POC. She stated the medications Thera Tears eye drop and the Safe Tussin cougn syrup should have been listed in Patient 7’s current medication profile and current POC. On October 11, 2024, at 1:30 p.m., the Clinical Coordinator was interviewed. She stated the licensed nurses should have conducted the medication reconciliation on every visit for Patient 7. A review of the agency’s policy and procedure tilled, “Comprehensive Assessment,” dated October 2014, indicated,”...A comprehensive patient assessment will be performed by the hospice IDG...in consultation with attending physician...During the comprehensive assessment relevant information will be documented...Review of current and related past medications, including prescription and over-the-counter medications...” A review of the agency’s policy and procedure titled, “Medication Monitoring,” dated October 2014, indicated, “...Ongoing patient medication monitoring will be use a collaborative approach among the clinicians, physicians, pharmacist, and patients and family/caregivers...Evaluate the continued use of a medication in the current regimen, evaluate patient adherence to the prescribed medication...””