Tranquil Oaks Hospice Care

“Upon patient record review, 2 of 14 (Patient #1,#4) 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 #1: The medication profile indicated Melatonin 5 mg tablet, strength 05 mg, and instruction to take 1 tablet daily as needed for sleep. Discrepancy with the milligram and the strength noted. Patient #4: The medication profile instructs nystatin powder to be applied to the affected area 2 times daily for 14 days. No evidence noted where the medication is to be applied. The medication profile has diclofenac topical gel, to apply every 6 hours to affected joint as needed. No evidence noted where to apply the medication. Medication reconciliation completed while performing a home visit, Milk of Magnesia and PRN oxygen were present on the hospice medication profile but was not reflected on the LTC medication profile.”

“Upon patient record review, 2 of 14 (Patient #5, #8) 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 #5: The patient admitted on 5-9-24. The initial bereavement risk assessment was completed on 2-24-25 and is outside of the 5 day requirement. Patient #8: The patient admitted on 4-24-26. The initial bereavement risk assessment was completed on 4-30-26 and is outside of the 5 day requirement.”

“Upon patient record review, 3 of 14 (Patient #1,#2,#4) 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 #1 The patient was admitted with Senile Degeneration of the Brain. It was documented patient has a complaints of pain, constipation, incontinence, unsteady gait, sleep disturbance and altered skin integrity. There is no evidence the plan of care reflects patient goals, interventions and outcomes for these issues. Documentation by RN noted patient uses a cane for ambulation. No evidence of safety with the use of a cane noted in the care plan. The medical record indicated patient was on aspirin therapy. There was not evidence of bleeding precautions initiated on the plan of care. Patient #2: The medical record indicated patient has a unsteady gait requiring use of a walker. There is no evidence that the hospice plan of care reflects patient goals, interventions and outcomes for safety with use of a walker. The medication profile indicates oxygen therapy for shortness of breath. There is no evidence of patient goals and interventions for management of shortness of breath. Patient #4: The medical record indicated the patient is incontinent and utilizes barrier cream for prevention of impaired skin integrity. There is no evidence the plan of care reflects patient goals, interventions and outcomes for monitoring skin integrity.”

“Upon patient record review, 3 of 14 (Patient #1,#2,#4) 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 #1: The record indicated an order for melatonin 5 mg, strength 05, to take 1 tablet every night with discrepancy in strength noted. The record indicated an order for the nurse to check oxygen saturation every visit if patient appears short of breath. The order was lacking additional instructions on parameters and when to notify the physician. Patient #2: The record indicated an order for the nurse to check oxygen saturation every visit if patient appears short of breath. The order was lacking additional instructions on parameters and when to notify the physician. Patient #4: The record indicated an order for nystatin powder to the affected area without evidence of a specific location. The record indicated an order for Diclofenac topical gel to apply every 6 hours to affected joints as needed without evidence of a specific location.”

“Upon patient record review, 6 of 14 (Patient #1,#2,#3,#4,#5,#9) 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 equipment and supply needs. Patient #1: Documentation by the nurse in the medical record indicated the patient utilized a cane with ambulation. No evidence of this equipment present on the hospice plan of care. Patient #2: Documentation by the nurse in the medical record indicated the patient utilized a nebulizer machine, walker, and oxygen. No evidence of this equipment present on the hospice plan of care. Patient #3: Documentation by the nurse in the medical record indicated the patient utilized oxygen and a Hoyer lift. No evidence of this equipment present on the hospice plan of care. Patient #4: Documentation by the nurse in the medical record indicated the patient had a fall mat, shower chair and bed rails. No evidence of this equipment present on the hospice plan of care. Patient #5: During a home visit a bedside commode, fall mat and heel protectors were noted in the patients room. No evidence this equipment present on the hospice plan of care. Documentation by the nurse in the EMR wound console of weekly wound care being provided. No evidence of wound care supplies listed on the hospice plan of care. Patient #9: Documentation by the nurse in the medical record indicated the patient utilized a hospital bed, over the bed table, and shower chair. No evidence of this equipment present on the hospice plan of care.”

“Upon patient record review, 2 of 14 (Patient #3,#5) 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 #3: Documentation by the nurse in the medical record identified a Hoyer lift was to be used with all transfers from bed to chair. The aide plan of care was not updated to reflect the use of a Hoyer lift. Patient #5: During a home visit heel protectors, half rails, fall mat and bedside commode were present in the patients room. No evidence these items were identified on the aide plan of care. No evidence of documentation or instructions to when the heel protectors should to be applied. Documentation by the nurse identified the patient requires assist of 1 to stand and transfer from the bed to wheelchair. The wheelchair was not identified as a form of mobility on the aide plan of care.”

“Upon patient client record review, 1 of 14 (Patient #2) 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 #2: The medical record shows the start of care began on 4-4-26. This date did not match the signed election of benefits document which noted the hospice start of care to begin 4-3-26.”