Dahlia Palliative and Hospice Care

“Upon patient record review, 1 of 14 (Patient #1) 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 01: The medication profile includes Debrox Otic drops 6.5%, 1-2 drops three times a day in affected ear for 3 days, ordered on 4/29/24. The medication does not specify which ear to instill the drops and the medication remains on the medication profile although instructed use is for 3 days. The medication profile includes Lidocaine 4% topical patch initiated on 7/14/23, apply to affected area for 12 hours as needed for joint pain, it does not include an application site. The medication profile includes Voltaren Topical Gel 1%, initiated on 6/27/23, apply thin layer on the affected area every 12 hours as needed for mild pain, it does not include an application site. (Orders updated and corrected at time of survey.)”

“Upon patient record review, 1 of 14 (Patient #3) 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 03: The patient was admitted on 6/9/24, the initial bereavement assessment was completed on 7/1/24.”

“Upon patient record review, 2 of 14 (Patient #5, 9) 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 05: The patient was admitted on 4/22/24 with a primary diagnosis of Alzheimer’s, the plan of care does not include a problem statement with interventions and goals for the management of the Alzheimer’s. The record includes documentation of weight loss and a history of dysphagia, the plan of care does not include a a problem statement with interventions and goals for the management of the nutritional status of the patient. The patient record includes evidence of psychosocial needs (the patient resides in a board and care home) and is receiving scheduled monthly visits, the plan of care does not include a problem statement with interventions and goals for the psychosocial needs. Patient 09: The patient was admitted on 6/1/23 with a diagnosis of chronic obstructive pulmonary disease, she receives monthly visits with the MSW, there are no problem statements with interventions and goals in included in the plan of care.”

“Upon patient record review, 2 of 14 (Patient #2, 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 02: Visit frequency orders for volunteer services effective 1/5/24 are entered “as needed,” it does not include a frequency for volunteer visits. Patient 05: Visit frequency order for volunteer services effective 4/22/24 are entered “as needed,” it does not include a frequency for volunteer visits.”

“Upon patient record review, 1 of 14 (Patient #1) 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 01: The medication orders on 4/29/24 for Debrox Otic drops 6.5%, 1-2 drops three times a day in affected ear for 3 days, the medication does not specify which ear to instill the drops. There is no discharge order or date indicated although instruction for use is for 3 days. Medication orders on 7/14/23 for Lidocaine 4% topical patch initiated on 7/14/23, apply to affected area for 12 hours as needed for joint pain, it does not include an application site. Medication orders on 6/27/23 for Voltaren Topical Gel 1%, apply thin layer on the affected area every 12 hours as needed for mild pain, it does not include an application site. (Orders corrected and updated at the time of survey.)”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 01: The patient was admitted on 6/9/23 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery. The record indicates she was started on Lasix 20mg, one pill daily on 12/21/23 for edema, the plan of care does not include interventions and goals for the management of the edema. (Corrected on site.)”

“Upon client record review, 3 of 14 (Patient #1, 4, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 01: The patient was admitted on 6/9/23, there is evidence in the patient record of monthly visits being performed since the start of care, by the MSW and the Spiritual Care Coordinator, there are no orders in the plan of care for the monthly visits for either discipline. Patient 04: The patient was admitted on 6/28/23, there is evidence in the patient record of visits performed monthly by the MSW since 9/25/23 , the plan of care does not include orders for MSW services. The record indicates Spiritual Care visits were performed monthly since August 2023 - to current date, there are no orders in the plan of care for Spiritual Care services. Patient 08: The plan of care includes visit frequency orders for spiritual care effective 12/1/23, as 1 time per month and 1 prn, the patient received phone call visits only on 2/27/24, 5/27/24 an 7/26/24.”