Comfort Nursing Care Hospice, Inc.

“Upon patient record review, 5 of 14 (Patient #2,3,4,6,7) 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 #2: The record indicates Triamcinolone acetonide 0.025% is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Antifungal powder 1% is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Corrected on site. Patient #3: The record indicates Clobetasol Propionate 0.05% is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Corrected on site. Patient #4: The record indicates Calmoseptine is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Corrected on site. Patient #6: The record indicates Voltaren is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Corrected on site. Patient #7: The record indicates Hydrocortisone cream is ordered topically PRN. However, there is no evidence of a specified area of application noted on medication profile. Corrected on site”

“Upon patient record review, 4 of 14 (Patient #1,#2,#4,#6) 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 #1, #2, #4, #6: The record indicates the initial bereavement assessment was completed but did not identify the primary bereaved in the assessment. Corrected on site.”

“Upon patient record review, 6 of 14 (Patient #2,#3,#4,#6,#7,#8) 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: The record indicates per nurse documentation that the patient has care needs related to high risk of skin impairment, sleep impairment, nutrition/diet, and incontinence. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient #3: The record indicates per nurse documentation that the patient has care needs related to incontinence, fall precautions, and nutrition/diet including cardiac and diabetic diet, NAS, low fat/cholesterol, controlled carbohydrate and Glucerna. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient #4: The record indicates per nurse documentation that the patient has care needs related to nutrition, aspiration precaution, incontinence and high risk of skin impairment. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient #6: The record indicates per nurse documentation that the patient has care needs related to psychosocial and incontinence. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient #7: The record indicates per nurse documentation that the patient has care needs related to nutrition/diet needs, diabetic diet and Glucerna. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient #8: The record indicates per nurse documentation that the patient has care needs related to education and use of Glucometer kit, monitoring blood sugar, and gout management. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site.”

“Upon patient record review, 1 of 14 (Patient #5) 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 #5: The record indicates there is form in the chart that indicates Dr William as the choice for attending. On another form it is indicated Dr Benyamin as the choice for attending physician. Staff verified the incorrect form. Corrected on site.”