Paradigm Health

“Upon patient record review, 1 of 27 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: On 12/05/25, the patients spouse and facility staff called stating that patient was experiencing symptoms of a UTI. Augmentin was ordered and called in, however, there was no visit made, and no follow up on infection or new medication until 12/11/25. In the meantime, on 12/7/25, the facility called stating patient fell but there was no injury followed by a call from the facility the next day on 12/8/25 stating they needed antibiotic cream for abrasions on face received from fall the day prior. No visit that day and no follow up visit or phone call until 12/11/25.”

“Upon patient record review, 9 of 27 (Patient #2, 3, 4, 5, 7, 8, 12, 14, 16) 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 patient is on Melatonin, however there are no interventions or goals on the POC for sleep. The patient has Music Therapy, however there is no POC with interventions or goals for the Music Therapist. The patient is on several medications for constipation, however, there is no evidence of interventions or goals in the POC for constipation. Patient #3: The patient has been prescribed Boost as a nutritional supplement. There is no evidence of interventions or goals for use of supplements in a nutritional POC. The patient is on Melatonin, however there are no interventions or goals on the POC for sleep. The patient has Music Therapy, however there is no POC with interventions or goals for the Music Therapist. Patient #4: The patient is prescribed phenylephrine for cough, there is no evidence of interventions or goals for cough on the POC. The patient is on service for intestinal cancer. They are prescribed Loperamide and Zofran for GI upset - there is no evidence of interventions or goals for GI disturbance on the POC. Patient #5: The patient is taking Seroquel and Sertraline for depression. There is no evidence of interventions or goals related to depression on the POC. The patient is on Melatonin, however there are no interventions or goals on the POC for sleep. Patient #7: The patient has Music Therapy, however there is no POC with interventions or goals for the Music Therapist. Patient #8: The patient is on service with Cirrhosis. The patient is receiving warfarin. Although there is a bleeding precautions POC, there is no evidence of interventions or goals for education on the use of anticoagulants. The patient is a full code, however there is no evidence of interventions or goals regarding advanced directives. The patient is on Melatonin, however there are no interventions or goals on the POC for sleep. Patient #12: This patient is on service for ALS. She has DME including a Trilogy ventilator, a suction machine, and a cough assist. There is no evidence of interventions or goals for these DME items. In addition, there is no evidence of interventions or goals for cough included on the respiratory POC. The patient has a peg tube. There are interventions and goals for the peg tube, however there is no evidence of interventions or goals for the site care ordered for the peg tube. Patient #14: The patient is on service with pulmonary fibrosis and has a nebulizer with nebulized medications. There is no evidence of interventions or goals related to use of a nebulizer on the POC. Patient #16: The patient is on service for Senile degeneration of the brain and co-morbidity of Lewy bodies dementia. The patient is prescribed Zyprexa, citalopram, and Trazadone for depression and anxiety. There is no evidence of interventions or goals for depression or anxiety on the POC.”

“Upon patient record review, 2 of 27 (Patients #5, 12) 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 #5: On 12/28/25, the facility nurse called stating patient was experiencing nosebleeds. The orders were to discontinue aspirin. There was no update to the POC. Patient #12: On 12/23/25, spouse called stating the patient was experiencing increased gas and bloating. New medications ordered, including Simethicone. There was no update to the POC.”