Eden Hospice

“Upon patient record review, 6 of 23 (Patient #1,#3,#4,#6,#7,#14) 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 contains Calazime paste with instructions to apply to affected area but does not specify the location. Patient 3: During medication reconciliation, the facility and hospice medications did not match. The facility medication profile contained Acetaminophen 325mg tablet; however, this medication was discontinued on the hospice med profile effective 5/18/2026. Patient 4: During medication reconciliation, the facility and hospice medications did not match. The facility medication profile contained Haloperidol 0.5mL; however, the hospice medication profile contained Haloperidol 0.25mL. Patient 6: Medication profile contained Fentanyl 100mcg and Fentanyl 25mcg. However, Fentanyl 25mcg was to be discontinued effective 5/13/2026 but remained active on the chart. Also, administration instructions for Fentanyl 100mcg was incorrect for placement on Wednesday and Saturday. The instructions for placement were ordered to be every 3 days. On 7/08/2026, RN documented instruction to administer Lactulose; however, there was no evidence of Lactulose on the medication profile. Patient 7: Medication profile contained Polyethylene Glycol with no instructions to mix with a diluent. Patient 14: On admission RN documented patient has and uses nebulizer; however, there was no evidence of medications for nebulizer use on the medication profile.”

“Upon patient record review, 3 of 23 (Patient #13,#16,#23) 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 13: On 7/26/2026, the RN documented receiving a call from patient’s daughter indicating patient complaining of pain to rectum and sacral area and states patient has a wound on her sacrum. RN made a visit on 7/27/2026; however, there was no evidence of assessment of sacrum in the visit documentation. Patient 16: Afterhours RN documented on visit dated 7/11/2026 that patient had a fall. Patient was found laying in floor, struck head on bedside, had skin tear to elbow and complaining of hip pain. However, there was no evidence of a follow up visit made until 7/15/2026. Patient 23: On 5/10/2026, RN documented need for visit, as SNF called to report patient in extreme pain. RN made visit and obtained a new order for Fentanyl patches. However, there was no evidence of a follow up visit to assess pain relief until 5/13/2026. Patient expired on 5/14/2026.”

“Upon patient record review, 5 of 23 (Patient #1,#4,#5,#12,#15) 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 nursing documentation since admission identified patient is a risk for respiratory infection and dysphagia. There was no evidence of problems, interventions and goals related to the issues included in the plan of care. Patient 4: The patient has a diagnosis of Parkinson’s Disease with documented dementia and dysphagia since admission. There was no evidence of problems, interventions and goals related to the issues included in the plan of care. Patient 5: The patient has a diagnosis of Vascular Dementia with documented dysphagia and risk for skin breakdown due to immobility since admission. There was no evidence of problems, interventions and goals related to the issues included in the plan of care. Patient 12: The nursing documentation since admission identified patient is a risk for dysphagia. There was no evidence of problems, interventions and goals for dysphagia included in the plan of care. Patient 15: The patient is a risk for bleeding due to use of Aspirin since admission. There was no evidence of problems, interventions and goals related to this issue in the plan of care.”

“Upon patient record review, 7 of 23 (Patient #1,#2,#3,#4,#6,#7,#14) 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 medical record contains an order for Calazime paste with instructions to apply to affected area but does not specify the location. Patient 2: On 7/21/2026, RN documented patient’s use of Thick-It for nectar thickened liquids; however, there was no evidence of an order for thickener. Patient 3: During medication reconciliation, the facility and hospice medications did not match. The facility medical record contained orders for Acetaminophen 325mg tablet; however, order to discontinue this medication was effective 5/18/2026. Patient 4: During medication reconciliation, the facility and hospice medications did not match. The facility medical record contained Haloperidol 0.5mL; however, the hospice medical record contained order for Haloperidol 0.25mL. Patient 6: Medical record contained order for Fentanyl 100mcg and Fentanyl 25mcg. However, Fentanyl 25mcg was to be discontinued effective 5/13/2026 but remained active on the chart. Also, administration instructions for Fentanyl 100mcg was incorrect for placement on Wednesday and Saturday. The instructions for placement were ordered to be every 3 days. Patient 7: The medical record contained an order for Polyethylene Glycol with no instructions to mix with a diluent. Patient 14: On admission RN documented patient has and uses nebulizer; however, there was no evidence of an order for nebulizer medications on the medical record.”

“Upon client record review, 2 of 23 (Patient #6, 16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: On 7/08/2026, RN documented instruction given to administer Lactulose; however, there was no evidence of an order for Lactulose to be given on the medical record. Patient 16: The medical record also contained an order for social worker visit frequency of once monthly. There was no evidence of a visit in June with last visit on 5/20/2026.”

“Upon patient record review, 2 of 23 (Patient #4,16) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 4: On 7/13/2026 and 7/20/2026, the RN documented patient having recurrent episodes of hypotension. However, there was no evidence of IDG discussion regarding current Losartan order or other management of hypotensive symptoms. Patient 16: Afterhours RN documented on visit dated 7/11/2026 that patient had a fall. Patient was found laying in floor, struck head on bedside, had skin tear to elbow and complaining of hip pain. There was no evidence of communication with the IDG.”