Serenity Hospice

“Upon patient record review, 7 of 19 (Patients #3,#5,#8,#9,#10,#11,#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 3: The medication profile contained Biofreeze topical gel no area defined for administration. Corrected on site. Patient 5: The medication profile contained Lidocaine topical patches no area defined for administration. The facility and hospice medication profiles did not match for Haldol with the facility identifying patient had an order for scheduled daily tablets and PRN daily tablets that were not on the hospice profile. Corrected on site. Patient 8: The medication profile contained polyethylene glycol oral powder with no instructions to mix with a diluent and duplicative oxygen listings. Corrected on site. Patient 9: The medication profile contained Miralax oral powder with no instructions to mix with a diluent and had oxygen on the medication profile in error. Corrected on site. Patient 10: The facility medication profile contained Milk of Magnesia which was not on the hospice profile. Corrected on site. Patient 11: The medication profile contained diclofenac topical gel, lidocaine topical patch, and methyl salicylate-menthol topical cream with no areas defined for administration. Corrected on site. Patient 14: The medication profile contained oxygen with no delivery method and polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site.”

“Upon patient record review, 10 of 19 (Patients #1,#2,#3,#6,#7,#9,#10,#12,#13,#14) 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 1,3,7,9,10,12,14: The medical records contained nursing documentation upon admission identifying the patients were a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 2: The medical records contained nursing documentation upon admission identifying the patient was a high risk for falls and aspiration due to dysphagia. There was no evidence of problems, goals, and interventions related to fall safety and dysphagia included in the plan of care. Corrected on site. Patient 6: The medical records contained nursing documentation upon admission identifying the patients were a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. The care plan also contained active problems, goals, and interventions related to spiritual care services to be provided by the chaplain in error due to patient declining services. Corrected on site. Patient 13: The medical records contained nursing documentation upon admission identifying the patient was a high risk for falls and constipation. There was no evidence of problems, goals, and interventions related to fall safety and constipation. The care plan also contained an active problem of cardiac dysfunction without goals and interventions. Corrected on site.”

“Upon patient record review, 6 of 19 (Patients #3,#5,#8,#9,#11,#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 3: The medical record contained an order for Biofreeze topical gel with no area defined for administration. Corrected on site. Patient 5: The medical record contained an order for Lidocaine topical patches with no area defined for administration. Corrected on site. Patient 8: The medical record contained an order for polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site. Patient 9: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. Corrected on site. Patient 11: The medical record contained orders for diclofenac topical gel, lidocaine topical patch, and methyl salicylate-menthol topical cream with no areas defined for administration. Corrected on site. Patient 14: The medical record contained an order for oxygen with no delivery method and polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site.”

“Upon patient record review, 7 of 19 (Patients #2,#4,#6,#7,#8,#10,#12) 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 2: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, hospital bed, and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a cane and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a cane. There was no evidence of an order for the cane included in the plan of care. Corrected on site. Patient 7,8,10: The medical records contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of orders for the walker included in the plans of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a commode. There was no evidence of an order for the commode included in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #1,#11) 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 1: The plan of care included active psychosocial problems, goals, and interventions to be completed by the social worker despite services discontinued with last visit 5/28/24. Corrected on site. Patient 11: The plan of care included active psychosocial problems, goals, and interventions to be completed by the social worker despite services discontinued per order 6/12/24. Corrected on site.”