Fairmont Hospice

“Upon patient record review, 7 of 19 (Patient #1,2,3,5,6,7,10) 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: Patient has 2 orders for acetaminophen on the medication profile, Tylenol 500mg PO q4h PRN and Tylenol suppository 650mg PR q6h PRN. There is no evidence of maximum dose warning. Patient 2: Patient has order for nystatin topical in plan of care. There is no evidence of application site. Patient has order for Keflex tablet X 7 days. Order written 9/17/23, but remains active on the medication profile. Patient 3: Patient has order for nystatin topical powder X10 days. Order written 2/15/23, remains active on the medication profile. Application instructions state “topical to skin infection.” Patient 5: Patient has order written 6/8/24 for Augmentin X5 days. Order remains active on the medication profile. Patient 6: Patient has order written 9/28/23 for bacitracin 2 percent for application to affected area for ten days. Patient has order written 5/24/24 for nystatin 100,000units/gram topical powder. Instructions read to apply to skin infection for ten days. Orders remain active on the medication profile and do not contain specific area of application. Patient has order written 9/28/23 for ophthalmic irrigation; extraocular solution. Apply one drop twice daily to affected eye twice daily without identifying which eye or eye(s). Patient 7: Patient with following subcutaneous medications ordered: enoxaparin 40mg and lispro insulin. There is no evidence of instructions to rotate injection sites on the medication profile. Patient with physician’s order for lispro insulin every six hours per sliding scale. There is no evidence of sliding scale on the medication profile. Patient with order for Bisacodyl enteric coated tablets. Administration instructions in plan of care state to administer via peg tube. Patient with physician’s order for Miralax 17 grams daily. There is no evidence of reconstitution instructions on the medication profile. Patient 10: Patient has physician’s order for Bactrim DS written 1/2/24: Bactrim 800/160mg, take one tablet twice a day for 7 days. This order is remains active on the medication profile.”

“Upon patient record review, 12 of 19 (Patient #1,2,3,4,5,6,7,9,11,12,13,14) 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: There is no evidence of the following care plans: pain, edema, falls, mobility. There is no evidence of the following precautions in the plan of care: falls. Patient 2: There is no evidence of the following care plans: oxygen, aspiration. There is no evidence of the following precautions in the plan of care: falls, aspiration. Patient 3: There is no evidence of the following care plans: fall, gastro/feeding tube, oxygen, pain, mobility. There is no evidence of the following precautions in the plan of care: falls, oxygen. Patient 4: There is no evidence of the following care plans: fall, gastro/feeding tube, bleeding, aspiration. There is no evidence of the following precautions in the plan of care: falls, oxygen, bleeding, aspiration. Patient 5: There is no evidence of the following care plans: oxygen, bleeding, aspiration, wound, neuro, foley. There is no evidence of the following precautions in the plan of care: wound, aspiration, bleeding, oxygen. Patient 6: There is no evidence of the following care plans: oxygen, fall, constipation. There is no evidence of the following precautions in the plan of care: wound, fall, oxygen. Patient 7: There is no evidence of the following care plans: neuro, constipation. There is no evidence of the following precautions in the plan of care: seizure, bleeding. Patient 9: There is no evidence of the following care plans: oxygen, bleeding. Patient 11: There is no evidence of the following care plans: oxygen, fall, constipation, aspiration, agitation, suicidal ideation, current pathological fracture related to osteoporosis. Patient 12: There is no evidence of the following care plans: oxygen, neuro, constipation. There is no evidence of the following precautions in the plan of care: oxygen. Patient 13: There is no evidence of the following care plans: mobility, constipation. Patient 14: There is no evidence of the following care plans: neuro, oxygen, falls, mobility.”

“Upon patient record review, 7 of 19 (Patient #1,2,3,5,6,7,10) 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: Patient has 2 orders for acetaminophen in the plan of care. Tylenol 500mg PO q4h PRN and Tylenol suppository 650mg PR q6h PRN. There is no evidence of maximum dose warning in the physician’s orders. Patient with documentation of foley catheter and bilateral peritoneal drains in place. There is no evidence of physician’s orders for any of these drains in the plan of care. Patient 2: Patient has physician’s order for nystatin topical 100,000 units/gram, apply small amount to affected area. There is no evidence of application site in the physician’s order. Patient has physician’s order written 9/17/23 for Keflex tablet X 7 days, 1 tablet my mouth daily for 7 days active on POC. Patient 3: Patient with documentation of feeding tube. There is no evidence of physician’s orders for feeding tube in the plan of care. Patient has physician’s order written 2/15/24 for nystatin topical powder 100,000units/gram powder topical to skin infection 3times daily for 10 days active on POC. Patient 5: Patient with documentation of wound care being provided. There is no evidence of physician’s orders for a wound in the plan of care. Patient has physician’s order written 6/8/24 for augmentin 250-62.5mg/5ml-take 5ml twice daily for 5 days active on POC. Patient 6: Patient has order written 9/28/23 for ophthalmic irrigation; extraocular solution. Apply one drop twice daily to affected eye twice daily. This order without evidence of application site. Patient has order written 9/28/23 for bacitracin 2 percent for application to affected area for ten days. Patient has order written 5/24/24 for nystatin 100,000units/gram topical powder. Instructions read to apply to skin infection for ten days. Both order remain active on POC. Patient 7: Patient with following subcutaneous medications ordered: enoxaparin 40mg and lispro insulin. There is no evidence of instructions to rotate injection sites in the physician’s order. Patient with physician’s order for lispro insulin every six hours per sliding scale. There is no evidence of sliding scale in the physician’s order. Patient with order for Bisacodyl enteric coated tablets. Administration instructions in physician’s order state to administer via peg tube. Patient with physician’s order for Miralax 17 grams daily. There is no evidence of reconstitution instructions in the physician’s order. Patient 10: Patient has physician’s order for Bactrim DS written 1/2/24: Bactrim 800/160mg, take one tablet twice a day for 7 days. This order is still active.”

“Upon client record review, 2 of 19 (Patient #1,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Patient with documentation of foley catheter and bilateral peritoneal drains in place. There was evidence nurse documented draining from drain per MD orders however, there is no evidence of physician’s orders for any of these drains in the plan of care. Patient 5: Patient with documentation of wound care being provided by hospice nurse however, there is no evidence of physician’s orders for a wound in the plan of care.”

“Upon patient record review, 11 of 19 (Patient #1,2,3,5,6,8,9,11,12,13,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Aide care plan without evidence of the following precautions: fall. Patient with documentation of foley catheter in place. No evidence of foley catheter care on aide care plan. Patient 2: Aide care plan without evidence of the following precautions: fall, oxygen, aspiration. Patient 3: Aide care plan without evidence of the following precautions: oxygen, fall. Patient 5: Aide care plan without evidence of the following precautions: oxygen, aspiration, wound. Patient with documentation of foley catheter in place. No evidence of foley catheter care on aide care plan. The following tasks are on the aide care plan: assist with feeding, transfer/ambulation. There is no evidence of ordered frequency for these tasks. Vital signs ordered every visit. There is no evidence of vital sign parameters in aide care plan. Patient 6: Aide care plan without evidence of the following precautions: oxygen, fall. The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 8: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 9: Aide care plan without evidence of the following precautions: oxygen, bleeding. Patient 11: Aide care plan incomplete. Contains only the following information: bed bath every visit. Report abnormal findings to nurse. Patient 12: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 13: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 14: Aide care plan without evidence of the following precautions: oxygen, fall.”

“Upon patient record review 4 of 19 (Patient #3,9,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: Aide visits ordered five times weekly beginning 6/9. There is evidence of visits made outside of frequency during weeks: 6/25,7/1, and 7/9. Visits made these weeks: 6/25,6/26,6/27,6/28,7/1,7/2,7/3,7/4,7/9,7/10,7/12. Patient 9: There is no evidence of aide visit made after 7/17, visit frequency ordered three times weekly, per physician’s order. Patient 13: There is no evidence of aide visit after 7/19, despite ordered visit frequency of three times weekly. Patient 14: Physician’s order for aide visits is three times weekly. There is no evidence of aide visit made after 7/3.”

“Upon patient client record review, 5 of 19 (Patient #8,10,12,13,14) 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 8: Patient with physician’s order for medications without evidence of indications on agency document: ABH cream, Miralax, 3/14/24 quetiapine order. Patient 10: Patient with physician’s order for medications without evidence of indications on agency document: Bactrim DS, mirtazapine amlodipine, trazadone (order number 2). Patient 12: Patient with physician’s order for medications without evidence of indications on agency document: acetaminophen. Patient 13: Patient with physician’s order for medications without evidence of indications on agency document: rosuvastatin, citalopram, levothyroxine, melatonin. Patient 14: Patient with physician’s order for medications without evidence of indications on agency document: quetiapine, memantine, levothyroxine.”