Serenity Hospice and Palliative Care of Texas

“Upon patient record review, 5 of 14 (Patient #2,#3,#4,#5,#8) 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: During home visit Metoprolol 25 1 daily was in home but not on agency medication profile. Caregiver indicated it was a current medication. RN contacted caregiver to remove medication as it was discontinued. Metoclopramide 5mg 1 prn every 8 hours was in home and being given per the caregiver. This was not on agency medication profile. Trazodone on agency medication profile shows 150mg 1 tab at bedtime, however the bottle in home is 100mg take 2 at bedtime. Oxcarbazepine 150mg is in the home and states take 1 tab daily. The medication profile states 150mg take 2 tabs daily. Corrected on site. Patient#3: The medication profile indicates MiraLAX is ordered for patient. There is no evidence of mixing instructions. Corrected on site. Patient#4: The medication profile indicates lidocaine patch ordered for patient. There is no evidence of specific instruction for application. Corrected on site. Patient#5: During home visit, caregiver indicated patient is currently taking gabapentin 300mg 1 twice a day, aspirin 325mg once daily, and acetaminophen 500mg 1-2 tabs by mouth every 6 hours prn. There is no evidence of these medications on agency medication profile. Corrected on site. Patient#8: The record indicates a physician order for oxygen PRN is currently in place. There is no evidence of oxygen on the agency medication profile. Corrected on site.”

“Upon patient record review, 3 of 14 (Patient #7,#8,#9) 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#7: The record indicates patient was admitted with terminal illness of Parkinson’s. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. The record indicates patient is on oxygen, takes medication for hypertension and hypotension, and a foley was placed on 6/28/24. There is no evidence of problems, goals, or interventions related to these issues on Plan of Care. Corrected on site. Patient#8: The record indicates patient was admitted with terminal illness of senile degeneration of the brain. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. Patient#9: The record indicates patient was admitted with terminal illness of malignant neoplasm of anal canal. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. The record indicates that the patient takes cardiac medications, has an ostomy, and has altered nutrition needs which the nurse is providing care and education on. There is no evidence of problems, goals, or interventions related to these issues on Plan of Care. Corrected on site.”

“Upon patient record review 3 of 14 (Patient #7, #8, #9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #7, #8, #9: The record indicates patient was a full code at time of death. There is no evidence of CPR being performed, 911 being called, or any information on why full code measures were withheld. During conversation with Administrator/DPCS, she indicated in each case the patient was found in a condition unable to resuscitate (such as rigor mortis and lividity present) or family withheld CPR and chose not to call 911.”

“Upon patient record review 3 of 14 (Patient #2,#3,#4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient#2: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 11/15/24 - 12/30/24. Corrected on site. Patient#3: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 05/14/24- 07/9/24. Patient#4: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 11/8/24 -01/3/25. Corrected on site.”

“Upon patient client record review, 1 of 14 (Patient #4) 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#4: The record indicates that RN narrative on 11/23/24 and on 12/02/24 were exactly the same. Both notes indicated a new wound (a laceration) and obtaining wound care order. There was no evidence of appropriate authentication based on individual events of each visit. Corrected on site. RN did late entry and redocumented the 12/2/24 narrative with the corrected narrative.”