Every finding on record at Blue Wave Hospice Inc

Upon patient record review, 1 of 5 (Patient #2) 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. Patient 2: The medication list, dated 09.28.2021, contained orders for both Ativan 0.5mg 1 tablet po q 12 hours PRN agitation and lorazepam 0.5mg 1 tablet po q 4 hours PRN agitation. This is a duplicate medication order and is unclear as to the correct utilization by the patient per the conflicted dosing frequency. (corrected onsite)

Upon patient record review, 1 of 1 applicable (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 5: The hospice aide care plan, dated 09.30.2021, does not specify the frequency of the tasks the aide is to perform. The aide is to provide the patient a bed bath, shampoo hair, and brush teeth.

Upon patient record review, 1 of 5 (Patient #3) 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 3: The patient record is marked in the plan of care as full code/attempt CPR code status; this indication is also noted in the patient information section of the EMR, so that anyone viewing the record would view the patient's code status as full code/attempt CPR. However, the patient has a signed POLST in the record which indicates DNR code status. The narrative portion of the comprehensive initial nursing assessment indicates that the custodial PCG is in agreement with the DNR orders. (corrected onsite)