Every finding on record at Breeze Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview and home visit observation. In 1 of 5 (20%) records reviewed, it was revealed that the agency did not ensure the medication profile included all drugs, supplements and alternative treatments that could affect drug therapy. Clinical Record 1: The patient's election of benefit was dated 3/29/23. The initial nursing assessment on 3/29/23 documented “Patient needs O2 and its ordered.” The initial plan of care dated 3/29/23 included an order for "Oxygen 2 LPM (liters per minute) via nasal cannula as needed for shortness of breath." The medication profile did not include Oxygen. During a home visit on 5/10/23, the patient's daughter confirmed that the patient used oxygen and stated, "She had to wear it two or three times yesterday." Personnel Record 3: During interview on 5/9/23, the director of nursing confirmed the finding and stated, "I need to add oxygen to the medication profile now before I forget again."