Every finding on record at Bridge to Wellness Hospice

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 profile contains Nitroglycerin 0.4mg 1 tab sublingual prn. There is no evidence of a frequency. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) 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 2: The plan of care contained an order for nitroglycerin 0.4mg 1 tab sublingual prn. There was no evidence of frequency. Corrected on site.

Upon patient record review, 2 of 5 (Patient #4,#5) 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 4: The aide care plan contains orders to apply adult diapers to patient and use chux for incontinence care. There was no evidence of these incontinence supplies on the plan of care. Patient 5: The medical record contains an RN comprehensive assessment with checked boxes that patient has a bed and air mattress. The was no evidence of a bed or air mattress on the plan of care. The aide care plan indicates the patient is to have adult diaper changed and chux for incontinence supplies. There was no evidence of adult diapers or chux on the plan of care.

Upon client record review, 1 of 5 records (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The plan of care contains order for SN visits 2 times per week. The medical record contains evidence of 3 SN visits made to patient home the week of 1-2-22 to 1-8-22 (1-3-22, 1-6-22, 1-8-22). There was no evidence that any of the visits were a PRN visit.

Upon patient record review 2 of 2 applicable (Patient #4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient 4: The plan of care contains order for Aide to visit 2 times per week. There was no evidence of a second aide visit the week of 1-2-22 to 1-8-22. Additionally, the medical record contains 3 aide visits, 1-7-22, 1-10-22, 1-14-22. There is evidence in all 3 visits the aide documented performing incontinence care and patient using a walker. These tasks were not included in the aide assignment. Patient 5: The medical record contains documentation from aide visit 1-10-22 that patient used a walker. This was not included in the aide assignment. The aide on 1-10-22 documented she gave patient a shower. Shower was not on the aide assignment (bed bath was assigned).

Upon client record review, 2 of 2 applicable records (Patient #4,#5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 4: There is evidence that patient revoked hospice on 1-17-22, there was no evidence of a discharge summary being forwarded to the attending physician. Patient 5: There is evidence that patient revoked hospice on 1-12-22, there was no evidence of a discharge summary being forwarded to the attending physician.