Every finding on record at Capital Hospice Services

Upon patient record review, 1 of 14 (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. 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 #2-There is a duplicate drug entry on the Medication Profile for Diclofenac Sodium 25mg BID.

Upon patient record review, 3 of 5 (Patients #1, 2, 4) 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. Patients 1 and 4: The initial comprehensive assessment and physician's CTI indicate that the patient is incontinent of urine. The IPOC indicates that the patient is supplied with diapers due to incontinence. The SN's initial assessment includes a Braden scale indicating that the patient is occasionally moist. However, there has not been a care plan initiated or developed to include goals and interventions related to the patient's GU status or risk for skin breakdown. (corrected onsite) Patient 2: The initial plan of care, dated 08.24.2022, includes an order for a Foley catheter. The initial comprehensive assessment and physician's CTI also indicate that the patient utilizes a Foley catheter. The SN's initial assessment includes a Braden scale indicating that the patient is moist. It also indicates the patient is bedbound and requires assistance with repositioning. However, there has not been a care plan initiated or developed to include goals and interventions related to the patient's GU status or risk for skin breakdown. (corrected onsite)

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 order for the Foley catheter on the initial plan if care, dated 08.24.2022, indicates change 16French Foley and provide catheter care every 3-4 & PRN. This is an incomplete treatment order as it does not contain a catheter balloon size, complete frequency, or indicator for the PRN order. (corrected onsite)

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 equipment and supply needs. Patient 2: The comprehensive initial nursing assessment, dated 08.24.2022, indicates the patient utilizes a trapeze bar for repositioning. The trapeze bar was observed to be present during the home visit. However, the plan of care does not indicate the patient has a trapeze bar. (corrected onsite)