Every finding on record at Cardinal Care Hospice

Upon patient record review, 9 of 12 (Patient #1,#3,#4,#5,#6,#7,#8,#9,#10) 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#1: The record indicates the patient was ordered calmoseptine and A&D ointment by physician on admit order. There is no evidence of these items on the medication profile. Corrected on site. Patient#3: The record indicates patient has a physician order for Oxygen 2-3LPM via NC PRN, calmoseptine, and A&D ointment. There is no evidence of these item on the medication profile. Corrected on Site. Patient#4: The record indicates Oxygen was ordered 2lpm prn on 10/13/23. On 11/13/23, calmoseptine was ordered by physician to be applied to coccyx. There is no evidence of these items being included on the medication profile. Corrected on site. Patient#5: The record indicates an order on admit for calmoseptine and A&D ointment. On 12/6/23 nurse documents using Neosporin for wound near left eye. There is no evidence of these items on the medication profile. Corrected on site. Patient#6,#8,#10: The record indicates a physician order for Oxygen, calmoseptine, and A&D ointment. There is no evidence of these items on the medication profile. Corrected on site. Patient#7: The record indicates a physician order for Oxygen, calmoseptine, and A&D ointment. There is no evidence of these items on the medication profile. Corrected on site Patient#9: The record indicates a physician order for Oxygen and A&D ointment. There is no evidence of these items on the medication profile. Corrected on site. Corrected on site

Upon patient record review, 1 of 12 (Patient #8) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#8: The record indicates patient had wounds on admit. There is no evidence of measurements of wounds during comprehensive assessment on admit or week of April 15th.

Upon patient record review, 9 of 12 (Patient #1,#2,#3,#4,#5,#7,#8,#9,#10) 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#1,#4,#9,#10: The record indicates patient is ordered oxygen PRN. There is no evidence of goals or interventions related to this on the plan of care. Corrected on site Patient#2: The record indicates the patient has an IV and is receiving Normal saline intravenously. There is no evidence of goals or interventions related to this on the plan of care. The record indicates Nurse performing site care for 16 Fr g-tube. There is no evidence of goals or interventions related to g-tube care on the plan of care. Corrected on site. Patient#3: The record indicates patient has needs for fall precautions, soft diet, ensure, crushed meds, oxygen, and risk of skin impairment. There is no evidence of goals or interventions related to these issues on plan of care. Corrected on site. Patient#4: The patient was admitted with a terminal diagnosis of atherosclerotic heart disease. There is no evidence of goals or interventions related to this diagnosis on plan of care. Corrected on site. Patient#5: The record indicates the patient has been diagnosed with dysphagia. There are no evidence of goals or interventions related to this on plan of care. Corrected on site. Patient#7: The record indicates patient was ordered oxygen, puree diet and ensure. There is documentation of patient requiring aspiration precautions. There is no evidence of goals or interventions related to these needs on plan of care. Corrected on site. Patient#8: The record indicates patient has an order for oxygen and is receiving wound care. There is no evidence of goals or interventions related to these needs on the plan of care. Corrected on site.

Upon patient record review, 4 of 12 (Patient #2,4,8,9) 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 record indicates patient has an IV that is being used to administer fluids. There is no evidence of a physician order for IV care or maintenance including changing of IV tubing and cannula. Corrected on site Patient#4: The record indicates patient is receiving wound care which includes cleaning with wound cleanser, covering with nickel thick layer of Santyl and covering with mepilex. There is no evidence of physician order for wound care. Corrected on site Patient#8: The record indicates patient receiving wound care for venous stasis to bilateral lower extremities, or pressure wound to Left heel and Right hip. There is no evidence of physician order for wound care. Corrected on site Patient#9: The record indicates an order for Miralax 17grams per powder dose one time daily and PRN. There is no evidence of instructions specific to diluent. Corrected on site.

Upon patient record review, 8 of 12 (Patient #1,#2,#4,#5,#6,#7,#9,#10) 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#1: The record indicates patient having wheelchair, walker, bed, oxygen, chux, gloves, diaper, suction, nebulizer, and oral swabs. There is no evidence of these items being included on plan of care. Corrected on site Patient#2: The record indicates patient having wheelchair, oxygen, bed, IV supplies, oxygen, nebulizer, suction, OTB table, diaper gloves, oral swabs. There is no evidence of these items being included on plan of care. Corrected on site Patient#4: The record indicates patient having wheelchair, oxygen, bed, over the bed table, diapers, gloves, chux, suction. Corrected on site Patient#5: The record indicates patient having Bed, over the bed table, diaper, chux, gloves, oral swabs. There is no evidence of these items being included on plan of care. Corrected on site Patient#6: The record indicates patient having wheelchair, oxygen, transfer equipment, bed, oxygen, diaper, chux, oral swabs. There is no evidence of these items being included on plan of care. Corrected on site Patient#7: The record indicates patient having oxygen, walker, suction, neb, oral swabs, gloves, diaper. There is no evidence of these items being included on plan of care. Corrected on site Patient#9: The record indicates patient having oxygen bed, suction, neb, chux, gloves, diaper, swab. There is no evidence of these items being included on plan of care. Corrected on site Patient#10: The record indicates patient having oxygen, bed, neb, suction, chux, gloves, diaper, oral swabs, disposable wash cloths. There is no evidence of these items being included on plan of care. Corrected on site

Upon patient record review, 2 of 12 (Patient #1,#2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: The nurse visit frequency is 1 time per week and 2 prn visits. There is no evidence of a visit or a missed visit for the week of 3/3/24 and week of 4/14/24. The visit frequency for spiritual care is 1 time per month and 1 PRN. There is no evidence of a visit documented and no missed visit documented for March or April. Corrected on site. Patient#2: The nurse frequency is ordered 1 time for week one with 1 prn visit, then 2 times a week with 1 prn visit. The record indicates patient has received daily SN visits since admit. Corrected on site.

Upon patient record review, 1 of 12 (Patient #4) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient#4: The record indicates Hastings Wound Solutions was providing specialized care to patient for graft on wound. There is no evidence in any IDG notes mentioning Hastings wound care being provided or coordination of care between agency and Hastings.

Upon patient record review 1 of 12 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: The aide frequency is ordered for 2 times a week starting on week 2. There is no evidence of any aide visits being made or missed since admission 10/10/24. Corrected on site.

Upon patient record review, 1 of 12 (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient#1: There is no evidence of a physician narrative for initial CTI on 2/22/24, the CTI was signed by the physician.

Upon patient record review, 2 of 12 (Patient #1, 4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient#1: There is no evidence of a physician narrative for recertification CTI on 5/7/24. The CTI was signed by the physician. Patient#4: There is no evidence of a physician narrative or a physician signature for recertification CTI on 3/17/24. There is no evidence of a narrative on CTI for 1/17/24, this CTI is signed by the physician.

Upon patient record review, 1 of 12 (Patient #8) 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#8: The documentation of nurse for 4/3/24-4/18/24 states that wound care was performed. However, there is no evidence of documentation as to what the nurse did for the wound care.