Every finding on record at Celestial Care Hospice

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-SN documents that patient takes the following constipation regime medications, which are not documented on Medication Profile: Senna 8.6 mg, MOM 400mg/mL, Dulcolax suppository, and docusate sodium 100mg.

Upon patient record review, 1 of 14 (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. #2-SN documents that patient takes the following constipation regime medications, Senna 8.6 mg, MOM 400mg/mL, Dulcolax suppository, and docusate sodium 100mg however, there are no orders for these items.

Upon patient client record review, 1 of 5 records (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. Patient 3: The medical record contained differing medication lists in the medication profile and medications listed on the plan of care. The plan of care list was verified by nursing leadership as accurate and the handwritten medication profile was data entry error.