Every finding on record at Coral Hospice, Inc.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4: Although the RN performed a screening for Spiritual care, the initial nursing assessment did not include elements of the spiritual care initial assessment including but not limited to spiritual beliefs and rituals, as well as the nature and scope of spiritual concerns and needs.

Upon patient record review, 7 of 14 (Patients #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 Patients #4, 5, 6, 7, 8, 9, 10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting. Patient #6: The patient record has no evidence of a medication profile in the EMR.

Upon patient record review, 1 of 14 (Patients #7) 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 #7: The patient has oxygen. There are 3 oxygen orders written on the same day and all three remain active. 1. Oxygen treatment at 2 LPM via Nasal Cannula Continuously for SOB. May titrate up to 4 LPM if oxygen is at or below 90% 2. Oxygen at 4 LPM via nasal cannula or face mask continuously SOB/dyspnea, anxiety and agitation. May titrate to 6-10 LPM as needed on basis of titration Scale: If O2 sat > 90% continue oxygen rate. If SPO2 86-89% increase oxygen by 2 LPM (6LPM). If SpO2 is 81-85% increase O2 by 4LPM (8L) If SpO2 <80% increase O2 by 6LPM (10 L) recheck SpO2 after 5 minutes and follow guidelines if you reach the max level of 10 LPM and patient SpO2 is < 90% notify MD/Case Manager. 3. Oxygen at 15 liters per minute via non-rebreather mask as needed for severe shortness of breath/respiratory failure. Administer 30 minutes and then re evaluate. If no relief after 30 minutes notify hospice case manager.

Upon client record review, 3 of 14 (Patient #4, 6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The order in the record calls for SC once monthly and PRN. There is no evidence of SC visits in the chart. Patient #6: On 05/28/25, the record states at 7:30pm, "administered morphine 5mg as per MD orders to be administered every 2 hours as needed" There was no order for Morphine in the patient record. Morphine was administered on 05/28/25 at 7:30pm, 11pm. Morphine was administered by hospice nurse multiple times on 05/28/25 and 05/29/25. On 05/28/25, the record states that nurse administered Lorazepam 1mg SL. The nurse note states Lorazepam to be administered q6 hours as needed. There was no order from a physician in the record. Lorazepam was administered multiple times on 05/29/25 as well without order. On 05/29/25, Nurse documented administering Zofran 8mg SL per MD order. There is no evidence of an MD order for Zofran in the record. Patient #10: The patient was admitted with a stage 2 on the coccyx. The nurse documented "cleans with NS pat dry apply triple antibiotic ointment and cover with a foam dressing." There was no order written for this wound that would include the above and in addition, frequency of dressing change and who was to do the dressing change.

Upon patient record review 1 of 14 (Patient #10) 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 #10: On 02/25/25, The Aide did not complete the following ordered tasks: 2 person transfer, fall precautions, feeding assistance. There was no documentation of notifying the RN that these things were not completed, nor is there documentation that the patient declined these tasks. The Aide documented completing tasks that were not ordered on the Aide assignment including, brush and comb hair. There is no documentation of contacting the RN to get Aide order to complete these tasks. On 03/01/25, the Aide documented completing the following tasks that were not on the aide assignment: urinary incontinent care, ambulation, bedrails (patient did not have bedrails) as well as turn and reposition patient. There is no documentation of contacting the RN to get Aide order to complete these tasks.