Every finding on record at Ella E.M. Brown Charitable Circle

Upon patient record review, 1 of 14 (Patient #7) 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 #7: on 4/10/25, at admission, Levsin SL 0.125mg tablet was entered as a routine medication, 1-2 tablets every 4 hours. This medication should have been entered as an "as needed" medication every 4 hours as above. The medication profile was not updated throughout hospice services to current date of survey. Administrator verified and agreed and spoke with CM to ensure this was corrected.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #7: POC upon admission (07/10/25) did not contain the "PRN" indicator for Levsin SL 0.125mg tablets, 1-2 tablets every 4 hours. In addition, this was not reflected on the medication record. Administrator verified and agreed with this. CM was notified and record was corrected.

Upon patient record review, 1 of 14 (Patient #9) did not contain evidence in the patient record that the hospice Aide POC/assignment sheets and duties indicated what tasks are to be done by the Aide, to include any of the other individualized/pertinent patient information: Patient #9: patient had oxygen ordered by RN on 6/10/25, after initial SOC 5/16/25, and the Aide POC was not updated to reflect the new order for oxygen. The Administrator confirmed this and agreed.

Upon patient record review, 1 of 11 (Patient #9) 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 #9 Nursing visits on 7/27/22, 8/5/22, 8/11/22, 8/16/22, 8/23/22 and 8/24/22 did not include evidence of wound measurements.

Upon client record review, 1 of 11 (Patient #9) did not have evidence that the hospice plan of care identified the care and services that are needed and specifically identifies which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #9 Review of clinical record revealed wound care orders dated 5/25/22 for dressing changes every Tuesday/Thursday/Saturday and prn., for soiling and dislodgement of dressing; cleanse with 1 application wound cleanser, pat dry with non-sterile gauze; apply Xeroform dressing to fit open wounds; cover with sterile abdominal dressing. Dressing changes to be completed by SNF licensed nurse (LN) or hospice RN. Order did not clearly define who is responsible for wound care dressing changes.