Every finding on record at Fortuna Hospice Inc

Upon patient record review, 5 of 5 (Patient 1,2,3,4,5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1-5: Assessment of imminence of death not documented on any of the records reviewed. Section left blank and no evidence of freehand text documenting this requirement in records.

Upon patient record review, 2 of 5 (Patient #1, 3) 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: Oxygen is listed on the treatment section but not on the medication list in this record. "Oxygen 2-5l/min via NC prn SOB" Patient 3: Oxygen is listed on the treatment section but not on the medication list in this record. "Oxygen 2-5l/min via NC prn SOB"

Upon patient record review, 1 of 5 (Patient #4) 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 4: This patient developed urinary retention on 9/5/22 which required the RN to request verbal order for foley catheter insertion. RN failed to document the size of the foley within the order.

Upon patient record review, 1 of 5 (Patient 4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 4: This patient developed urinary retention on 9/5/22 which required the RN to request verbal order for foley catheter insertion. RN did not update the plan of care to include problems, goals and interventions to manage the urinary symptoms.

Upon client record review, 1 of 5 (Patient 4) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 4: Record contains a discharge summary that states patient was admitted to a non-contracted hospital on 9/7/22.No evidence that a discharge summary and copy of the patient record was provided to that facility.

Upon client record review, 2 of 5 (Patient 4,5) did not have evidence that the discharge summary includes all required information. Patient 4: Revocation form in record indicates patient chose to pursue aggressive treatment. No evidence in discharge summary of the patient's plan of care, latest physician orders, or any other documentation that would assist in post discharge continuity of care. Patient 5: Patient was discharged from service due to move out of service area. No evidence in discharge summary of the patient's plan of care, latest physician orders, or any other documentation that would assist in post discharge continuity of care.