Every finding on record at High Desert Hospice Services, Inc.

Observed in Record Review. In 7 of 10 patient records reviewed, During document review and confirmed by the Director of Nursing. It had been identified that the updated Plan of care and IDG review had not documented progress to goals. Example During review of HOSrr#5 the initial plan had been developed over 6 months ago to include that the patient/caregiver will be knowledgeable with safety measures. The progress to goals during current update remained at 0%. Review of all goals remained at 0%

Observed in Record Review. In 1 of 10 patient records reviewed and confirmed by the Director of Nursing. It had been identified that the plan of care had not included interventions or goals based on the patient assessment . Example: During review of HOSrr#6 the patient assessment had identified a draining breast wound being cared for by the patient and right hand edema. SN notes documented the ongoing assessment of the breast wound and interventions to decrease the edema, however the plan of care had not identified interventions or goals.

Observed in Record Review. In 7 of 10 patient records reviewed, Confirmed by the Director of Nursing. Medication orders had not al elements for PRN medications with duplicate therapies per organization policy. Example: During review of HOS v#1 medication orders had documented Morphine 0.25 po prn for pain, Tramadol 50mg prn for pain, Morphine 0.25 prn for shortness of breath and Atrovent 17 mcg/act 2 puffs prn for shortness of breath. Elements to include which medication to administer first had not been documented. HOSrr#7 had documented Lorazepam1mg/1tab prn for anxiety, Xanax 0.25mg prn for anxiety, Tylenol 1-2 tabs prn for pain and Morphine 0.25mg prn for pain.

Observed in Individual Tracer. In 1 of 3 Hospice visits observed and confirmed by the Director of nursing. A list of medications had not been accurate to contain all medications the patient had been taking. Example: During observation of HOSv#3 it had been observed that OTC medications , identified by the surveyor , had been found at bedside to include Advil, tums and preparation H. Facility staff confirmed that the medications had been there since patient arrived at facility prior to admission to hospice. Facility staff confirmed that the medications had been administered on an as needed basis.