Every finding on record at Ingma Hospice Care

Upon patient record review, 1 of 5 (Patient #4) 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 Patient 4: The medication profile indicates Voltaren topical gel 1% apply to BLE joints PRN for joint pain; this medication profile does not contain a frequency.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 1: On 08.18.2022, the narrative portion of the SN visit note indicates the SN obtained a verbal order from the MD to initiate O2 at 2L/min via nasal canula PRN for the treatment of SOB. However, the SN did not obtain a written order or update the plan of care to include the O2 therapy. (corrected onsite)