Every finding on record at La Vera Hospice, Inc

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 14: Upon record review, a skilled nursing visits were performed on 5/21/23, 5/14/23, 5/7/23, and 4/30/23 by the LVN. The record indicates that the patients blood pressure on 5/21/23 was 249/109, on 5/14/23 the blood pressure was 189/99, on 5/7/23 the blood pressure was 200/99 and on 4/30/23 the blood pressure was 180/90. The plan of care includes orders to notify the physician for systolic blood pressure greater than 160 and/or diastolic blood pressure greater than 90. There is no evidence in the record that the LVN contacted the physician. The patient record includes 4 medications for the treatment of hypertension (Clonidine, Lisinopril, Metoprolol and Hydralazine.) There is no evidence that the LVN assessed for medication compliance, provided interventions for medication administration, or made contact with the RN case manager.

Upon patient record review, 3 of 14 (Patient #4, 5, 7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 04: The hospice task assignment for shower, shampoo, hair care, oral care, nail care, linen change, empty trash, tidy patients room do not include the frequency of task performance. The patient takes aspirin 325mg daily as a blood thinner, the aide care plan does not include bleeding precautions. Patient 05: The hospice task assignment for shower, shampoo, hair care, oral care, nail care, linen change, empty trash, tidy patients room do not include the frequency of task performance. The patient takes aspirin 81mg daily as a blood thinner, the aide care plan does not include bleeding precautions. Patient 07: The hospice task assignment for bed bath, hair care, shaving, oral care, nail care, linen change, tidy patients room, and empty trash do not include the frequency of task performance.