Every finding on record at Lakewood Health System Hospice

Based on observation, interview and document review, the facility failed to include all medications received in the patients' plans of care for 2 of 3 patients (P3, P2) observed during home visits. Findings Include: P3's Plan of Care (POC), revised 6/15/22, identified P3 was admitted to hospice services on 6/2/22, and included diagnoses of multiple myeloma (type of blood cancer) and malignant neoplasm of colon (bowel cancer). P3's POC medication listin included the following medications: - acetaminophen (pain medication) 325 mg tablet, take 650 milligrams (mg) by mouth every 6 hours as needed for pain. -morphine (copied pain medication, also used to treat shortness of breath) 5 mg/0.25 milliliters (ml) take 5 mg by mouth every 2 hours s needed for shortness of breath (SOB) P3's POC dated 6/15/22, failed to include orders for prochlorperazine (nausea medication). P3's most recent Interdisciplinary team (IDT) meeting notes dated 6/28/22, indicated the team met and reviewed P3's general condition, care, services and medications ordered. The IDT notes did not address orders for prochlorperazine along with updated the medication list On 6/29/22, at 12:55 p.m. registered nurse (RN)-B entered P3's home to complete a home visit. During the home visit P3 indicated he would need more prochlorperazine, as he held the medication card up in his hand, and indicated it helped with his stomach. RN-B checked P3's medication card which included 4 tablets of 10 mg of prochlorperazine. The directions directed P3 to take prochlorperazine every 6 hours for nausea and it was ordered by medical director (MD)-A. RN-B told P3 she would reorder the medication and deliver it on her next visit. - RN-B stated she was aware P3 was taking prochlorperazine, but was not aware it was not included on P3's POC. RN-C ordered P3's medications, as they had co-managed P3's cares. RN-B would add prochlorperazine to P3's medication list, which she did at that time. It was important for all medications to be included in residents' POC in case medication interactions or issues arose and it was important for all staff to know what medications residents were receiving. On 6/29/22, at 3:30 p.m. director of home based services (DBS) confirmed P3's current POC and medication listing did not contain prochlorperazine. DBS indicated she would expect all medications to be included in the patients' POC because it was important for all other nurses to be able to see the current orders. P2's POC dated 6/16/22, indicated an admission date of 10/19/21, and included diagnoses of Diagnosis included cerebrovascular disease, atrial fibrillation, Alzheimer's disease and failure to thrive. P2's POC medications listed, included the following medications: -Brimonidine 0.2% eye drops, one drop into both eyes two times per day (BID). -citalopram 10 mg one tablet by mouth (po) one time per day. -Cosopt ophthalmic solution one drop into both eyes BID. -gabapentin 100 mg po every six hours as needed. -Lidocaine 4% patch apply one patch to low back one time daily as needed. -mirtazapine 15 mg one tablet po at bedtime. -Miralax 17 grams po one time per day. -Systane 0.4-0.3% solution one drop into both eyes every morning. -acetaminophen 500 mg two tables po BID. During a home visit on 6/29/22, at 1:00 p.m. RN-A reviewed P2's medication with the assisted living staff where she resided. The assisted living staff identified P2 used her as needed lorazepam the week prior with good results. The assisted living's medication administration record identified P2 had orders for lorazepam 0.5 mg po every four hours as needed for anxiety and morphine 5 mg po every two hours as needed for shortness of breath or pain. During interview on 6/29/22, at 2:00 p.m. RN-A stated the orders for the lorazepam and morphine were initiated on 3/16/22, however, the medications were not included on P2's POC. Medications were reviewed with every visit and RN-A was not sure why they were not included on P2's POC. It would be important to list all the patient's current medications on the hospice POC so the hospices nurses and on call staff would be aware of all the patient's medications that were in use and available for symptom control. P2's POC dated 6/16/22, failed to include orders for lorazepam (antianxiety medication) and morphine (an opioid pain medication). R2's most recent Interdisciplinary team (IDT) meeting notes dated 6/28/22, indicated the team met and reviewed P2's general condition, care, services and medications ordered. The IDT notes did not address morphine and lorazepam was available in the home for use as needed (prn) for symptom control and lorazepam had recently been administered by the assisted living staff with good results to manage P2's anxiety. The medication list was not updated to reflect the medications identfied for use. When interviewed on 6/3/22, at 10:30 a.m. DBS stated medication reconciliation was done at every visit by the case manager. It would be important to have a current list of patient medications so the hospice staff would know what is available in the home for control of symptoms.

Based on interview and document review, the agency failed to document medication set up to maintain current and accurate records of the receipt and disposition of all controlled drugs when setting up controlled substance medications for 1 or 3 patients (P4) reviewed for medication setup. Findings include: P4's plan of care (POC) identified a start of care date of 4/27/22. Diagnoses included dementia, recurrent falls, and progressive aphasia. Medications included lorazepam (antianxiety medication) 0.5 milligrams (mg) every four hours as needed (prn), melatonin 3 mg by mouth (po) every evening, memantine (to treat dementia) 10 mg po two times a day (BID), morphine (opioid pain medication) 5 mg po every hour as needed for pain, and a nutritional supplement one to two containers a day. P4's medical record identified the following: - 4/28/22, a skilled nurse visit was made to deliver morphine and lorazepam. The medications were drawn up in syringes and verified with assisted living staff. Education was provided to the assisted living staff for their use. - 4/29/22, a skilled nurse visit was made and more morphine was drawn up into syringes for the assisted living staff to administer if needed for symptom control. P4's medical record lacked documentation of amount and strength of medications delivered, the doses and amount of syringes drawn up, as well as a current and accurate narcotic count for the disposition of the controlled medications. When interviewed on 6/30/22, at 12:15 p.m. director of home based services (DBS) stated all medications the hospice nurses set up should be documented in the nurses visit progress notes. It was important to document medication set up to track controlled substances to prevent diversion and for other hospice staff to know what and how much of each medication was setup when working with the patients and assisted living staff for symptom control. The agency's policy General Procedures For Medication Administration, Set up and Documentation Of All Medications reviewed 4/26/22, indicated any person setting up or administering medications would be responsible for performing the steps according to the policy. Steps included when setting up medications, staff were to document each medication and the number of days set up, as well as any exceptions. The agency's policy Controlled Medications for Hospice Patients at Home reviewed 4/27/22, indicated it was the responsibility of the hospice staff to ensure all controlled drugs were properly disbursed and safeguarded in the home. Records of controlled drugs in the home were maintained in sufficient detail to reflect accurate accounting of disposition and reconciliation. The hospice nurse would establish a record for each controlled medication with name of medication, date received, amount of medication received and date, time and amount disbursed.