Every finding on record at Legacy Hospice, LLC

Based on observation, record review, and staff interviews, the hospice agency failed to update the plan of care and the medication profile to match the current medical directors orders for Tramadol and lorazepam for one patient (P) (P#1) of four sampled patients (P#1, P#2, P#3, P#4). --- The findings include: During a home visit observation conducted on 7/18/2023 at approximately 12:15 p.m., with the Administrator, also a Registered Nurse (RN) for P#1, revealed that P#1 was admitted on 8/15/2022 with a diagnosis of senile degeneration of the brain (a disease that causes progressive memory loss over a period of time). The surveyor compared P#1 current medication list in her chart at the agency and the Medical Director (MD) orders in P#1 chart at the agency. Discrepancies were found. The following medication doses were not consistent between the current medication profile for P#1 and the MD orders: Medication profile revealed lorazepam (medicine that helps to decrease anxiety or agitation) 0.5 milligrams (MG) by mouth four times a day as needed. The medication profile was reviewed by RN AA on 5/2/2023. Review of ";Physicians Orders" written on 5/24/2023 by the MD to increase the lorazepam to 1 MG by mouth to three times a day as needed for anxiety or agitation. The dose increase failed to be noted on the medication profile. Medication profile revealed Tramadol (medicine that helps to relieve pain) 50 MG by mouth every 12 hours as needed. The medication profile was reviewed by RN AA on 5/2/2023. Review of ";Physicians Orders" written on 5/24/2023 by the MD to increase the Tramadol to 50 MG by mouth every eight hours as needed for pain. The dose increase failed to be noted on the medication profile. During a phone interview at approximately 10:20 a.m., on 7/18/2023, RN AA acknowledged that she ";forgot to update the medication profile." On 7/19/2323 at 10:45 a.m., Administrator revealed that an in-service was conducted with RN AA on 7/18/2023 regarding importance of updating the plan of care and medication profile as changes occur. Administrator revealed that she will start auditing all active charts weekly.