Every finding on record at Lower Cape Fear Hospice, Inc

Upon patient record review, 2 of 14 (Patient #5, 13) 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 • Drug therapy currently associated with laboratory monitoring Patient #5: ALF medication profile has Seroquel ordered, where as hospice medication profile does not. Hospice nurse reports medication had been discontinued. Patient #13: During home visit with RN, noted medication discrepancies between hospice med profile and what patient is reportedly taking: Patient is taking Furosemide 20 mg po daily prn for fluid retention. The medication had been discontinued on the hospice medication profile. The patient takes Azithromycin 250 mg po M-W-F prophylactically. The hospice medication profile reflects that the medication was previously discontinued. Guaifenesin ER on medication profile is ordered every 12 hours, but the patient reports that she generally takes only once per day most days prn. Hyzaar 100-12.5 mg 1/2 tab daily po is on hospice medication profile. Patient is taking whole tablet. Patient and RN reported and confirmed that patient is using oxygen 10 L/M via nasal cannula. The hospice record has 9 L/M as most recent prescribed rate 6/11/24.

Upon patient record review, 2 of 14 (Patient #1,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Admitted 6/13/24 with standing orders for If patient is on Coumadin, draw PT and/or INR monthly and If patient is on Lovenox, draw CBC monthly. However, patient admitted with specific order for Eliquis. The Coumadin and Lovenox standing orders were not discontinued to reflect individualized care planning. Patient #13: Admitted 6/24/23 with standing orders for may initiate hospice standing order: Oxygen via nasal cannula at 1-4 LPM PRN dyspnea or for comfort. Patient also had physician order specifically for 2-4.5 continuous LPM via nasal cannula. Furthermore, at time of survey patient is now on 10 L/M via nasal cannula confirmed by the RN with the hospice record documented 9 L/M and original standing orders still active in the medical record. Patient #13: Patient is taking Furosemide 20 mg po daily prn for fluid retention and Azithromycin 250 mg po M-W-F prophylactically. There is no evidence of an order for these medications that patient has in the home and is taking.

Upon personnel record review, 1 of 14 (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Reading and recording temperature, pulse, and respiration ·Normal range of motion and positioning ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #4: The agency's Hospice Aide competency form did not specifically list the above competencies.

Upon patient record review, 1 of 14 (Patient #13) 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 #13: Admitted 6/24/23 with orders for oxygen 2-4.5 continuous LPM via nasal cannula, and most recently 6/11/24 with oxygen at 9 LPM continuous via nasal cannula. Hospice aide care plan includes oxygen maintenance only without specifying the high liter flow rate.

Upon patient client record review, 2 of 14 (Patient #15,16) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #15, 16: DC Summary heading says Mercy Care Hospice instead of Lower Cape Fear which was prior hospice agency name.

Upon patient record review, 3 of 11 records (Patient #1,#4,#10) 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. Patient #1: The medication profile contained Lactulose solution 10 GM/15ml, daily by mouth. There was not evidence of a quantity to be dispensed with each dose. Patient #4: The medication profile contained Miralax powder by mouth 17 GM. May take 1 scoop/capful, 17 GM by mouth daily as needed for constipation. There was not evidence of a diluent. Patient #10: The medication profile contained Miralax by mouth powder. There was not evidence of a dose, concentration, route, frequency, or diluent.

Upon patient record review, 1 of 11 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: The nurse documentation indicated that the patient was a Full Code. There was not evidence of goals and interventions related to end of life issues included in the plan of care.

Upon patient record review, 3 of 11 records (Patient #1,#4,#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record contained an order for Lactulose solution 10 GM/15ml daily by mouth. There was not evidence of a quantity to be dispensed with each dose. Patient #4: The record contained an order for Miralax powder by mouth 17 GM. May take 1 scoop/capful, 17 GM by mouth daily as needed for constipation. There was not evidence of a diluent. Patient #10: The record contained an order for Miralax by mouth powder. There was not evidence of a dose, concentration, route, frequency, or diluent.

Upon patient record review, 1 of 11 records (Patient #10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #10: The record indicated that a Foley catheter was inserted on 7/18/21. There was not evidence of progress to outcomes with goals and interventions related to the Foley catheter.

Upon observed visit, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #6, RN: The staff member was observed going into her nursing bag several times to retrieve equipment without washing or sanitizing her hands between entering the bag and providing patient care.

Upon patient record review, 4 of 8 applicable records (Patient #2,#6,#7,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Specific written patient care instructions for a hospice aide that is 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 specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient #2,#6,#7: The aide plan of care indicated to provide a bath each visit. The type of bath (tub, bed, chair) was not specified. Patient #10: The aide plan of care indicated to provide a bath each visit. The type of bath (tub, bed, chair) was not specified. In addition, the patient was on Eliquis and there was not evidence of bleeding precautions on the aide plan of care.

Upon patient record review 1 of 8 applicable records (Patient #2) did not have evidence of documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #2: The aide visit frequency was indicated at 3x/week until 10/27/21 when it was revised to 2x/week. There was not evidence of aide visits between 10/7/21 and 10/27/21, or missed visit documentation.

Upon patient record review, 1 of 11 records (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #3: Documentation by the social worker from 9/24/21 to current indicated that the patient was DNR. Documentation by the RN indicated that the patient was a Full Code. It was not able to be determined which was the accurate code status of the patient.

Upon patient record review, 1 of 1 applicable record (Patient #9) did not have evidence that the discharge summary included all required information. There was not evidence that medications were included in the discharge summary.