Every finding on record at Marilux Inc.

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 • Drug therapy currently associated with laboratory monitoring Patient 4: The medical record includes an entry on the medication profile of Oxygen 2-3 liters per minute via nasal cannula. There is no evidence that the profile includes instructions for titration of oxygen. The medical record includes an entry on the medication profile upon admission of Metamucil 2 tablespoons po daily PRN. There is no evidence that the profile includes a type and amount of diluent for administration.

Upon patient record review, 1 of 5 (Patient #2) 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 2: The medical record contains nursing documentation upon admission that the patient has a history of Gastrointestinal bleeding and the current medication regimen includes ASA 81 mg daily for anticoagulant therapy. There is no evidence that the plan of care includes problems, goals or interventions for potential bleeding or hemorrhage.

Upon patient record review, 1 of 5 (Patient #5) 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 4:The medical record includes an order on admission for Oxygen 2-3 liters per minute via nasal cannula. There is no evidence that the plan of care includes instructions for oxygen titration. The medical record includes an order upon admission of Metamucil 2 tablespoons po daily PRN. There is no evidence that plan of care includes a type and amount of diluent for administration of Metamucil.