Every finding on record at Peaceful Bridge Hospice II

Upon patient record review, 4 of 5 records (Patients #1,#3,#4,#5) 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 a nitroglycerin prn and cetirizine prn with no indications for when to administer. The profile also contained cipro started for 5 days 8/16/22 still listed as an active medication. Patient 3: The medication profile contained Tylenol codeine #4 prn with no indication for when to administer. Patient 4: The medication profile contained lorazepam prn, hydromorphone prn, Senna prn and quetiapine prn with no indications when to administer. Patient 5: The medication profile contained Imodium prn with each stool with no defined maximum number of doses allowed within a certain time frame.

Upon patient record review, 4 of 5 records (Patients #1,#3,#4,#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 1: The medical record contained orders for nitroglycerin prn and cetirizine prn with no indications for when to administer. Patient 3: The medical record contained an order for Tylenol codeine #4 prn with no indication for when to administer. Patient 4: The medical record contained orders for lorazepam prn, hydromorphone prn, Senna prn and quetiapine prn with no indications when to administer. Patient 5: The medical record contained an order for Imodium prn with each stool with no defined maximum number of doses allowed within a certain time frame.

Upon record review, 1 of 11 (Personnel 11) did not have evidence of COVID vaccination status.