Every finding on record at Pecos County Memorial Hospital District

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 1: The election of the hospice benefit was 12/15/2023. The medication profile reviewed between 12/15/2023-1/30/2024 revealed medications Lorazepam oral tablet 0.5mg take 1-2 tablets by mouth every 4 hours as needed for anxiety or restlessness, Diazepam oral tablet 5mg take 0.5 of a tablet (2.5mg) by mouth at bedtime if needed, Escitalopram Oxalate oral tablet 10mg take one tablet by mouth daily for depression, Losartan Potassium oral tablet 100mg take one tablet by mouth daily for high blood pressure, and Amlodipine Besylate oral tablet 5mg take tablet by mouth daily for high blood pressure. The medications were reviewed with the daughter during the home visit on 1/31/2024 with the Hospice Aide (Personnel Record 9). Lorazepam Intensol 2mg/ml 0.5-1ml po q4h prn anxiety/agitation dated/last dispensed on 12/19/2023 was found in the home. Lorazepam tablets were not in the house. The daughter stated that the patient has not been taking Diazepam, Escitalopram Oxalate, Losartan Potassium, and Amlodipine Besylate since admission to hospice. During a joint review of the record and an interview on 1/31/2024, the Director of Nursing confirmed there was no documented evidence the medications were reconciled, including Lorazepam Intensol, Lorazepam oral tablets, Diazepam, Escitalopram Oxalate, Losartan Potassium, and Amlodipine Besylate, at the time of each comprehensive assessment and updated to the drug profile.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Document 2: Agency policy, “Hand Hygiene IC.15,” dated 12/15/2022, stated in part, "Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves." Home Visit 1: During the home visit (Clinical Record 4) on 1/31/2024 with the Hospice Aide (Staff 9), the Hospice Aide was observed to have removed the gloves without washing the hands before donning another pair of gloves. During an interview on 1/31/2024, the Director of Nursing confirmed the staff did not follow the hand hygiene policy.