Every finding on record at Programa De Salud En El Hogar Y Hospicio San Lucas, Inc.

It is required that the documented comprehensive assessment includes. a drug profile that contains the patient's current: Prescription and over the counter (OTC) Supplements; Herbal remedies; 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; 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 a review of clinical records, document review and interviews. 3 of 20 (15%) records revealed the agency did not ensure that all medications were documented on the medication list and reviewed for potential interactions and updated with changes so accurate medication review was completed. Agency Policy #OC..3008PHC, [review date March 2020] stated in part, "During the admission process and as an integrated part of the initial estimate, the evaluating therapeutic staff will request all medications from the patient. Identify and record in the medical record all medications ordered by the doctor, including those used without a prescription. ...Review and update the medication list if alterations to the treatment regimen arise." Clinical Record 11: Patient admitted 05/03/2023 with an order for Rocephin (an antibiotic to treat infection) 2 grams administered intramuscular daily for 5 days. The physician order was for Rocephin 2 grams with 3 milliliters of lidocaine to be administered daily for 5 days. The diluent lidocaine was not documented on the medication list and consequently not reviewed. Clinical Record 16: Observed visit on 1/25/2023 patient and family stated that she has been applying Benadryl (a cream to relieve itch) cream for itchy skin for several weeks and using Orejel (a pain relief gel) for pain for a sore in her mouth. The nursing comprehensive assessment on 12/30/2022 stated patient had a sore mouth with a gel that helped and was using a cream for itchy skin, but the medications were not documented. A physician visit was made 1/23/2023 and he administered an IM (intramuscular) dose of Benadryl and ordered lotrisone (a prescription cream for itch) which had yet to be started. The medication profile was not updated with Benadryl cream or the Orejel that had been used for several weeks as of review 1/25/2023. Clinical Record 20: Patient admitted 11/14/2022 with epiglottis cancer and TPN (total parental nutrition) 5% administered 3 times a week. IV (intravenous) catheter maintained with daily normal saline flush of 10 cc. The normal saline was not on the medication profile as of review 1/26/2023 and was not reviewed for potential interactions. The Director of Home Health and Hospice who performed joint record review with the site visitor was interviewed and agreed that the medication list was not completed and that the documented review was incomplete for all medications that the patients were taking.

It is required that each patient’s individualized written plan of care: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 20 (5%) records reviewed revealed the agency did not ensure that the physician plan of care documented the complete medication order to include diluent and total amount of medication to be given. Agency Policy OC-PH-3006 [review date March 2014] stated in part, "The content of the Plan of Care includes Treatment, medications, supplies and durable medical equipment needed to meet patient needs." Clinical Record 11: The initial plan of care was dated 05/03/2022 with documented medication Rocephin (antibiotic for infection) 2 Grams IM (intramuscular) daily for 5 days. (This was missing the diluent and total amount of medication to be given). The physician order documented that Rocephin 2 grams with 3 milliliters of lidocaine to be given intramuscular daily for 5 days. The diluent lidocaine and the total dose of 3 milliliters to be delivered was not documented on the plan of care. The Director of Home Health and Hospice who performed joint record review with the site visitor was interviewed and agreed that the diluent was missing from the plan of care.