Every finding on record at Rmg Hospice Care, Inc

Upon patient record review, 1 of 8 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2:The medical record includes documentation by the RN on 02/12/25 that the patient had an increase in the frequency of shortness of breath with mild exertion. There is no evidence that the RN offered or provided interventions to manage the symptom of shortness of breath.

Upon patient record review, 1 of 8 (Patient #1) 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 equipment and supply needs. Patient 1:The medical record includes an order on 01/24/25 for symptom management to include nebulization treatments. There is no evidence that the plan of care includes the equipment and supply needs for nebulization.

Upon patient record review, 2 of 8 (Patient #1,#3) 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 1:The medical record includes an order on 01/24/25 for Albuterol/Atrovent nebulizers to treat respiratory symptoms. There is no evidence of an update to the plan of care with problems, goals, and interventions for the management of the respiratory symptoms. Patient 3:The medical record includes SN documentation on 02/05/25, 02/07, 02/14 and 02/21 that the patient was noted to have increased shortness of breath with mild exertion which is being managed by increasing the head of bed. There is no evidence of an update to the plan of care with problems, goals, and interventions for the management of respiratory symptoms.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness The primary terminal diagnosis on the plan of care and the certification of terminal illness was documented as Hypertensive heart disease with heart failure. The narrative on the certification of terminal illness and the narrative in the nurse comprehensive assessment indicated that the patient 'presents with a terminal illness such as Parkinson's.'