Every finding on record at Samaritan Healthcare & Hospice

Observed in Record Review. In 2 of 2 patients with music therapy orders, During the record review for HV 2and 3, the hospice nurse surveyor noted that visits were ordered for the music therapist and 4 PRN. This was validated in a discussion with and observation by the Clinical IT Manager.

Observed in Record Review. In 1 of 4 with Aide services, During the record review for HV 1, the hospice nurse surveyor noted that the visits made on 6/7, 6/15, 6/21, 6/30 and 7/7 were blank in the area of the supervisory visit section. This was validated in a discussion with and observation by the Clinical IT Manager.

Based on staff interview, review of one (1) of ten (10) medical records (#1), and a review of facility documents, it was determined that the facility failed to ensure all patients receive ordered medications while under hospice care. Findings include: Reference: Facility policy titled, "Admission Process" states, "... Procedure ... 4. ... the initial home visit will be made within twenty-four hours ... The purpose of the initial visit will be: ... g. To provide services ... ordered by the physician ..." On 6/15/22 at 11:00 AM, review of Medical Record #1 was conducted with Staff #5 and revealed the following: Patient #1 was admitted to the hospice on 5/4/22. The "Medications" section of the "Hospice Plan of Care" contained orders for haloperidol lactate 2 mg/ml [milligrams/milliliter] ... start effective date: 5/4/22, and hyoscyamine 0.125 mg ... start effective date: 5/4/22. The "Hospice Nursing Initial Comprehensive Admission Assessment" was conducted by the Registered Nurse (RN) on 5/4/22 at 6:00 PM. Staff #5 stated that it is the responsibility of the admission RN to provide the pharmacy utilized by the hospice facility with the patient's medication orders on the day that the initial comprehensive admission assessment is conducted. Staff #5 explained that the medications are delivered either next day or 2nd day after the order is received. Review of "Delivercare" pharmacy reports provided by Staff #2, indicated that the pharmacy received the orders for haloperidol lactate 2 mg/ml and hyoscyamine 0.125 mg on 5/8/22, four (4) days after the patient was admitted to the hospice. The medications were shipped on 5/8/22 and delivered to the patient's home on 5/9/22 at 5:27 PM. The patient expired at home on 5/9/22 at 11:30 AM, prior to the medications being delivered. The above findings were confirmed on 6/15/22 at 1:08 PM by Staff #1.