Every finding on record at Santa Teresa Hospice Care

Upon patient record review, 1 of 5 (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 medications and treatments. Patient #1: As observed during a home visit, a medication discrepancy was found and the frequency of the medication order was incorrect. The physician order is for hydrochlorothiazide 25 mg by mouth three times a day. The medication bottle contained 2 different instructions. The instructions labeled by the pharmacy were written for the same dosage but the frequency was two times a day; written underneath in Armenian language "once". Corrected on site.

Upon patient client record review, 3 of 5 records (Patients #1,#2,#3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patients #1, 2, 3: The medical record contained a discrepancy on the comprehensive nursing assessment in the neurological assessment section; the box for depression was marked in error. There was no evidence that the patients had depression. Patient #3: The medical record contained a discrepancy in documentation on the IDG narrative by the nurse dated 9/9/22. The narrative stated "patient spending more time in wheelchair". There was no evidence that the patient had a wheelchair and was non-ambulatory.