Every finding on record at Sentara Enterprises

Upon patient client record review, 1 of 19 (Patient 2) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 2: The medical record contains nursing note on 6/27/23 "Pt shows discomfort with lower extremity manipulation" and on 7/13/23 "The wounds are painful for her as she was pressing down really hard as I was trying to wrap her foot". There is no evidence of the Hospice nurse recording any symptom management interventions or response to any symptom management. There is evidence of Tylenol and morphine being on the POC. The SNF record and upon visit finding, pt is being medicated prior to wound care and appears comfortable when at rest, this is not reflected in the hospice documentation.