Every finding on record at Serenity Hospice and Palliative Care of Texas

Upon patient record review 2 of 14 (Patient #8,#9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#8,#9: There is no evidence of a spiritual assessment being completed.

Upon patient record review, 5 of 14 (Patient #2,#3,#4,#5,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2: During home visit Metoprolol 25 1 daily was in home but not on agency medication profile. Caregiver indicated it was a current medication. RN contacted caregiver to remove medication as it was discontinued. Metoclopramide 5mg 1 prn every 8 hours was in home and being given per the caregiver. This was not on agency medication profile. Trazodone on agency medication profile shows 150mg 1 tab at bedtime, however the bottle in home is 100mg take 2 at bedtime. Oxcarbazepine 150mg is in the home and states take 1 tab daily. The medication profile states 150mg take 2 tabs daily. Corrected on site. Patient#3: The medication profile indicates MiraLAX is ordered for patient. There is no evidence of mixing instructions. Corrected on site. Patient#4: The medication profile indicates lidocaine patch ordered for patient. There is no evidence of specific instruction for application. Corrected on site. Patient#5: During home visit, caregiver indicated patient is currently taking gabapentin 300mg 1 twice a day, aspirin 325mg once daily, and acetaminophen 500mg 1-2 tabs by mouth every 6 hours prn. There is no evidence of these medications on agency medication profile. Corrected on site. Patient#8: The record indicates a physician order for oxygen PRN is currently in place. There is no evidence of oxygen on the agency medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) 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#4: The record indicates wound found and assessed on 11/23/24. There is no evidence of measurements or comprehensive assessment in record after 11/23 by an RN.

Upon patient record review, 3 of 14 (Patient #7,#8,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#7: The record indicates patient was admitted with terminal illness of Parkinson's. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. The record indicates patient is on oxygen, takes medication for hypertension and hypotension, and a foley was placed on 6/28/24. There is no evidence of problems, goals, or interventions related to these issues on Plan of Care. Corrected on site. Patient#8: The record indicates patient was admitted with terminal illness of senile degeneration of the brain. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. Patient#9: The record indicates patient was admitted with terminal illness of malignant neoplasm of anal canal. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site. The record indicates that the patient takes cardiac medications, has an ostomy, and has altered nutrition needs which the nurse is providing care and education on. There is no evidence of problems, goals, or interventions related to these issues on Plan of Care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) 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#8: The record indicates a physician order was completed on 8/11/24. The ordered stated "Oxygen for dyspnea". There is no evidence of a route or rate on the order. Corrected on site.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#9: The record indicates that nurse visits are ordered at 1 time per week. Starting 2/26 the nurse was seeing patient twice a week. There is no evidence or documentation of visits being PRN. Corrected on site.

Upon patient record review 3 of 14 (Patient #7, #8, #9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #7, #8, #9: The record indicates patient was a full code at time of death. There is no evidence of CPR being performed, 911 being called, or any information on why full code measures were withheld. During conversation with Administrator/DPCS, she indicated in each case the patient was found in a condition unable to resuscitate (such as rigor mortis and lividity present) or family withheld CPR and chose not to call 911.

Upon patient record review 3 of 14 (Patient #2,#3,#4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#2: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 11/15/24 - 12/30/24. Corrected on site. Patient#3: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 05/14/24- 07/9/24. Patient#4: The record indicates patient was receiving aide services. There is no evidence of aide supervisory visits being completed between 11/8/24 -01/3/25. Corrected on site.

Upon patient client record review, 1 of 14 (Patient #4) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#4: The record indicates that RN narrative on 11/23/24 and on 12/02/24 were exactly the same. Both notes indicated a new wound (a laceration) and obtaining wound care order. There was no evidence of appropriate authentication based on individual events of each visit. Corrected on site. RN did late entry and redocumented the 12/2/24 narrative with the corrected narrative.

Upon patient record review 1 of 11 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4 There is no evidence in the patient record that the spiritual or psychosocial assessment was completed at the time of admit or through the course of hospice services.

Upon patient record review, 2 of 11 (Patient #1,2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1: There is evidence in the patient record of a care plan for management of nausea with ongoing interventions that include education and instruction for use of Reglan. Reglan is not on the medication profile. Patient #2 There is evidence in the patient records of the use of ceftriaxone x 3 days, beginning 2/8/22, for treatment of a UTI. The medication remains on the medication profile to date although it has been completed. The medication profile does not contain the ordered Lidocaine with the ceftriaxone injection.

Upon patient record review, 1 of 11 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Patient #1 The patient record does not contain evidence of the initial bereavement assessment.

Upon patient record review, 1 of 11 (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 There is evidence in the patient record of a care plan for management of nausea with ongoing interventions that include education and instruction for use of Reglan. There are no orders for Reglan in the plan of care.

Upon patient record review, 2 of 11 (Patient #1, 2) 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 and #2: The plan of care includes nursing interventions for nausea/vomiting starting 12/14/21. There is missing evidence of documentation in the IDG plan of care update of the patient's progress towards the goals for the relief from nausea.