Every finding on record at Seventh Ocean Hospice Care Inc

Upon patient record review, 1 of 5 (Patient #1) 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 #1: RN visit note 6/2/22 RN documents administered Tylenol 500 mg. Medication profile did not include Tylenol.

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: RN visit note 6/2/22 RN documents administered Tylenol 500 mg. There was no physician order for Tylenol.

Upon patient client record review, 4 of 5 (Patient 1, 2, 3, 5) 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 #1, 2, 3, 5 RN Pain Assessment documented nonverbal patient with pain. No reference of pain interventions. Upon patient interview no active pain concerns. Documentation appears to be influenced by language barrier in that RN lists s/sx that she is observing for, rather than actually observed. Patient #3 RN'S 5/7/22 Comprehensive Assessment Narrative begins with 71 yo female with primary hospice dx of heart disease unspecified is admitted to Heaven's Angel's Hospice for comfort care .... in agency record for Seventh Oceans Hospice admission.