Every finding on record at Solomon Valley Hospice

Based on interview and review of the emergency preparedness plan (EPP) the Hospice Agency failed to develop and maintain an emergency preparedness plan that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. --- Findings Include: During review of the EPP on 10/31/23, between the times 8:00 AM and 10:30 AM, there was no documentation for review of the process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. During an interview on 10/31/23, between the times 8:00 AM and 10:30 AM, the Director stated that 2018 was the last time the process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials was done.

Based on record reviews, and interviews, it was determined that the agency failed to conduct a complete and accurate medication regimen review, in that the agency failed to consider the drug interactions of all patient medications at the time of admission or when a patient's medication changed for 5 (Patients 1,3,7,9, and 12) of 14 patients reviewed. The failure to consider all drug interactions, effective drug therapy, and correct dosing of ordered medications, has the potential for the patient to not receive education and guidance on the use of the medications. --- Findings Include: Patient 1 Review of a document titled, "Active Medication Profile" for Patient 1 showed a comment section from the pharmacist stating there were medications missing directions. The "Active Medication Profile" was attached to the Interdisciplinary Group notes, however, there was no documentation in the note to indicate that the comments and recommendations from the pharmacist who had performed the drug regimen review were considered or discussed. Patient 3 Review of a document titled, "Active Medication Profile" for Patient 3 showed a comment section from the pharmacist stating there were medications missing directions. The pharmacist also noted drug to drug interactions between QT (a measurement made on an electrocardiogram used to assess some of the electrical properties of the heart) prolonging agents, Seroquel (antipsychotic medication that treats several kinds of mental health conditions) and Lexapro (used to treat depression and anxiety) in combination may increase risk of prolongation of QT interval. The "Active Medication Profile" was attached to the Interdisciplinary Group notes, however, there was no documentation in the note to indicate that the comments and recommendations from the pharmacist who had performed the drug regimen review were considered or discussed. Patient 7 Review of a document titled, "Active Medication Profile" for Patient 7 showed comment section from the pharmacist stating there was duplicate drug therapy of Plavix (used to prevent heart attacks and strokes) and Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) with recommendations to consider streamline therapy. The pharmacist also indicated drug to drug interactions: bleeding with Plavix and Eliquis, concurrent use may increase the risk of bleeding. Also, drug to drug interactions: Azithromycin (used to treat infections) and Aricept (used to treat symptoms of Alzheimer's disease like memory loss and confusion) - concurrent use may increase risk of QT interval prolongation. The "Active Medication Profile" was attached to the Interdisciplinary Group notes, however, there was no documentation in the note to indicate that the comments and recommendations from the pharmacist who had performed the drug regimen review were considered or discussed. Patient 9 Review of a document titled, "Active Medication Profile" for Patient 9 showed comment section from the pharmacist stating there was drug to drug interactions: Potassium (a mineral that your body needs to work properly) and Spironolactone (a potassium-sparing diuretic [water pill]) - concurrent use may result in hyperkalemia (high potassium level), which may be sever or even fatal. The "Active Medication Profile" was attached to the Interdisciplinary Group notes, however, there was no documentation in the note to indicate that the comments and recommendations from the pharmacist who had performed the drug regimen review were considered or discussed. Patient 12 Review of a document titled, "Active Medication Profile" for Patient 12 showed comment section from the pharmacist stating there was drug to drug interactions: QT prolonging agents Ondansetron (used to prevent nausea and vomiting) and Levofloxacin (used to treat infections), concurrent use may increase risk of QT interval prolongation. Pharmacist also questioned the dosing for Tylenol Arthritis, stating the typical dose is every 8 to 12 hours, maximum of 3000 milligrams (mg)/day from all sources. Pharmacist provided instructions to clarify every 4 hours as needed order. The "Active Medication Profile" was attached to the Interdisciplinary Group notes, however, there was no documentation in the note to indicate that the comments and recommendations from the pharmacist who had performed the drug regimen review were considered or discussed. During an interview conducted on 11/01/23 at 3:40 PM, the Administrator confirmed that the drug regimen review was being done by an outside pharmacist and that the agency had failed to review the recommendations received regarding patient medications. The Administrator also stated that currently the agency has a PIP (Performance Improvement Project) regarding the failure by the Interdisciplinary Group to review the drug regimen review performed by the pharmacist.