Every finding on record at Teton Healthcare, Inc

Upon patient record review, 11 of 19 (Patient #1, #2, #3, #4, #5, #6, #9, #10, #11, #12, #14) 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- On 09/10/23 the nurse received an order for Mylanta 30 cc q4h prn stomach pain/burning. The medication profile lists Mylanta 20 cc q4hprn stomach pain /burning. (corrected on site) Patient #2-The medication profile includes Morphine 20 mg/ml .25ml-1ml hourly prn pain. The profile does not include parameters to differentiate dosage to be administered. (corrected on site) Patient #3-The medication profile includes Acetaminophen 300mg-Codeine 30 mg 1 tab q4h prn pain. The profile also includes Acetaminophen 500 mg 2 tabs q6h prn pain/fever and Acetaminophen 650 mg 1 suppository rectal q4h prn pain/fever. The profile does not include parameters for differentiating which medication to administer for pain. The profile also does not include a maximal allowable daily dosage of Acetaminophen from all sources. The medication profile includes Morphine 20 mg/ml .25ml-1ml hourly prn pain. The orders do not include parameters to differentiate dosage to be administered. (corrected on site) Patient #4-The medication profile includes Nitrostat .4 mg sl tab 1 tab q5min or until pain relieved. The profile does not include the maximal allowable doses. (corrected on site) Patient #5-The medication profile includes Acetaminophen 500mg 1 tab three times daily. The profile also includes Acetaminophen 500 mg 1 tab q4h prn pain and Acetaminophen 650 mg 1 suppository rectal q4h prn pain/fever. The profile does not include parameters for differentiating oral versus suppository to administer for pain. The profile also does not include a maximal allowable daily dosage of Acetaminophen from all sources. (corrected on site) Patient #6-The medication profile includes Glucagen kit 1 mg/ml 1 ml as needed for Diabetes. The profile does not include the symptom for medication administration (hypoglycemia). (corrected on site) Patient #9-On 10/06/23 the LPN documented instructing the patient to alternate Advil with Naproxen. Naproxen was not an ordered medication. (corrected on site) Patient #10-The medication profile includes 2 duplicative/unclear doses of Lorazepam. Lorazepam .5mg tab 1 q6h prn anxiety and Lorazepam 2mg/ml .5-1ml q2h prn anxiety. Oxygen is listed as 2 lpm prn respiratory (symptom for administration and route is not listed). The medication profile includes 2 duplicative/unclear doses of Ondansetron. Ondansetron 4 mg 1 tab q6h prn nausea and Ondansetron 8 mg 1 tab q8h prn nausea. (corrected on site) Patient #11-The medication profile includes Latanoprost .005% eye drops 1 drop at hour of sleep. The profile does not specify which eye(s) for administration. (corrected on site) Patient #12- The medication profile includes Nitroglycerin .4mg SL tab as needed for chest pain. The profile does not include the frequency and maximal allowable doses. Oxygen is listed as 2 lpm prn respiratory (symptom for administration and route is not listed). Polyethylene glycol powder 17 gm dose 1 capfull po every pm is listed without a diluent. (corrected on site) Patient #14-The medication profile includes the following prn medications for pain without differentiation for administration: Hydrocodone 5mg-Acetaminophen 325mg 1 tab bid prn pain, Morphine 20mg/ml .5-1ml sl q1h prn pain, Tramadol 50 mg 1 q4h prn pain and Morphine 15 mg ER 1-2 tabs twice daily prn pain. (corrected on site)

Upon patient record review, 11 of 19 (Patient #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #14) 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 specific orders for all medications and treatments. Patient #2-The plan of care includes Morphine 20 mg/ml .25ml-1ml hourly prn pain. The orders do not include parameters to differentiate dosage to be given. The plan of care includes orders for skilled nurse to teach patient blood glucose testing. The orders are not specific for frequency of blood glucose testing. (corrected on site) Patient #3-The 08/20/23 plan of care includes Acetaminophen 300mg-Codeine 30 mg 1 tab q4h prn pain. The plan also includes Acetaminophen 500 mg 2 tabs q6h prn pain/fever and Acetaminophen 650 mg 1 suppository rectal q4h prn pain/fever. The orders do not include parameters for differentiating which medication to administer for pain. The plan of care also does not include a maximal allowable daily dosage of Acetaminophen from all sources. (corrected on site) Patient #4-The medication profile includes Nitrostat .4 mg sl tab 1 tab q5min or until chest pain relieved. The profile does not include the maximal allowable doses. (corrected on site) Patient #5-The 09/18/23 plan of care includes Acetaminophen 500mg 1 tab three times daily. The plan also includes Acetaminophen 500 mg 1 tab q4h prn pain and Acetaminophen 650 mg 1 suppository rectal q4h prn pain/fever. The plan does not include parameters for differentiating oral versus rectal administration for pain. The profile also does not include a maximal allowable daily dosage of Acetaminophen from all sources. (corrected on site) Patient #6-The 07/19/23 plan of care includes Glucagen kit 1 mg/ml 1 ml as needed for Diabetes. The orders do not include the symptom for medication administration (hypoglycemia). The plan of care includes orders for skilled nurse to teach patient blood glucose testing. The orders are not specific for frequency of blood glucose testing. (corrected on site) Patient #7-The nurse documents on 09/07/23 the patient was admitted with a L lateral pretibial skin tear. The plan of care does not address management of the skin tear. (corrected on site) Patient #9-The plan of care includes Eylea 2mg/0.05 ml intravitreal syringe 2 mg every 8 weeks intravitreal. The plan of care does not include who administers the injection. (corrected on site) In addition, on 10/06/23 the LPN documented instructing the patient to alternate Advil with Naproxen. Naproxen was not an ordered medication. (corrected on site) Patient #10-The 08/31/23 plan of care includes 2 duplicative/unclear doss of Lorazepam. Lorazepam .5mg tab 1 q6h prn anxiety and Lorazepam 2mg/ml .5-1ml q2h prn anxiety. Oxygen is listed as 2 lpm prn respiratory (symptom for administration and route is not listed). The plan of care also includes 2 duplicative/unclear doss of Ondansetron. Ondansetron 4 mg 1 tab q6h prn nausea and Ondansetron 8 mg 1 tab q8h prn nausea. Orders on the plan of care include PICC line dressing change qwk. The orders are not specific for the actual dressing change to be performed. (corrected on site) Patient #11-The 09/13/23 plan of care includes Latanoprost .005% eye drops 1 drop at hour of sleep. The profile does not specify which eye(s) for administration. (corrected on site) Patient #12- The 08/16/23 plan of care includes Nitroglycerin .4mg SL tab as needed for chest pain. The orders do not include the frequency and maximal allowable doses. Oxygen is listed as 2 lpm prn respiratory. Polyethylene glycol powder 17 gm dose 1 cap full po qpm is ordered without a diluent. (corrected on site) Patient #14-The 10/11/23 plan of care includes the following prn medications for pain without differentiation for administration: Hydrocodone 5mg-Acetaminophen 325mg 1 tab bid prn pain, Morphine 20mg/ml .5-1ml sl q1h prn pain, Tramadol 50 mg 1 q4h prn pain and Morphine 15 mg ER 1-2 tabs twice daily prn pain. (corrected on site)

Upon patient record review, 4 of 19 (Patient #4, #6, #11, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4- On 08/23/23 the Social Worker was ordered to visit the patient three times a month for one month. The patient was seen once in August on 08/23/23. (late entry clarification/correction on site) Patient #6-On 07/19/23 the Social Worker was ordered to visit the patient two times a month for one month. The patient was seen once in July on 07/19/23. (late entry clarification/correction on site) Patient #11-On 09/13/23 PT was ordered to visit the patient for a safety evaluation. A Physical Therapy evaluation is not on record. (late entry clarification/correction on site) Patient #12- On 08/16/23 the SW was ordered twice monthly for 3 months. One visit was made in August on 08/16/23. (late entry clarification/correction on site)

Upon patient record review, 1of 19 (Patient #2) did not have evidence that all Social Work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #2-The patient was evaluated by the Social Worker 8/22/23 and accepted Social Work services. The social worker documented on the evaluation the patient would be visited twice monthly to provide the patient and caregiver with end of life education, psychosocial support and assistance with funeral arrangements. In the 09/13/23 IDG notes the social worker documented upon chart review orders failed to be written for social worker in the new certification period beginning 09/04/23. The social worker would update orders and visit the patient monthly. A Social Work visit was not performed following the evaluation visit and orders for social work services have not been obtained to meet the family's identified needs and acceptance of the service. (corrected on site)

Upon patient record review, 3 of 19 (Patient #10, #12, #13) did not have evidence that all entries are complete and accurate. Patient #10-On 09/21/23 and 10/12/23 the nurse documented performing a sterile PICC line dressing change. The documentation is not specific for the actual dressing change that was performed. (late entry clarification/correction on site) Patient #12-On 10/17/23 the nurse documented the patients suprapubic catheter was changed. The patient has an indwelling Foley catheter (not suprapubic). (late entry clarification/correction on site) Patient #13-On 09/13/23 the nurse documented administering SL Morphine to the patient. The documentation is not specific for the dose administered.