Every finding on record at Triniti Hospice

Based on interview and document review the facility failed to complete a comprehensive medication review for 1 of 4 patients (P12) reviewed during home visits. --- P12's Patient Information Report dated 6/12/23, indicated P12s diagnoses included: unspecified severe protein-calorie malnutrition, schizophrenia (serious mental disorder, which may cause delusions, hallucinations or cause disordered thinking and behaviors), and anxiety. P12s hospice Medication List dated 6/12/23, included the following medication orders: -olanzapine (antipsychotic) 20 milligram (mg) tablet-oral, one tablet daily-evening for schizophrenia -Benadryl allergy 25 mg tablet-none [sic], take 25 mg every six hours only as needed for rash or itching P12s facility Physician Order Report dated 6/12/23, included the following medication orders: -olanzapine 5 mg tablet, take 25 mg, oral, once a day -Benadryl -discontinued on 6/7/23 -sodium chloride one gram tablet, take one gram, oral, three times a day for hypo-osmolality (a decrease in the levels of electrolytes, chemicals, and other fluids in the blood required for adequate functioning) and hyponatremia (low blood sodium level) -Senna-S (sennosides-docusate sodium) (stool softener/laxative) 8.6-50 mg tablet, take one tablet, oral, twice a day, for constipation -Senna-S (sennosides-docusate sodium) 8.6-50 mg tablet, take one tablet, oral, as needed, for constipation -bisacodyl (laxative) suppository 10 mg, take 10 mg, rectal, as needed P12's medication list provided by hospice on 6/12/23, was reviewed and lacked orders for sodium chloride, Senna-S, and bisacodyl. Additionally, the olanzapine order indicated P12 was to take 20 mg by mouth daily, not 25 mg as instructed on the facility physician order form. P12s medication list provided by hospice 6/12/23, included Benadryl, not currently included on P12s facility Physician Order Form. During a phone interview on 6/14/23, at 10:26 a.m. case manager, registered nurse (RN)-A confirmed P12's hospice medication list did not include Senna-S and P12's Benadryl had been discontinued at the facility, which she noted after P12's home visit she completed on 6/12/23. RN-A confirmed her usual practice during home visits did not include medication reconciliation. RN-A stated she was new to the position and was not aware when the patient's medications should be reviewed to assure the hospice patient medication lists matched the facility patient medication lists. During an interview on 6/14/23, at 10:36 a.m. clinical manager (CM)-A confirmed P12's medication list provided on 6/12/23, was P12's current medication list. CM-A indicated she expected the registered nurses to review facility orders at each visit to determine if any changes had been made since last visit, to find any new orders, and to transcribe them to the patient's hospice medication list for their records and notification to their pharmacy. During an interview on 6/14/23, at 1:12 p.m. hospice director (HD)-A indicated she had been informed that P12's current medication list did not match P12's facility orders, and stated she expected medication reconciliation to be completed at every patient visit to assure they were aware of what medications the patient was receiving. The facility policy Home Health And Hospice Policy Manual dated August 2020, identified medication reconciliation assessment and review was to ensure the agency completed a review of all medications the patient was currently using for the purpose of identifying: potential adverse effects, medication interactions, ineffective drug therapy, noncompliance, misuse, and need for interventions to educate the patient and/or caregiver for the purpose of improving quality of care, reducing errors, and promoting patient safety. The policy instructed a registered nurse to complete medication reconciliation as part of the comprehensive assessment and throughout the episode of care whenever any change in medication was observed/ordered. The registered nurse may complete medication reconciliation assessment and review during visits. The policy also instructed any discrepancies would be identified and reported to the physician or physician designee and to obtain an order and make corrections to the Medication Profile Report to document changes made.