AR Meth Med Ctr Hh

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Skilled Nurse (SN) failed to obtain orders and include all medications utilized by the patient on the medication list in 1 (#2) of 12 (#1-#12) clinical records reviewed. This failed practice presented a potential risk to all patients currently on census as the failure to conduct a medication review inhibited the patient’s attending physician from making an informed decision regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. The findings are as follows: Review of clinical record #2 with a start of care of 05/20/24 revealed a patient with the diagnosis of Chronic Obstructive Pulmonary Disease. Review of a document titled LPN/LVN-Skilled Nursing Visit and dated 05/30/2024 revealed documentation of “ASSESSMENT AND EDUCATION ON NEW MEDICATION BUMETANE GIVEN.” No documentation in the patient’s clinical record of a physician’s order for the new medication or evidence the medication was checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions. An interview on 06/11/24 at 3:30 PM with Agency Personnel #1 confirmed the failure to obtain orders or conduct a medication review on a new medication.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to obtain orders for a foley catheter in 1 (#8) out of 12 (#1-#12) clinical records reviewed. This failed practice presented a potential risk to all patients currently on census, in that patients may not receive treatments only as ordered by the Physician and this could result in adverse outcomes. Findings as follows: Review of clinical record #8 with a start of care of 05/23/24 revealed a patient with a diagnosis of Hypertensive Heart & Chronic Kidney Disease with Heart Failure. Review of a document titled “Skilled Nursing Visit” and dated 05/24/2024 states “SN CHANGED FOLEY CATHETER USING STERILE TECHNIQUE”. Review of a document titled “Home Health Certification and Plan of Care” with a certification period of 05/23/24 to 07/21/2024 orders include “DME (Durable Medical Equipment) & Supplies Foley Catheter.....Drainage Bag......Leg Bag...”. No physician’s order to insert or change a foley catheter. An interview on 05/12/24 at 3:30 PM with Agency Personnel #1 confirmed the patient had a foley catheter and it was changed without a physician’s order.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency failed to coordinate care delivery to ensure physical therapy services provided in 1 (#3) out of 12 (#1-#12) clinical records reviewed. This failed practice resulted in a delay in the initiation of physical therapy services and had the potential to affect all patients currently on census with a potential risk for decreased mobility and increased risk of falls. The findings are as follows.: Review of clinical record #3 with a start of care of 05/17/24 revealed a patient with a diagnosis of Pressure Ulcer Right Buttock Stage II (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.) Review of a document titled “LPN/LVN-Skilled Nursing Visit” and dated 06/04/2024 revealed “PATIENT IS VERY UNSTABLE WITH AMBULATION EVEN WITH ROLLING WALKER”. Skilled Nurse (SN) documented she talked to the patient about fall prevention and home physical therapy to which the patient was agreeable and notes “MD CALLED AND ORDERS OBTAINED”. No documentation in the patient’s clinical record of a physician’s order for physical therapy services or evidence of communication with the Physical Therapist to refer for evaluation. An interview on 06/12/24 with Agency Personnel #1 and #2 confirmed failure to coordinate care for physical therapy services with the Physician and the Physical Therapist.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record review and staff interview it was determined the clinical staff did not follow Physician orders for Home Health Aide (HHA) visit frequency in 1 (#2) of 12 (#1 - #12) records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments and services as ordered by the Physician which could result in adverse outcomes. Findings follow: Review of clinical record #2 with a start of care of 05/20/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of a document titled “Home Health Certification and Plan of Care” with a certification period of 05/20/2024 to 07/18/2024 revealed an order for “HHA (Home Health Aide): 2w9 (2 times per week for 9 weeks) FOR PERSONAL CARE”. No documentation of home health aide visits assigned or completed. An interview on 06/12/24 at 3:15 PM with Agency Personnel #1 and #2 reports HHA ordered in error and visits were not assigned. Confirms failure to provide HHA services as ordered on the patient’s plan of care.”