Saint Agnes Home Health and Hospice

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on interview and record review, the agency’s Registered Nurse (RN) 1 and RN 2 failed to assume their responsibility to communicate to their Clinical Manager (CM) or physician to clarify the use of Central Venous Catheter (CVC- a long, flexible tube inserted into a vein in the neck to receive drugs, fluids or blood for emergency or long-term treatment) port designated to dialysis (a treatment for people with kidney failure- performs the function of the kidneys by removing waste products and excess fluid from the blood) prior to use the same port for delivery of TPN (total parenteral nutrients-a special formula given through a vein provides most of the nutrients the body needs.) for one of three sampled patients (Patient 1). This failure placed Patient 1 at high risk of infection which could be fatal. During a phone interview on 1/23/25 at 3:00 p.m. with Registered Nurse (RN) 2, RN 2 was asked to describe the visit occurred on 10/8/24. RN 2 stated she was at Patient 1’s home to supervise RN 1’s skill to administer TPN correctly during the initial visit. RN 2 stated RN 1 was the case manager for Patient 1 but she (RN 2) was there to observe and check the competency of RN 1’s TPN infusion therapy (a way of delivering medication or fluids through a needle or catheter, usually through vein.) RN 2 stated she was aware of that Patient 1 was on dialysis and the CVC line ports were designated for access during dialysis treatment. RN 2 stated, she had a Physician Order (PO) to administer the TPN and Patient 1 had only one central line. RN 2 stated she allowed RN 1 to use the CVC placed on left upper chest to start TPN infusion therapy. RN 2 stated she knew it was not permitted to use the same line as dialysis, but she did not prioritize the safety over the task. RN 2 stated, Patient 1’s caregiver reported Patient 1 received TPN through the CVC in the upper chest while in the hospital. RN 2 stated, instead of calling the Clinical Manager (CM) or physician to consult the situation she listened to Patient 1’s caregiver and allowed connection of TPN to the CVC on Patient 1’s upper left chest. RN 2 stated, she thought it was okay to use Patient 1’s CVC on the upper left chest as long as Patient 1’s caregiver let the dialysis staff know that the same line was used to administer the TPN, therefore the dialysis staff could take care of the line properly. RN 2 stated RN 1 did not know Patient 1 had a Medi-port (a small medical appliance that is surgically installed beneath the skin. It is a catheter that connects to a vein to deliver medication, blood products, nutrients or fluid into the bloodstream). RN 2 stated four days later, she found out Patient 1 had an additional central line which she could use for TPN after Patient 1 went to the dialysis treatment. RN 2 stated if she knew Patient 1 had an alternative route to receive TPN she would not administer TPN through the CVC designated to dialysis. RN 2 stated at that moment she thought she made a safe decision but turned out she was wrong. RN 2 stated she should have called doctor or her supervisor to consult first. RN 2 stated, RN 1 was no longer employed with the agency. During a telephone interview on 1/23/25 at 3:15 p.m. with the Clinical Educator, (CE) the CE stated the standard of nursing practice for use of CVC designated to dialysis was not to use that line for anything else to minimize any chance of infection. The CE stated RN 2 should not connect TPN to CVC which was designated for dialysis. The CE stated RN 2 should have called doctor or Clinical Supervisor (CS) for direction instead of taking the risk to proceed with her assignment. During a concurrent interview and record review on 1/12/25 at 3:45 p.m. with the Administrator/Director of Care Patient Services (Adm/DPCS), the agency’s document titled “Apparent Cause Analysis (ACA) Report” dated 11/11/24, was reviewed. The “ADA Report” indicated, “[Patient 1] SOC (start of care) on [10/8/24] for TPN and line care. SOC RN had not completed an independent TPN visit, so another RN accompanied the SOC RN. On [10/11/24], per ON CALL note, patient went for dialysis treatment and the dialysis center noted the TPN was connected to patient’s dialysis port. Patient has a Medi-port to the right chest that was not assessed. MD was notified and stated patient should be okay. Discussion with RNs on [10/15/24] regarding occurrence. Issues noted during chart review and per discussions with RNs: Failed to assess and note of Medi-port access. RN stated per patient had only one line to left chest. Did not assess or question further…” During a phone interview on 1/23/25 at 3:45 p.m. with the CM, the CM stated she found out Patient 1 was receiving TPN infusion therapy via CVC designated for dialysis the same day Patient 1 went to dialysis treatment. The CM stated as soon as she found out the mistake, she immediately sent a RN to activate the Medi-port on the right side of Patient 1’s chest to administer the TPN infusion therapy instead of using CVC designated to dialysis on the left side of Client 1’s chest. The CM stated she was glad there was no harm, and the agency fixed the issue before too late. The CM stated RN 2 should have contacted her or doctor to clarify the safe use of CVC designated to dialysis use. The CM stated if she called the TPN would never been administered through the same line. The CM stated it was her responsibility to maintain her licensure in good standing by practicing safe nursing practice. During a review of the agency’s job description for “Primary Care Nurse” dated 12/14/23, the job description indicated, “Communicates with Clinical Manager…” During a review of the agency’s job description for “Primary Care Nurse” (undated), the job description indicated, “ Maintains a working knowledge of applicable Federal, State and local laws and regulations … Participate in own professional development by maintaining required competencies, licenses & certifications, identifying learning needs & seeking appropriate assistance or educational offerings … Professional Nursing Practice: Acts independently & appropriately within license, scope of knowledge & experiences in practice area…””

“Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This Element is not met as evidenced by: Based on interview and record review, the agency failed to conduct a comprehensive assessment (a thorough evaluation) to accurately reflect patient’s integumentary (skin) status for one of three sampled patients (Patient 1) when Registered Nurse (RN) 1 did not document the presence of a Medi-port (a small medical appliance that is surgically installed beneath the skin that connects to a vein to deliver medication, blood products, nutrients or fluid into the bloodstream) on Patient 1’s right side of upper chest in the OASIS (Outcome and Assessment Information Set-a comprehensive data collection tool that is used by home health agencies across the United States to measure patient outcome and assess the quality of care provided) as required. Patient 1 had a history of requiring TPN (Total Parenteral Nutrition -a special formula given through a vein provides most of the nutrients the body needs) and dialysis (a treatment for people with kidney failure- performs the function of the kidneys by removing waste products and excess fluid from the blood). This failure placed Patient 1 with the potential to receive TPN through Central Venous Catheter (CVC- a long, flexible tube inserted into a vein to receive drugs, fluids or blood for emergency or long-term treatment) port designated only for dialysis for four days increasing the risk of infection which could lead to sepsis (life threatening condition that occurs when the body’s immune system responds excessively to an infection leading to organ dysfunction) and death. During a phone interview on 1/23/25 at 3:00 p.m. with RN 2, RN 2 was asked to describe the visit with Patient 1 that occurred on 10/8/24. RN 2 stated, she was at Patient 1’s home to supervise RN 1’s skill to administer TPN correctly during the initial visit. RN 2 stated, RN 1 was the case manager (person responsible for managing the patient’s care) for Patient 1 and she (RN 2) was there to observe only and check the competency (a method used to evaluate a nurse’s ability to perform essential nursing skills and demonstrate the knowledge and abilities required for safe care) of TPN infusion therapy (a way of delivering medication or fluids through a needle or catheter, usually through vein). RN 2 stated, she was aware Patient 1 was on dialysis and the CVC line ports were designated to access and used for dialysis treatment. RN 2 stated, she had a Physician Order (PO) to administer the TPN and Patient 1 had only one central line. RN 2 stated, she allowed RN 1 to use the CVC placed on left upper chest to start TPN infusion therapy. RN 2 stated, she knew it was not permitted to use the same line as dialysis, but she did not prioritize the safety over the task. RN 2 stated, Patient 1’s caregiver reported Patient 1 received TPN through the CVC in the upper chest while in the hospital. RN 2 stated, instead of calling the Clinical Manager (CM) or physician to consult the situation she listened to Patient 1’s caregiver. RN 2 stated, she thought it was okay to use Patient 1’s CVC on the upper left chest as long as Patient 1’s caregiver let the dialysis staff know that the same line was used to administer the TPN, therefore the dialysis staff could take care of the line properly. RN 2 stated, she allowed RN 1 to use the CVC placed on left upper chest to start TPN infusion therapy. RN 2 stated she knew it was not a safe practice connecting the TPN to the same line as dialysis, but she took the risk to administer the TPN. RN 2 stated, RN 1 did not know Patient 1 had a Medi-port (a small medical appliance that is surgically installed beneath the skin. It is a catheter that connects to a vein to deliver medication, blood products, nutrients or fluid into the bloodstream). RN 2 stated, she found out Patient 1 had an additional central line which she could have used for TPN after Patient 1 went to the dialysis treatment four days later. RN 2 stated, if she knew Patient 1 had an alternative route to receive TPN she would not have allowed administration of TPN through the CVC designated for dialysis. RN 2 stated, RN 1 failed to assess Patient 1’s assessment accurately. RN 2 stated, at that moment she thought she made a safe decision but turned out she was wrong. RN 2 stated, RN 1 was no longer employed with the agency. During a telephone interview on 1/23/25 at 3:40 p.m. with the Clinical Educator, (CE) the CE stated the standard of nursing practice for use of CVC designated to dialysis was not to use that line for anything else to minimize any chance of infection. The CE stated, RN 2 should not have connected TPN to CVC which was designated for dialysis. The CE stated, RN 2 should have called doctor or CM for direction instead of taking the risk to proceed with her assignment. During a concurrent interview and record review on 1/12/25 at 3:45 p.m. with the Administrator/Director of Care Patient Services (Adm/DPCS), the agency’s document titled “Apparent Cause Analysis (ACA)” report dated 11/11/24, was reviewed. The “ADA” report indicated, “[Patient 1] SOC (start of care) on [10/8/24] for TPN and line care. SOC RN had not completed an independent TPN visit, so another RN accompanied the SOC RN. On [10/11/24], per ON CALL note, patient went for dialysis treatment and the dialysis center noted the TPN was connected to patient’s dialysis port. Patient has a Medi-port to the right chest that was not assessed. MD was notified and stated patient should be okay. Discussion with RNs on [10/15/24] regarding occurrence. Issues noted during chart review and per discussions with RNs: Failed to assess and note of Medi-port access. RN stated per patient had only one line to left chest. Did not assess or question further…” During a phone interview on 1/23/25 at 3:50 p.m. with the CM, the CM stated, she found out Patient 1 was receiving TPN infusion therapy via CVC designated for dialysis the same day Patient 1 went to dialysis treatment. The CM stated, as soon as she found out the mistake, she immediately sent a RN to activate the Medi-port on the right side of Patient 1’s chest to administer the TPN infusion therapy instead of using CVC designated to dialysis on the left side of Client 1’s chest. The CM stated, RN 1 was no longer with the agency. The SM stated, RN 2 and the rest of RN’s at the agency were scheduled to attend the case study involving Patient 1’s scenario to reinforce the safe infusion therapy practice and the importance of comprehensive assessment. The CM stated, RN 1 should have identified the presence of Medi-port during skin assessment. During a review of Patient 1’s Initial Assessment “OASIS” dated 10/08/24, the “OASIS” indicated, “… Indicate Integumentary assessment findings:(Mark all that apply) … Infusion Access … Indicate type of infusion access: (Mark all that apply) … Central Venous Catheter (CVC) … Indicate catheter type (Mark all that apply): … Indicate CVC Catheter location: Left upper chest …” During a review of Patient 1’s acute hospital “History and Physical (H&P)“ dated, 9/20/24, the Chest X-ray (a picture taken that shows the inside of someone’s body) findings on the “H&P” indicated, “… A Medi port catheter from the right jugular (vein in the neck) approach has its tip in the superior vena cava (vein in the heart) …” During a review of Patient 1’s acute hospital “Discharge Summary” dated 10/7/24, the “Discharge Summary” indicated, “Successful placement of a left internal jugular tunneled dialysis catheter. Tip is at the right atrium (upper chamber of the heart). Catheter is ready for immediate use … signed by [MD] on 9/26/2024 …” During a review of Patient 1’s “Infusion Therapy Order” from [pharmacy name-pharmacy] dated 10/7/24, the order indicated, “Infusion Directions: … IV Access: Tunneled CVC [check mark] Implanted Port [check mark] …” The TPN order contained check marks indicating Patient 1 had two infusion access. During a review of Patient 1’s “Plan Of Care (POC)” dated 10/8/24 to 12/6/24, the “POC” indicated, the SOC was 10/8/24 and skilled nurse to administer IV medications and flushes per order via left jugular central venous catheter. During a review of Patient 1’s “Client Coordination Note Report” dated 10/12/24, the “Client Coordination Note Report” indicated, “TC (telephone call [patient’s wife]. Advised a nurse is assigned to access his Medi-port and will hook up his TPN to the Medi port ...” During a review of the agency’s policy and procedure (P&P) titled “Care management and Plan of Care” dated 4/15/24, the P&P indicated, “The plan of care is based on problems/needs identified through a comprehensive assessment of the patient (i.e., including OASIS elements as required … Completes comprehensive assessments including (OASIS assessment depending on insurance requirements) as appropriate …””

“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 observation, interview and record review, the agency failed to provide service as physician ordered for one of three sampled patients (Patient 3) when Registered Nurse (RN) 3 did not educate Patient 3 of the signs and symptoms of fluid retention related to Patient 3’s cardiac function in the plan of care (POC-a written plan outlines specific treatments and support services needed to address the patient’s needs while receiving care at home) indicated during home visit (HV). This failure resulted in Patient 3 not monitoring his weight, not understanding signs and symptoms of concern related to his diagnosis of altered cardiovascular status had the potential fluid retention from TPN (total parenteral nutrients-a special formula given through a vein provides most of the nutrients the body needs) to go unnoticed leading to edema, shortness of breath or hospitalization. During an observation on 1/23/25 from 1:10 p.m. to 2:10 p.m. at Patient 3’s home, RN 3 was observed checking vital signs, collecting blood specimen from the Central Venous Catheter (CVC- a long, flexible tube inserted into a vein in the neck to receive drugs, fluids or blood for emergency or long-term treatment) and providing line care (dressing change to the CVC). Patient 1 was observed being independent and cooperative. RN 3 asked Patient 3 TPN related questions and Patient 3 answered confidently on administrating TPN. RN 3 explained the purpose of Patient 3 receiving TPN but was not observed asking Patient 3 about his cardiac function and weight variance. During an interview on 1/23/25 at 2:10 p.m. with RN 3, RN 3 was asked about how he accomplish monitoring Patient 3’s weight variance as POC indicated. RN 3 stated, he monitored the vital signs, blood sugar levels, and pain level but did not monitor cardiac functions or any weight variance. RN 3 stated, he did not know if Patient 3 weighed himself routinely or not. During an interview on 1/23/25 at 2:20 p.m. with Patient 3, Patient 3 stated no one from the agency checked or asked him about his weight. Patient 3 stated, he did not know how to describe the warning signs of altered cardiac function. Patient 3 stated, he was not educated to keep a log to monitor the weight periodically. During a review of Patient 3’s POC dated 11/20/24 to 1/18/25, the POC indicated, the SN (skilled nursing) to provide HV weekly for CVC line care and education. The POC indicated, “Patient /Caregiver will verbalize/demonstrate an ability to care for altered cardiovascular status as evidenced by ability to list 3 S/S (signs & symptoms) of exacerbation (the process of making a problem worse): weight gain of 3 lbs. (pounds) or more in 24 hours, increased short of breath, increased edema (swelling in arms or legs) …” During a concurrent interview and record review on 1/27/25 at 3:30 p.m. with the Quality Assurance (QA), Patient 3’s “SN Visit Notes” dated 11/21/24 to 1/22/25 were reviewed. Patient 3’s “SN Visit Notes” indicated, Patient 3’s weight was recorded 139.2 pounds (lbs.) on 11/21/25, 138.2 lbs. on 11/22/25 and 148 lbs. on 1/17/25. The QA stated, during eight weeks period the weight was checked by the clinician only twice. The QA stated she could not validate the weight gain of 10 pounds were gradual or sudden. During a review of the agency’s policy and procedure (P&P) titled “Care Management and Plan of Care“ dated 1/15/24, the P&P indicated, “The plan of care is based on problems/needs identified … The plan of care takes into consideration … The patient’s educational needs regarding the services identified in their plan of care to facilitate a timely discharge. During visits and other patient contacts, the clinician regularly evaluates … the lack of achievement goals and outcomes …””

“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 observation, interview and record review, the agency failed to coordinate the referral to pain management specialist for one of three sampled patients (Patient 2) when Patient 2 had been assessed to have had a high level of pain (5 out of 10 on numerical pain scale [a tool to assess pain intensity where 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, 7 to 9 = severe pain and 10 = worst pain possible]) following pain relieving remedies and pain medication. This failure had the potential for Patient 2 to remain in pain unnecessarily and to be at risk for not thriving. During an observation on 1/23/25 at 9:30 a.m. at Patient 2’s home. Registered Nurse (RN) 4 and the Clinical Coordinator (CC) were discussing the patient 2’s Plan Of Care (POC-a written plan outlines specific treatments and support services needed to address the patient’s needs while receiving care at home). Patient 2 was talking to RN 4 and the CC passionately expressing how she came a long way to maintain her weight to 89 pounds since the TPN (a special formula given through a vein provides most of the nutrients the body needs) was discontinued (stopped). When Patient 1 was asked about her pain management of chronic pain around her stomach, Patient 1 stated it started with intolerable pain as scale (pain scale- of 10 being highest. Patient 1 stated due to her condition she was not allowed to take any pain medication stronger than acetaminophen (a pain medication used for mild pain). Patient 2 also stated she used heating pack to relieve pain as well. When RN 4 asked to describe the pain level after taking acetaminophen, she stated “5.” The CC talked to RN 2 and the CC stated that staying pain level 5 after pain medication and the use of heat pack was a concern. RN 4 confirmed that has been going on for a while. RN 4 stated Patient 2 had high tolerance in pain but Patient 2’s Nurse Practitioner only gave Patient 2 to try topical ointment to try. The CC stated Patient 2 needed to be referred to pain specialist to manage her pain. During a review of Patient 2’s “POC” dated 1/19/25 to 3/19/25, the “POC” indicated, SOC (start of care) was 3/31/23 and Patient 2’s primary diagnosis was Crohn’s disease (a chronic inflammatory bowel disease characterized by recurrent episodes of intestinal inflammation, primarily manifesting as diarrhea and abdominal pain). During a concurrent interview and record review on 1/27/25 at 3:45 p.m., with the Quality Assurance (QA), Patient 2’s “Visit Note Report” dated 1/23/24, was reviewed. The “Visit Note Report” indicated, that the pain level was assessed to level 8 and acceptable level of pain was assessed to 2. The “Visit Note Report” indicated, “RN and patient to notify [Dr] of patient’s unmanaged pain Patient reporting high levels of pain.” There was no evidence RN 4 or the CC contacted Patient 2’s primary doctor to discuss Patient 2’s pain management. During a review of the agency’s policy and procedure (P&P) titled “Care Management and Plan of Care” dated 4/15/24, the P&P indicated, “Documents the name of the physician contacted in the electronic medical record, recording issues that were discussed and/or orders clarified as appropriate.””