Guardian Home Health Care & Hospice, Inc.

“Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure one of 12 sampled patients, (Patient 2) received a patient-specific, comprehensive assessment that accurately reflected the patient’s current status when the gastrostomy tube (G tube- a tube surgically inserted through the stomach to deliver liquid nutrition or medications) was not noted on the admission assessment. This failure had the potential for the HHA to not accurately develop and implement a care plan to address the patient’s home health services needs and GT care, including an inaccurate baseline skin assessment. Findings: During a review of Patient 2’s Home Health Certification and Plan of Care (POC), with the certification period of, 1/7/2024 to 3/6/2024, which indicated Patient 2’s primary diagnosis was type 2 diabetes mellitus (blood sugar disorder) with end stage renal (kidney) disease (kidneys cease functioning on a permanent basis leading long-term dialysis, an artificial kidney machine or a kidney transplant to maintain life), anemia (lower-than-normal amount of healthy red blood cells), hypothyroidism (thyroid gland doesn’t make enough thyroid hormone which regulates metabolism) and muscle weakness. During an observation on 1/10/24 at 11:32 a.m., in Patient 2’s home, Patient 1 showed Licensed Vocational Nurse (LVN) 1 her G-tube. Patient 2 asked LVN 1 when the G tube was going to be removed and informed LVN 1 she is not using the G tube anymore. During an observation on 1/10/24 at 11:58 a.m., LVN 1 asked the Responsible Party (RP) 1 if they were taught how to change the dressing on the G tube site and what signs and symptoms of infection to watch out for. RP 1 responded that no one told them they had to check and change the dressing on the G tube site. During an interview on 1/10/24 at 11:59 a.m. with RP 1, RP 1 stated the nurse who first came did not tell them to check on the G tube site or change the GT dressing. During an interview on 1/10/24 at 12:05 p.m. with LVN 1, LVN 1 stated the G tube site should have been noted during the start of care admission assessment and teaching G tube site care should have been done upon admission. During a review of Patient 1’s OASIS-E Start of Care (OASIS SOC (undated) indicated the patient did not have a surgical wound which was not accurate. During a review of Patient 2’s Skilled Nursing Visit Note, dated 01/10/2024, for Wounds Addressed on this Visit, indicated Patient 2 has an open wound present on admission on the left abdomen. During a telephone interview on 1/11/2024 at 12:42 p.m., with Registered Nurse (RN) 1, RN 1 stated she was not able to do a full skin assessment upon admission for Patient 2. RN 1 further indicated she noted the dialysis (access) port on the right chest. During a telephone interview on 1/11/2024 at 2:12 p.m., with the Director of Nursing (DON), DON stated the skin assessment upon admission is done from head-to-toe and includes any type of tubes to make sure they are okay and not causing any skin breakdown. During a review of the agency’s policy and procedure (P&P) titled, “Initial Assessment/Comprehensive Assessment,” dated 2015, the P&P indicated “The Initial Comprehensive Assessment also includes: Relevant medical history, physical assessment/review of systems and pertinent physical findings, any medical equipment.” The P&P also indicated “The initial comprehensive assessment will also include the OASIS items: Integumentary status, Surgical wound, Skin lesion or open wound.””

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review, the licensed nursing staff did not update the plan of care for one of 13 sampled patients (Patient 9). Licensed nursing staff did not assess and document Patient 9’s open wound on his finger. Staff also did not document the status of the wound at each visit. This resulted in the potential for delayed wound healing. Record review of the “Home Health Certification and Plan of Care” showed Patient 9’s Start of Care date was 12/26/2023, with the current certification period of 12/26/2023 to 2/23/2024. The diagnoses included gout (form of arthritis that causes severe pain, swelling, redness and tenderness in joints). Record review of the “ED (emergency department) Triage (prioritizing patient care)-Text” showed Patient 9 went to the ED, on 12/13/2023 and was treated for “2nd finger swelling and redness.” Record review of the “OASIS-E Start of Care,” dated 12/26/2023, indicated the “Integumentary (skin) Status” section showed Patient 9 had no open wounds. Record review of the “LPN (licensed practical nurse)/ LVN (licensed vocational nurse) – Skilled Nursing Visit,” dated 12/28/2023, showed Patient 9 complained of pain on his right pointer finger due to gout. The wound was dressed. There was no description of the size of the wound, exact location, depth, color, or if there was wound drainage. Further record review indicated, on 1/2/2024, Patient 9 had a wound to the right pointer finger and had no documented wound description. During an interview on 1/11/2024 at 11:06 a.m., LVN stated she had not assessed or measured Patient 9’s wound during the visits. LVN stated the RN “Usually measures it at the start of care.” LVN further stated it was important to document what the wound looks like in order to prevent infection. During an interview on 1/11/2024 at 2:10 p.m., with the Director of Nursing (DON), DON stated a patient’s initial skin assessment should be “Head to toe.” Anything on the skin such as wounds, tubes, and IVs (intravenous-a tube inserted into the vein to deliver fluids or medications) should be noted. Record review of the “Initial Assessments/Comprehensive Assessments,” dated 2015 showed, “Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient’s current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes.” The initial assessment will include “Integumentary status, skin lesion or open wound.” Review of the document Assessment and Reassessment Guidelines” dated 2014 showed, “Assessment data gathered by each discipline will be used to assess the patient’s needs and problems initially and on an ongoing basis.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation and interview, the agency failed to ensure one of 12 sampled patients (Patient 1’s) responsible party (RP) was informed in advance of the scheduled skilled nursing visit. This deficient practice had the potential for the patient and responsible party to not be prepared for the home visit. Findings: During a review of Patient 1’s Home Health Certification and Plan of Care (POC) with the certification period of 1/7/2024 to 3/6/2024, indicated Patient 1’s primary diagnosis was acute myocardial infarction (heart attack), type 2 diabetes mellitus (blood sugar disorder), congestive heart failure (heart can’t pump blood well enough to to deliver oxygen to the body), end stage renal (kidney) disease, and muscle weakness. The POC indicated the frequency of skilled nursing visits was, two times a week for two weeks, and once a week for three weeks. During an observation on 1/10/2024 at 12:55 p.m., in Patient 1’s home, the Responsible Party (RP) 2 told the Licensed Vocational Nurse (LVN) 2 that nobody informed her or anyone in the family there would be a nurse coming in for a visit today. RP 2 told LVN 2, the only call received was for the admission visit and did not receive any information on when the next visit would be. During an interview on 1/10/2024 at 12:59 p.m., with LVN 2, LVN 2 stated the office calls the patient or the patient’s family for her (LVN 2) to let them know of the visit. LVN 2 stated she did not call the patient or the patient’s family for this visit on 1/10/24. During an interview on 1/11/2024 at 11:07 a.m. with the Administrator (Admin), Admin stated they use the Google Calendar Task system for scheduling clinician visits. Admin stated the office informs the clinicians of their scheduled visits and asks the clinicians to arrange the visit to their preference. Admin further stated once the clinician arranges the visit, the office calls the patient/patient’s RP to inform them of the visit and set up the time. When the visit is confirmed with the patient/patient’s RP, the scheduled visit would be changed to ‘green’ on the Google Calendar Task. Admin stated LVN 2 did not call the patient/patient RP to confirm the visit for 1/10/2024, because he already marked the visit for Patient 1 green on the Google Calendar Task. During a concurrent interview and record review on 1/11/2024 at 11:35 a.m., with Admin, the document titled, “Google Calendar Tasks” was reviewed. The document indicated, “Everyday, patient will get a text message/phone call from the Office for the next day visit time window.” Admin stated he did not call/text Patient 1 or Patient 1’s RP about the visit done on 1/10/2024. During an interview on 1/11/2024 at 2:12 p.m. with DON, DON stated the clinician assigned to the home visits should call the patient/patient’s RP ahead of time to arrange the visit to make sure they are going to be available at the planned time of visit. During a review of the agency’s document titled, “Patient & Family Handbook,” undated indicated, “Patient Rights: 6. Participate in, be informed about, and consent to or refuse care in advance of and during treatment, where appropriate, with respect to: … (5) frequency of visits.””

“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 licensed nursing staff provided care without a doctor’s order for one (Patient 5) of 13 sampled patients. Staff provided treatment for an infected toe without a doctor’s order. This resulted in the potential for a delay in healing. Findings: Record review, on 1/9/2024 at 2:25 p.m., of the “Home Health Certification and Plan of Care” showed Patient 5’s Start of Care was 6/5/2021, with the current certification period of 11/22/2023 to 1/20/2024. The diagnoses included a foot ulcer. Review of the “Physician Orders” (for January 2024) showed there was no wound care order from Patient 5’s doctor. During a home visit on 1/9/2024 at 2:25 p.m., Registered Nurse 2 (RN 2) was observed treating Patient 5’s infected toe. The left infected (second toe) was red, swollen, and oozing a small amount of clear drainage. RN 2 cleaned it with betadine (iodine) and wrapped the wound with gauze. During a concurrent interview, RN 2 stated she had no doctor’s order for the wound treatment and staff usually, “Go by word of mouth” because the doctor gets busy. During an interview on 1/11/2024 at 2:10 p.m., the Director of Nursing (DON) stated the clinicians know what type of treatments to provide based on what the doctor orders. Record review of the document, “Plan of Care – CMS #485 and Physician Orders” showed, “Care and services provided will be provided according to physician orders. Orders are current and updated.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the home health agency’s licensed staff did not notify the doctor for a change in condition for four of 13 sampled patients (Patients 7, 8, 10 and 13). The licensed nursing staff did not notify the doctor when Patients 7, 8 and 10 were experiencing on-going pain. For Patient 13, the patient’s elevated blood pressure (BP) and shortness of breath (SOB) were not reported to the doctor. This resulted in unnecessary hospitalizations, pain, stress, and the inability to reach established health care goals. 1. Record review on 1/9/2024 at 10:47 a.m., “Home Health Certification of Care” showed Patient 7’s Start of Care was 8/9/2022 with the current certification period 12/2/2023 to 1/3/2024. The diagnoses for Patient 7 included left and right artificial knee joints. The goals included, “…interventions to minimize hospitalization risks…” Review of the licensed nurse visit note (not titled), dated 1/3/2024, showed Patient 7 had pain “All of the time” and was made worse with movement. Patient 7’s BP was 154/105 (normal range 120/80). Review of the document “SNV (skilled nursing visit) w/LVN (with licensed vocational nurse) Supervision,” dated 1/5/2024, also showed Patient 7 had pain “All of the time” and made worse with movement. In an interview on 1/10/2024 at 1:50 p.m., Registered Nurse 2 (RN 2) stated the MD had recently decreased Patient 7’s pain medication and she was “Not sure why.” RN 2 stated she had not notified the doctor regarding the pain, and it was important to stay on top of the pain because it, “Doesn’t help with healing and (patient’s) mental status.” During an interview on 1/11/2024 at 11:06 a.m., the Licensed Vocational Nurse 3 (LVN 3) stated, during the visit on 1/3/2024, she had notified RN 2 regarding Patient 7’s pain and LVN 3 had not called the doctor. During an interview on 1/11/2024 at 2:10 p.m., the Director of Nursing (DON) stated when the patient is having pain and there are no available pain medications, the doctor should be notified. DON further stated if the patient is taking pain medications which are ineffective, the doctor would again be notified so a possible adjustment (dosage) could be made. DON stated it was important to treat the pain because it is part of the healing process. Record review of the “Health Certification and Plan of Care” showed Patient 8’s Start of Care was 12/22/2023, with the current certification period of, 12/22/2023 to 2/19/2024. The diagnoses included leg pain. 2. Review of the nursing visit note (not titled) dated 1/2/2024 showed Patient 8 had left thigh pain “All of the time,” and the pain medication was ineffective. Patient 8 reported “…Occasional irritability and agitation related to pain.” There was no documentation which showed the doctor had been notified. Review of the visit note showed Patient 8 would report the unrelieved pain to her doctor, on 1/5/2024 (three days later). Review of the visit note dated 1/5/2024 showed Patient 8 continued to complain of left thigh pain along with a cough, headache, low grade fever and heart rate of 116 (normal range is 60- 100 beats per minute). There was no documentation the doctor was notified. During an interview on 1/11/2024 at 10:26 a.m., Licensed Vocational Nurse 4 (LVN 4) stated he had not notified the doctor regarding the pain and increase in urine frequency. He stated it was important to stay on top of the pain because it was, “Hard to get back (pain) under control.” Record review of the “Surge ED Triage” document showed Patient 8 went to the Emergency Department on 1/5/2024. Review of the “Final Report” showed Patient 8 was admitted to the hospital with “…left lower extremity pain and swelling for 2 weeks.” Patient 8 was discharged six days later, on 1/11/2024. 3. Record review of the “Home Health Certification and Plan of Care” showed Patient 10’s Start of Care was 8/13/2022, with the current certification period of, 12/6/2023 to 2/3/2024. The diagnoses included abdominal pain. Review of the nursing visit note (not titled), dated 1/2/2024, showed Patient 10 complained of nerve pain to the right of the wound and was made worse by “Movement.” Review of the visit notes dated 1/4/2024, 1/8/2024, and 1/10/2024, showed continued complaints of abdominal pain. There was no documentation the doctor had been notified. During an interview on 1/10/2024 at 1:50 p.m., RN 2 stated she had not notified the doctor regarding Patient 10’s pain. During an interview on 1/11/2024 at 11:06 a.m., LVN 3 confirmed there was no documentation in the clinical record the doctor had been notified for Patient 10’s pain. LVN 3 stated she, “Never calls the Doctor. I tell the RN or the office. They then call the doctor.” 4. Record review of the “Home Health Certification and Plan of Care” showed Patient 13’s Start of Care was 6/27/2023, with the current certification period of, 10/25/2023 to 12/23/2023. The diagnoses included asthma (airway becomes inflamed, narrow and swell, and produce extra mucus). Review of the documents titled, “RN-Skilled Nursing Visit” notes, dated 11/15/2023, 11/21/2023, and 11/29/2023, showed Patient 13 was short of breath with minimal exertion. There was no documentation the doctor was notified. Patient 13 was then admitted to the hospital. Record review of the “Final Report” document, dated 12/4/2023, showed Patient 13 went to the hospital Emergency Department on 12/1/2023 in respiratory distress. Patient 13 was admitted and discharged three days later. During an interview on 1/12/2024 at 10:19 a.m., Registered Nurse 3 (RN 3) stated she had not notified the doctor regarding Patient 13’s shortness of breath that could indicate respiratory distress and could not recall notifying the doctor. During an interview on 1/11/2024 at 2:10 p.m., DON stated the licensed nursing staff were to notify the doctor for a change of condition and for any patient concerns. DON further stated the nurse should call the doctor before leaving the patient’s home because the doctor “May want you do something right then.” Record review of the “Coordination of Patient Care,” dated 2000 showed, “Staff provides the physician with patient information on an ongoing basis regarding: Current condition and changes in condition. Outcomes of care and service.””