Estrella Home Health Care Inc.

“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 interview and record review the agency failed to ensure services were provided in accordance with physician’s orders for 1 of 2 patients reviewed who received skilled nursing (SN) services for blood glucose monitoring (Patient #6). Findings include: 1. The clinical record for Patient #6 was reviewed on 2/11/25. The plan of care (POC) for the certification period dated 11/2/24 to 12/31/24 revealed a start of care date of 1/12/23; diagnoses included: dysphasia, hypertension, bipolar disorder, type two diabetes mellitus, and flaccid hemiplegia. POC orders included: SN visits four to seven times a week and two as needed (PRN) visits for 60 days for assessment including vital signs, medication set-up, monitoring of fasting blood sugar (FSBS) levels once Patient #6 started the medication Glipizide (medication used to lower blood sugar and restore the way a patient uses food to make energy) four times a week, and to report FSBS if 200 or above during each visit to Patient #6’s physician; and certified nursing assistant (CNA) visits one time per day and one PRN visit for 60 days to assist with activities of daily living (ADLs). The POC for the certification period dated 1/1/25 to 3/1/25 revealed a start of care date of 1/12/23; diagnoses included: dysphasia, hypertension, bipolar disorder, type two diabetes mellitus, and flaccid hemiplegia. POC orders included SN visits three times a week and two PRN visits for 60 days for assessment including vital signs, medication set-up, monitoring FSBS levels at each SN visit and report FSBS if 200 or more to Patient #6’s physician; and CNA visits one time a day and one PRN visit for 60 days to assist with ADLS. a) The agency failed to ensure Patient #6’s physician was notified when Patient #6’s FSBS was 200 or above as ordered on Patient #6’s plan of care. Further review of the POCs for the certification periods dated 11/2/24 to 12/31/24 and 1/1/25 to 3/1/25 showed the following: - on Patient #6’s POC for the certification period dated 11/2/24 to 12/31/24, the 60 day summary showed for the certification period dated 9/3/24 to 11/1/24, Patient #6’s FSBS ranged from 112 to 304; and -on Patient #6’s POC for the certification period dated 1/1/25 to 3/1/25, the 60 day summary showed, for the certification period dated 11/2/24 to 12/31/24, Patient #6’s FSBS ranged from 105 to 474. Review of a journal note dated 10/29/24 at 3:18 p.m., showed the director of nursing (DON), who was also the alternate administrator, documented registered nurse (RN) #3 reported Patient #6’s physician was changing Patient #6’s diabetic medication from Lantus (a long lasting insulin medication) to Glipizide 2.5 mg daily, and to discontinue the Lantus once Patient #6 received Glipizide from the pharmacy. RN #3 also reported SNs caring for Patient #6 were ordered by Patient #6’s physician to check Patient #6’s FSBS two to four times a week for three weeks when the Glipizide was started and to call Patient #6’s physician if Patient #6’s FSBS was 200 or greater every visit during the three week period after Patient #6 started taking Glipizide. Review of a journal note 12/2/24 at 3:20 p.m., showed the DON documented the agency had received a verbal order from Patient #6’s physician office to reduce SN visits to three times a week. Review of a journal note on 12/12/24 at 12:18 p.m., showed the DON documented she received a phone call from licensed practical nurse (LPN) #4 where LPN #4 informed the DON during her 12/11/24 SN visit with Patient #6, she felt Patient #6 was “high on some-sort” of drug. LPN #4 informed the DON a CNA (the CNA’s name was not documented) was present during LPN #4’s visit and Patient #6 “refused to have his brief changed, refused to take his shower, refused toileting and refused to change his clothes.” The DON documented, LPN #4 reported Patient #6 was soiled, smelt like urine, and his blood sugar was over 400. The DON documented LPN #4 reported she notified Patient #6’s physician of LPN #4’s clinical findings and observation, including his blood glucose over 400 and his refusal of care by the CNA. LPN #4 informed the DON, Patient #6’s physician directed LPN #4 to continue to report these findings to Patient #6’s physician as they occurred for documentation purposes. Review of a journal note on 1/25/25 at 6:28 p.m., showed the DON documented Patient #6’s physician left her practice and Patient #6 chose to change his physician to a physician group that made house calls, but Patient #6’s original physician office would continue to refill Patient #6’s medication until Patient #6’s new physician took over his care. Review of journal notes from November 2024 through 1/31/25 (Patient #6 was admitted to the hospital and discharged from the agency on 1/31/25) failed to show any further communication to Patient #6’s physician regarding Patient #6’s FSBS of 200 or greater. Review of supplemental orders showed, on 12/2/24, RN #3 received a verbal order at 12:30 p.m. from Patient #6’s physician to decrease SN visits to three times a week. This order was not signed by Patient #6’s physician. Review of supplemental orders showed, on 1/31/25, RN #3 documented Patient #6 was transferred and admitted to an acute care hospital and was discharged from the agency. This order was signed on 2/4/25 by Patient #6’s physician. Review of supplemental orders showed, on 2/12/25 (during the survey), the DON wrote a clarification order for the certification period 1/1/25 to 1/31/25 (Patient #6’s discharge date) to state the 1/1/25 to 3/1/25 POC should “not have included the statement *call MD for blood glucose levels > 200*” as this parameter was discharged 11/29/24. This order was not signed by Patient #6’s physician. Review of Patient #6’s physician orders from November 2024 through 1/31/25 failed to show any further supplemental physician orders. A review of the SN note for 11/8/24, revealed RN #3 documented Patient #6’s FSBS was 286 and Patient #6 had begun taking Glipizide on 11/7/24. RN #3 documented she assisted Patient #6 with taking his medications from his medication minder; educated Patient #6 to take his medication every day to avoid having to restart insulin injections; reviewed the signs and symptoms of hypoglycemia (low blood sugar); and clipped Patient #6’s nails on his left hand, but Patient #6 refused to have his nails on his right hand clipped. The 11/8/24 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 286 as ordered on Patient #6’s POC. A review of the SN note for 11/9/24, revealed RN #3 documented Patient #6’s FSBS was 245 and Patient #6 had taken his Glipizide. RN #3 documented she assisted Patient #6 to take his medications from his medication minder and educated Patient #6 on the importance of taking his medications when going out to eat. The 11/9/24 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 245 as ordered on Patient #6’s POC. A review of the SN note for 11/13/24, revealed LPN #4 documented Patient #6’s FSBS was 254. The 11/13/24 SN note failed to show documented evidence LPN #4 notified Patient #6’s physician of his FSBS of 254 as ordered on Patient #6’s POC. A review of the SN note for 11/15/24, revealed RN #3 documented Patient #6’s FSBS was 247. RN #3 documented Patient #6 was incontinent of stool and RN #3 assisted Patient #6 to clean up and change his clothes; assisted Patient #6 to take his medication; educated Patient #6 on importance of taking his medication to control his diabetes and his other health conditions; and Patient #6 had food available and continued to eat sweet foods. The 11/15/24 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 247 as ordered on Patient #6’s POC. A review of the SN note for 11/22/24, revealed RN #3 documented Patient #6’s FSBS was 214. RN #3 documented Patient #6 had food available and assisted Patient #6 to take medication from his medication minder. The 11/22/24 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 214 as ordered on Patient #6’s POC. A review of the SN note for 11/29/24, revealed RN #3 documented Patient #6’s FSBS was 304. RN #3 documented she observed Patient #6 eating cookies with a coke and sugar. RN #3 educated Patient #6 to limit his intake of sweets; assisted Patient #6 to take his morning medications; and left written instructions on Patient #6’s kitchen cabinet to remind Patient #6 to take his medications. The 11/29/24 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 304 as ordered on Patient #6’s POC. A review of the SN for 12/11/24, revealed LPN #4 documented Patient #6’s FSBS was 474. LPN #4 documented she notified Patient #6’s physician of Patient #6’s FSBS and no new orders were provided for Patient #6. A review of the SN note for 1/4/25, revealed LPN #4 documented Patient #6’s FSBS was 300. The 1/4/25 SN note failed to show documented evidence LPN #4 notified Patient #6’s physician of his FSBS of 300 as ordered on Patient #6’s POC. A review of the SN note for 1/8/25, revealed LPN #4 documented Patient #6’s FSBS was 231. The 1/8/25 SN note failed to show documented evidence LPN #4 notified Patient #6’s physician of his FSBS of 231 as ordered on Patient #6’s POC. A review of the SN note for 1/16/25, revealed RN #3 documented Patient #6’s FSBS was 210. RN #3 documented: Patient #6 was assisted to take his morning medications; RN #3 observed Patient #6’s home to be unkempt and Patient #6 continued to refuse homemaker services; RN #3 observed minimal food in Patient #6’s home and a verbal confrontation between Patient #6 and a friend of Patient #6’s who offered to bring him food; Patient #6’s frequent refusals of CNA assistance with bathing; and Patient #6’s friend informed RN #3 of Patient #6 knocking on neighbors’ doors requesting help. The 1/16/25 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 210 as ordered on Patient #6’s POC. A review of SN note for 1/17/25, revealed RN #3 documented Patient #6’s FSBS was 274. RN #3 documented Patient #6 refused to have his blood pressure taken; RN #3 assisted Patient #6 to take his morning medications: and RN #3 observed Patient #6 to be well groomed and his apartment to be unkempt. The 1/17/25 SN note failed to show documented evidence RN #3 notified Patient #6’s physician of his FSBS of 274 as ordered on Patient #6’s POC. The surveyor was unable to interview LPN #4 as she was out on a medical leave. During an interview on 2/11/25 at 12:13 p.m., RN #3 confirmed she was Patient #6’s RN case manager. RN #3 stated she could not recall the parameter Patient #6’s physician had provided for Patient #6’s FSBS to notify the physician, but she was aware as a SN to notify a patient’s physician if a patient’s FSBS was over 350. RN #3 stated she communicated frequently with Patient #6’s physician regarding his noncompliance with his diabetic diet, but could not recall communicating to Patient #6’s physician if his FSBS was over 200. RN #3 stated she recalled Patient #6’s physician informing RN #3 to stop calling regarding Patient #6’s FSBS levels as Patient #6’s was noncompliant, but acknowledged she could not recall the new parameters on when Patient #6’s physician ordered her to call regarding Patient #6’s FSBS; and RN #3 acknowledged she failed to write a verbal order for the new orders she received from Patient #6’s physician regarding to stop reporting when his FSBS was 200 or greater. During an interview on 2/12/25 at 9:11 a.m., RN #3 stated she communicated frequently with Patient #6’s physician regarding his noncompliance with his diabetic diet and Patient #6 frequently had FSBS from 100 to 300 and was asymptomatic with these FSBS. RN #3 stated she could not recall if she called Patient #6’s physician each time his FSBS was over 200 as ordered on his POC. RN #3 stated the order to call Patient #6’s physician when his FSBS was over 200 on his 1/1/25 to 3/1/25 POC was a mistake, and she should have removed that order from this POC as the original order she received from Patient #6’s physician was to report his FSBS of 200 or over for the first three weeks Patient #6 took Glipizide. RN #3 acknowledged she failed to write the three week parameter on Patient #6’s POC for the certification period 11/2/24 to 12/31/24 and failed to remove the order to report Patient #6’s FSBS from Patient #6’s POC for the certification period 1/1/25 to 3/1/25. RN #3 stated she communicated frequently with Patient #6’s physician, but might have forgotten to document each of these instances in Patient #6’s record. During an interview on 2/12/25 at 10:13 a.m., the DON reviewed Patient #6’s POCs for the certification periods 11/2/24 to 12/31/24 and 1/1/25 to 3/1/25 and acknowledged both POCs had orders for SN to check Patient #6’s FSBS at each visit and to notify Patient #6’s physician when his FSBS was 200 or over. The DON stated RN #3 struggled with using the agency’s electronic medical record (EMR) system and the DON had educated RN #3 multiple times on how to use the EMR (but acknowledged she did not document all of the education she provided to RN #3). The DON stated RN #3 must have forgotten to remove the order for the SN to report Patient #6’s FSBS 200 or over on the POC for the certification period 1/1/25 to 3/1/25 as the original verbal order RN #3 received was for SN to report this for the first three weeks Patient #6 was taking Glipizide. The DON acknowledged she was responsible for the quality assurance (QA) at the agency, and her QA system did not catch this oversight. During continued interview, the DON also acknowledged the POC for certification period dated 11/2/24 to 12/31/24 failed to have an end date on when to report the FSBS of 200 or over, and RN #3 had failed to write a clarification order when the SNs were to stop reporting a FSBS of 200 or over to Patient #6’s physician. The DON reviewed the seven SN notes (11/8/24, 11/9/24, 11/13/24, 11/15/24, 11/22/24, 11/29/24 and 12/11/24) which showed a FSBS over 200 and the journal notes for this time period and acknowledged she could not see documented evidence either RN #3 or LPN #4 had reported the FSBS of 200 or over as ordered on the POC except for when LPN #4 documented on 12/11/24 she reported Patient #6’s FSBS of 474 to Patient #6’s physician. The DON stated she was surprised to not to see documented evidence LPN #4 had communicated to Patient #6’s physician his FSBS of 254 on 11/13/24, as LPN #4 typically documented all communication she had with physicians. The DON stated RN #3 was in close communication with Patient #6’s physician and more than likely reported the FSBS of 200 or greater, but acknowledged there was no documented evidence of this communication. The DON stated she would revise her QA process to ensure SN were following POC orders to ensure compliance with this regulation. In a text messages to the surveyor on 2/12/25 at 11:59 a.m. and 1:35 p.m., the DON stated she wrote a clarification order on 2/12/25 to end FSBS checks at each visit and reporting of his FSBS of 200 or more on 11/29/25 (three weeks after Patient #6 had started taking Glipizide). The DON also documented she had record of LPN #4 texting the DON to inform the DON she had communicated with Patient #6’s physician on 11/13/24 when his FSBS was 254 in a text message on her phone, but the DON acknowledged she failed to document this communication in Patient #6’s record. The DON also documented RN #3 informed her she did not call Patient #6’s physician on 11/8/24, when Patient #6’s FSBS was 286, as RN #3 stated Patient #6 had just started taking Glipizide; and the DON documented RN #3 did inform Patient #6’s physician of Patient #6’s low and high FSBS in the 60 days summaries listed on Patient #6’s POCs for the certification periods dated 11/2/24 to 12/31/24 and 1/1/25 to 3/1/25. During an interview on 2/12/25 at 1:13 p.m., the administrator acknowledged Patient #6’s record failed to show documented evidence of SN reporting to Patient #6’s physician when his FSBS was 200 or over as ordered on the POC. The administrator stated she and DON, moving forward, would ensure there was improved documentation in patient case conference and audit SN notes, particularly RN #3’s notes, to ensure POC orders were being followed and patient records showed documented evidence of SN following POC orders to comply with this regulatory requirement.”