Visiting Nurse & Hospice of Litchfield County, Inc.

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for two of seven patients (Patient #1 and #2) who required wound care in the survey sample, the agency failed to assess wounds in accordance with the agency’s policy. The findings include: a. Patient #1 had a start of care date of 02/12/2024 with diagnosis that included an unstageable pressure ulceration to the coccyx, cellulitis to the right ear, Parkinson’s disease, and dementia. The physician’s orders for the certification period of 02/12/2024 to 04/11/2024 included nursing services two to three times per week for eight weeks for nursing assessments and wound care to the coccyx. Additionally, the Patient received physical and occupational therapy services weekly. Review of Patient #1’s start of care nursing summary dated 02/12/2024, identified while in the hospital, Patient #1 developed a stage three (3) pressure ulceration (full thickness tissue loss, subcutaneous fat maybe visible) to the coccyx area. The nursing summary further identified the pressure ulceration to the coccyx was 1 cm (centimeter) in length, 0.4 cm in width and depth was unknown due to 95% of the wound being covered by slough (a yellowish/white material in the wound bed) and was unstageable. Review of Patient #1’s start of care OASIS (The Outcome and Assessment Information Set is a group of data points collected during comprehensive assessments) dated 02/12/2024, identified Patient #1’s pressure ulceration to the coccyx as stage three (3). Review of Patient #1’s nursing notes dated 02/14/2024, 02/16/2024, 02/19/2024, 02/21/2024, 02/23/2024, 02/26/2024 and 02/28/2024, identified the Patient’s pressure ulceration to the coccyx as stage two (2) (partial thickness loss of dermis, presenting as a shallow opened wound, without slough). b. Patient #2 had a start of care date of 07/04/2023 and a home health agency recertification date of 02/26/2024 with diagnosis that included a stage four (IV) pressure ulceration (tissue injury that extend to muscle, tendon and bone) to the right hip, malignant neoplasm to the bladder, neurogenic bladder, spina bifida and colostomy. The physician’s orders for the certification period of 02/29/2024 to 04/28/2024 included nursing services two to three times per week for eight weeks for nursing assessments and wound care to the right hip. Review of Patient #2’s start of care nursing summary dated 02/26/2024, identified the Patient underwent a surgical debridement (removal of dead/damaged tissue) to the right hip pressure ulceration in the hospital on 02/22/2024. Patient #2’s pressure ulceration to the right hip measured 6 cm in length x 6 cm in width x 5 cm depth and required the application of a wound vacuum device (a device applied to the wound, that uses suction to remove fluid and infection from the wound and promoting healing). Review of Patient #2’s resumption of care nursing summary dated 03/06/2024, identified the Patient visiting nurse services were resumed after being admitted to the hospital and returned home on 03/05/2024. The physician’s resumption of care orders dated 03/06/2024 included nursing services two to three times per week for nursing assessments and wound care to the right hip pressure ulceration. Review of Patient #2’s nursing notes dated 03/11/2024, 03/13/2024, 03/13/2024, 03/18/2024 and 03/20/2024, identified the right hip pressure ulceration as stage two. i. Interview and review of Patient #1 and #2’s clinical documentation with the Quality Assurance Nurse Manager on 03/27/2024 at 11:30 AM, identified the agency’s nurses failed to utilize the National Pressure Ulcer Prevention and Wound Ostomy and Continence Nurse Society (WOCN) wound staging guidelines in accordance with the agency’s Wound Assessment policy. Review of the agency’s Wound Care Assessment and Treatment policy identified a licensed skilled nurse would be responsible for the assessment and care of wounds. Inspection of the patient’s skin would be completed at minimum upon admission, resumption of care and recertification using the Braden Pressure Ulcer Risk Assessment. The nurse would document wound appearance, drainage amount and type, signs/symptoms of infection, as well as education provided, physician or other qualified licensed practitioner notifications and other relevant data, at every visit. The agency would use online procedures and current best practice resources for specific wound procedures. Additional resources included the National Pressure Ulcer Prevention and Wound Ostomy and Continence Nurse Society (WOCN) guidelines. Wound care documentation would be reviewed on a regular basis by the Home Health Clinical Manager or designee as part of the agency’s quality improvement program.”