Tallahassee Memorial Home Health Care

“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 record review, observations, and staff interview agency skilled nursing (SN) staff failed to provide care and services ordered by the physician in the plan of care (POC) for 3 of 17 sample patients. (Patients #1, #4 and #7) The findings include: A review of the POC dated 01/04/2025 - 03/04/2025 for patient #1 revealed physician orders for the SN to perform all systems assessment each nursing visit and to assess cardiac status, lung sounds, and skin integrity. A home visit for patient #1 was made on 02/25/2025 at 12:00 PM with SN staff F. Staff F was observed to enter the home, wash hands, set up visit supplies on a clean field, obtain the patient’s vital signs, and set up supplies to perform wound care to the patient’s right heel. The patient was lying in bed, under sheets/blankets. The SN was observed to untuck the bedding from around the patient’s feet and to remove his socks in order to provide wound care to the right foot. Wound care was provided per the POC and the SN examined the patient’s left foot for new skin breakdown which had been reported by the patient’s wife. The SN then tucked the covers back around the patient’s feet, cleaned her equipment (blood pressure cuff, pulse oximeter, stethoscope) and returned it to her bag, concluding her visit. At no time was the SN observed to assess cardiac status (heartrate and rhythm), lung sounds, or skin integrity to any part of the body other than the patient’s feet. A complete systems assessment was not conducted at any time during the visit, such as monitoring for bowel sounds, skin integrity at common pressure points, presence or absence of edema. Bedcovers were never removed from the patient’s body other than to expose one arm to obtain his blood pressure. Review of the SN clinical note for this visit revealed none of these systems assessments were documented. A review of the POC dated 01/13/2025 - 03/13/2025 for patient #4 revealed physician orders for the SN to assess cardiac status, respiratory status, weight, lung sounds, blood glucose level, gastrointestinal status, genitourinary status each nursing visit. A home visit was conducted on 02/25/2025 at 2:00 PM with SN staff G. Staff G was observed to enter the home, sanitize hands, set up supplies on clean field, obtain vital signs, ask the patient about pain levels, dietary intake, and discuss wound care with the patient’s spouse. Supplies were set up for wound care to the patient’s right leg stasis ulcers and wound care was performed as ordered. The patient was then transferred to his bed for wound care to the right and left buttocks. All wound care was provided per physician orders. The SN cleaned up all supplies and equipments and placed the equipment back into her bag. At no time during the visit was the SN observed to assess cardiac status, respiratory status (lung sounds), or assess for bowel sounds. The SN was not observed to either monitor directly for weight or blood glucose levels, nor to ask the patient or spouse about any weight changes or about blood glucose levels which might have been monitored by the patient/spouse. Review of the SN clinical note for this visit confirmed none of these areas/systems were addressed on the clinical note for this visit. A review of the POC dated 12/28/2024 - 02/25/2025 for patient #7 revealed physician orders for the SN to assess cardiac status, respiratory status, weight, and lung sounds each nursing visit. A home visit was done on 02/26/2025 at 12:30 PM with SN staff C. Staff C was observed to enter the home, sanitize hands, set up supplies on clean field, obtain vital signs, ask about pain level. The SN set up supplies for wound care and performed wound care as ordered to the patient’s legs and feet. Following completion of the wound care, the SN cleaned supplies and equipment and returned equipment to her bag, concluding the visit. At no time during the visit was the SN observed to listen to heartrate/rhythm, lung sounds, or bowel sounds. The SN did not obtain the patient’s weight, nor ask if he had been monitoring his weight, despite a significant history of Congestive Heart Failure (which calls for close monitoring of weight gain/fluid retention). A brief interview was conducted with the SN upon exiting the patient’s home. She was asked how often the nurse is to assess cardiac and respiratory status for this patient. She replied “every visit”, and confirmed she had not performed a full systems assessment as she should have done, stating “I didn’t do that on this visit, and I should have”. Review of the SN clinical note for this visit also confirmed no documentation of a systems assessment was conducted. An interview was conducted on 02/26/2025 at approximately 3:30 PM with the Administrator. She was informed of observations made during the home visits for patients # 1, #4 and #7 and that no systems assessment had been made by any of the nurses during these home visits. She stated it is the expectation that full systems nursing assessments will be conducted during all SN visits, no matter what the focus of care is for the individual patient (i.e. wound care). She said that orders for systems assessments are always included in orders on the POC, in general, and more specific orders may be included as well.”