USA Home Health Services

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview the agency Nurses failed to notify the physician involved in the plan of care of changes in Blood Pressure readings on 2 out of 3 patients (Patient #1 and Patient #2). Findings include: The plan of care for each resident included an order to notify the physician if Systolic BP is greater than 160 or less than 90, and Diastolic BP is greater than 90 or less than 60. Record review indicated Patient #1 had a Blood Pressure reading on 08/06/2024 of 90/50. Record review indicated Patient #2 had the following Blood Pressure readings: 04/19/2024 - 146/97, 04/24/2024 - 98/56, 04/26/2024 - 91/56. Interview concluded with the Director of Nursing on 08/12/2024 at 1:00 PM, she stated there were no calls to the physician on either patient or calls to the office to notify the case managers to reach out to the physicians. The agency uses within their Plans of Care Vital Sign Parameters and all staff should be aware and if any vital signs fall outside of the standards the physician must be notified.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the provider failed to follow the physician’s orders for frequency of visits and wound care for 1 of 3 patients (Patient #1). Review of Patient #1’s record revealed he started care on 12/10/23. Patient #1’s Podiatry visit note for 12/08/23 documents he had peripheral vascular disease (reduced blood flow to the limbs) and venous insufficiency (impaired blood return from the legs to the heart) and an ulcerative wound (crater-like open wound) to the right lower leg requiring daily wound care with dressing changes. Patient #1’s Home Health Certification and Plan of Care for 12/10/23 to 02/07/24, with physician signature dated 01/12/24, documents orders for Skilled Nursing visits as of 12/10/23 as 4wk1 (4 times weekly for 1 week), 3wk1 (then 3 times weekly for 1 week), 4wk1, 3wk1, 1wk5 (then weekly for 5 weeks) and “Wound care as follows: Cleanse with Normal Saline, pat dry, apply Adaptic (a type of nonstick dressing), cover with 4x4 gauze with ¼ strength Diluted Betadine, cover with dry dressing and secure with tape every other day x (for) 4 weeks decreasing to once weekly thereafter, may d/c (discontinue) wound care when wound is healed.” Review of Patient #1’s record revealed an interruption in wound care every other day as follows: Patient #1 had a Skilled Nursing visit for wound care on 12/20/23 and a physician appointment for wound care on 12/22/23, but then did not have a nurse visit until 12/27/23. A Missed Visit note by LPN, Staff A for 12/24/23 documents “no answer to phone call,” however, there was no evidence of attempt to reschedule the nursing visit or to conduct the next scheduled nursing visit, due on 12/26/23, until another nurse made a visit on 12/27/23 and performed wound care. This resulted in 5 days between wound care and an increased risk of wound infection. During telephonic interview on 03/05/24 at 2:43 pm LPN, Staff A stated she had called Patient #1 and their family member on 12/24/23 but was unable to reach them so could not complete the visit, but stated he had “back to back” office visits where he was getting the dressing changed; that she believed he had an appointment the Friday before and Monday after this date but, upon being advised that Monday 12/25/23 was Christmas Day, admitted he would not have had a doctor’s appointment that day; stated when she misses a visit she tries to make the next scheduled visit but does not try to make up the missed visit; could not answer whether she made any attempt to call and/or perform Patient #1’s next scheduled visit on 12/26/23 before she asked the office to assign him to another nurse.”