Angels Care Home Health

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined the agency did not ensure a verbal order for insulin administration was documented in the clinical record, and did not ensure the verbal order were authenticated and signed by the physician for one patient (#10) out of ten patients reviewed. Findings Included: Review of the clinical record for Patient #10 revealed a 485 Plan of Care for certification period of 12/10/23 to 2/7/24 Review of the Plan of Care revealed a diagnosis of Type 2 Diabetes Mellitus with hypoglycemia without coma. Review of the clinical record for Patient #10 revealed physician orders for sliding scale insulin administration : Medication orders on the Plan of Care included: Novolog 100 u/ml (units/milliliter) injectable solution per sliding scale three times daily. (151-200 2 units, 201- 250 4 units, 251-300 6 units, 301-350 8 units, 351- 400 10 units, over 401 or under 60 call MD). Review of the nursing note, written by Staff A, Licensed Practical Nurse (LPN), for 1/7/24 for Patient # 10 revealed: Endocrine : Glucometer Reading : RBS 413 at 07:30 PM . Comments: BG ( Blood Glucose) checked and insulin administered per orders. Review of the Medication Administration Record (MAR) for 1/7/24, entitled “Medications Administered” revealed the LPN wrote under comments he administered, “10 units of Novolog per PCP (Primary Care Physician) verbal order.” There was no other information regarding the receipt of the verbal order found in Patient #10’s clinical record. An interview was conducted with the Director of Nursing (DON), on 5/14/24 at 1:00 p.m. She stated she could not locate a verbal order other than what is written by Staff A, LPN on the medication record. She confirmed there was no written order for the physician to sign and the verbal order was not signed by the physician. Policy: Physician Order Processing, Policy Number C047, date 3/20/22, revealed the following: Policy: All medications, treatments and services provided to patients receiving skilled nursing must be ordered by a physician or allowed practitioner prior to provision of service or care, including changes in the care plan in accordance with applicable state and federal laws and regulations. The orders may be initiated via telephone or in writing and must be countersigned by the physician in a timely manner (within thirty 30 days). Orders may be received via facsimile, however, the agency is responsible for obtaining an original signature if required by regulatory personnel. Verbal orders may be taken by licensed personnel for his or her discipline, as designated by the agency in accordance with applicable State and Federal law and organization policy. All verbal orders must be “ read back” to the physician to verify accuracy of the orders and to decrease errors to inaccurate documentation of order. Procedure: When an RN [Registered Nurse] or therapist receives a verbal order from the physician or allowed practitioner he/she shall write the order as given and then read the order back to the physician verifying that the person receiving the order heard it correctly and interpreted the order correctly. The verbal order shall verify that the order was taken and verified by documenting this on the form and signing the form. The order must include the date and time received, specific order, be signed with the full name and title of the person receiving the order and be sent to the physician practitioner for signature. All orders for medications must contain the name of the drug, dosage , route of administration, and directions for use. Orders must be written completely and not contain any of the dangerous abbreviations ,acronyms or signals that may contribute to medication or treatment errors. Verbal orders are accepted by authorized , licensed agency personnel in accordance with applicable law and agency policy. When agency staff obtain verbal/ telephone orders from the physician/ practitioner, they must inform the DON, the RN responsible for furnishing or supervising the order service will co- sign the telephone order before it is sent to the physician/ practitioner. Orders can be initiated once the DON/Clinical Manager has been notified. Policy: Nurse Delegation, Policy Number C043, 3/20/22 revealed the following: Policy: Where State-approved, this policy is in place to determine what skills or supervisory responsibilities may be delegated to paraprofessionals, such as LPNS and Aides, as well as the procedures for performing the delegation of nursing responsibilities. RN may authorize an LPN or Aides to perform tasks of nursing services or supervisory responsibilities in selected situations and indicates the authorization in writing. The delegated tasks include medication administration, nursing assessment of a patient in a specific situation.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interviews, the provider failed to ensure documentation in the clinical record was completed on the Medication Administration Record (MAR) or in the nurse visit notes for three patients (#1, #2, and #4) out of 10 reviewed. Findings included: A review of the clinical record for Patient #1 revealed the MAR and the nurse visit notes had no documentation on the following days and times for Basaglar Kwik Pen 100 units per milliliter (u/ml) 35u subcutaneous (SQ) morning (am) and evening (pm): 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, and 5/12/24. A review of the clinical record for Patient #1 revealed the MAR and the nurse visit notes had no documentation on the following days and times for Novolog Flex pen 100 u/ml 8u SQ three times a day (tid): 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, and 5/12/24. A review of the clinical record for Patient #2 revealed the MAR and the nurse visit notes had no documentation on the following days and times for Basaglar Kwik Pen 100 u/ml 26u SQ every morning: 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, and 5/12/24. A review of the clinical record for Patient #4 revealed the MAR and the nurse visit notes had no documentation on the following days and times for Basaglar Kwik Pen 100 u/ml 55u SQ every morning and 50u every evening: 4/27/24, 4/28/24, 5/11/24, and 5/12/24. A review of the clinical record for Patient #4 revealed the MAR and the nurse visit notes had no documentation on the following days and times for Sliding Scale Novolog Flex pen 100 u/ml SQ tid (per the blood glucose reading: (151-200 2u SQ, 201-250 4u SQ, 251-300 6u SQ, 301-350 8u SQ, 351-400 10u SQ, 401-450 12u SQ, >450 call physician), on the following days and times for: 4/27/24, 4/28/24, 5/11/24, and 5/12/24. An interview was conducted with the Director of Nursing (DON) on 05/13/24 at 3:00p.m. She stated the expectation was the nurses are to document on the MAR when a medication is administered. A review of the provider’s policy titled “Clinical Documentation”, policy# C010, revised 3/2022 revealed “All skilled nursing services provided will be documented in the clinical record”.”