St Joseph’s/Candler Home Healthcare, Inc.

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on staff interview, and review of agency policy, it was determined the agency failed to follow the plan of care and document the teaching related to long term use of aspirin as ordered for one patient (P) (P#9) and to use the appropriate treatment for pressure ulcer stage II open wound for one patient (P#2) of 18 sampled patients. Findings include: Review of document titled “Therapeutic Anticoagulation,” Policy No: TX-177, revised 10/20, 2/22, reveals the following: Policy Statement It will be the policy of (facility), Home Health Services Inc. to manage patients on therapeutic anticoagulation including prescribing, dispensing, administering, monitoring, and educating. Definition of Terms. Therapeutic anticoagulation- An anticoagulation is a substance that prevents coagulation; that is, stops blood from clotting. Procedure: C. Educating 1. Patient/family education will be provided for the specific anticoagulant prescribed and will include: b. Medication action and possible side effects. c. Potential drug-drug and drug-food interactions. d. Importance of compliance. Review of the undated document titled “Dressing Change (Sterile, Non-sterile),” Policy No.: TX-172 reveals the following: Policy Statement It will be the policy of (facility) Home Health Services Inc. to evaluate the condition of a patient’s wound (s) and perform/tech wound care in accordance with the physician’s orders. NOTE: 3. Unless otherwise ordered by the physician, measurement of all wounds is to be performed and documented weekly. A. RN, LPN, PT will: 1. Obtain physician’s order for specific dressing change and order to teach patient/caregiver as appropriate. Document needed supplies on Plan of Care (485) or Physician’s Order. 1. Review of the plan of care (POC) for P#9 (certification period of 2/15/24 to 4/14/24) revealed P#9 was admitted on 2/15/2024 with a diagnosis of coronary artery disease (buildup of plaque that causes arteries to narrow limiting blood flow in the heart), and longtime use of aspirin, (antiplatelet blood thinner). Skilled Nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document long term use of aspirin complication. Plan of care for P#9 failed to reveal documentation by Registered Nurse (RN) CC of teaching or monitoring of long-term use of aspirin complications such as bruising or bleeding. 2. Patient #2 was admitted to home health agency on 3/5/2023, by RN BB with a diagnosis of type 2 diabetes (when pancreas does not produce enough insulin, it may cause poor wound healing). Review of the Physician’s order in Plan of Care revealed: Skilled Nurse (SN) to assess and perform/teach pressure ulcer to sacral pressure wound as follows: Cleanse with soap and water or wound cleanser, apply barrier cream and cover with padded foam dressing. Using clean aseptic technique. Change dressing every other day and prn (as needed). May be performed by PT/CG when taught or SN PRN (as needed). May discontinue wound care when healed. Review of document “Visit Note”, admission assessment dated 3/5/23 revealed 3x1x0.1 sacral pressure ulcer stage II, exudate (fluid released)-serosang (a type of wound drainage, or exudate, secreted by an open wound in response to tissue damage) with wound care documented by RN CC as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing…”. Review of the “Visit Note Report, Resumption of Care” dated 4/14/2023 revealed RN AA assessed and performed/taught wound as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing using clean/aseptic technique.””

“Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This Element is not met as evidenced by: Based on clinical record review, staff interviews, and review of agency policy, it was determined that the home health agency nurse failed to use the appropriate treatment for pressure ulcer stage II open wound for one patient (P) (P#2) of 18 sampled patients. Findings include: Review of the undated document titled “Dressing Change (Sterile, Non-sterile),” Policy No.: TX-172 reveals the following: Policy Statement It will be the policy of (facility) Home Health Services Inc. to evaluate the condition of a patient’s wound (s) and perform/tech wound care in accordance with the physician’s orders. NOTE: 3. Unless otherwise ordered by the physician, measurement of all wounds is to be performed and documented weekly. A. RN, LPN, PT will: 1. Obtain physician’s order for specific dressing change and order to teach patient/caregiver as appropriate. Document needed supplies on Plan of Care (485) or Physician’s Order. Patient #2 was admitted to home health agency on 3/5/2023, by Registered Nurse (RN) BB with diagnosis of type 2 diabetes (when pancreas does not produce enough insulin, it may cause poor wound healing). Review of the Physician’s order in Plan of Care revealed: Skilled Nurse (SN) to assess and perform/teach pressure ulcer to sacral pressure wound as follows: Cleanse with soap and water or wound cleanser, apply barrier cream and cover with padded foam dressing. Using clean aseptic technique. Change dressing every other day and prn (as needed). May be performed by PT/CG when taught or SN PRN (as needed). May discontinue wound care when healed. Review of document “Visit Note”, admission assessment dated 3/5/23 revealed 3x1x0.1 sacral pressure ulcer stage II, exudate (fluid released)-serosang (a type of wound drainage, or exudate, secreted by an open wound in response to tissue damage) with wound care documented by RN CC as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing…”. Review of the “Visit Note Report, Resumption of Care” dated 4/14/2023 revealed RN AA assessed and performed/taught wound as follows: “cleansed with wound cleanser, applied barrier cream and covered with padded foam dressing using clean/aseptic technique.” On 3/12/2024 at 11:45 a.m., an interview was conducted with RN AA, who said she knows better that barrier cream is inappropriate order treatment for sacral open wound pressure ulcer stage II with serosanguineous drainage. On 3/12/2024 at 12:00 p.m., an interview was conducted with RN BB who stated that she could not recollect the P#2, and she did not know the reason why she used barrier cream for sacral open wound pressure ulcer stage 2 with serosanguineous drainage. On 3/12/2024 at 12:00 p.m., an interview was conducted with the Administrator, who said that two of the skilled nurses that visits P#2 and continued to use inappropriate treatment to sacral open wound pressure ulcer stage II with serosanguineous drainage had resigned and were no longer working with the company. The Administrator also confirmed that the home health agency staff including the OASIS nurse, failed to follow the company policies and regulations for wound care treatment.”

“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 clinical record reviews, staff interviews, and review of agency policy, it was determined the agency failed to follow the plan of care and document the teaching related to long term use of aspirin as ordered for one Patient (P) (P#9) of 18 sampled patients. The findings include: Review of document titled “Therapeutic Anticoagulation,” Policy No: TX-177, revised 10/20, 2/22, reveals the following: Policy Statement It will be the policy of (facility), Home Health Services Inc. to manage patients on therapeutic anticoagulation including prescribing, dispensing, administering, monitoring, and educating. Definition of Terms. Therapeutic anticoagulation- An anticoagulation is a substance that prevents coagulation; that is, stops blood from clotting. Procedure: C. Educating 1. Patient/family education will be provided for the specific anticoagulant prescribed and will include: b. Medication action and possible side effects. c. Potential drug-drug and drug-food interactions. d. Importance of compliance. Review of the plan of care (POC) for P#9 (certification period of 2/15/24 to 4/14/24) revealed P#9 was admitted on 2/15/2024 with a diagnosis of coronary artery disease (buildup of plaque that causes arteries to narrow limiting blood flow in the heart), and longtime use of aspirin, (antiplatelet blood thinner). Skilled Nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document long term use of aspirin complication. Plan of care for P#9 failed to reveal documentation of the teaching or monitoring of long-term use of aspirin complications such as bruises or bleeding by Registered Nurse (RN) CC. On 3/12/2024 at 4:02 p.m., an interview conducted with RN CC, revealed that she was not aware that she must document the teaching of aspirin complication bleeding or bruises in the nurses’ notes. On 3/12/2024 at 4:20 p.m., an interview was conducted with the Administrator who said revealed that the nurses were in-serviced on the side effects and complication of long term use of antiplatelet medications such as monitoring for bruises or bleeding.”