Burgess Home Health

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 2 of 3 sampled patients with medications set up/monitoring (Patient #1 and #2) and 3 of 4 sampled patients with monitoring of weights (Patient #2, #6 and #7). The deficient practices was identified in the Onawa parent office. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy, titled Documentation-Patient Plan of Care, dated 11/2017, the physician that is primarily involved will have an opportunity to review all orders. The agency will be responsible for assuring communication with all physicians involved in the plan of care as well as integrating orders to assure the coordination of all services and interventions are provided to the patient. 1. Patient #1 had a start of care date of 2/21/22. Clinical record review revealed: Plan of Care, dated 12/13/23-2/10/24, included physician orders for skilled nursing services 1-2 times a week for medication set up. Home visit observation and Interview on 2/5/24 at 1:30 PM with Staff C, Registered Nurse (RN) reported the medication set up in the medication planner was 2 times a week due to Patient #1’s noncompliance with taking medications. a. Skilled nursing visit note, dated 12/19/23, documentation included missed 2 morning prefilled medication slots in 3 days. b. Skilled nursing visit note, dated 1/2/24, documentation included missed 1 morning and 1 evening prefilled medication slots. c. Skilled nursing visit note, dated 1/23/24, documentation included did not take any medications for Sunday, Monday, Tuesday or Saturday bedtime prefilled medication slots. d. Skilled nursing visit note, dated 1/26/24, documentation included missed 3 bedtime and 1 morning prefilled mediation since 1/23/24. e. Home visit observation and Skilled nursing visit note, dated 2/5/24, documentation included missed 1 morning prefilled medication. The HHA failed to notify the physician when Patient #1 had missed taking their medications as ordered. 2. Patient #2 had a start of care date of 6/2/23. Clinical record review revealed: Plan of Cares, dated 11/29/23-1/27/24 and 1/28/24-3/7/24, included physician orders for skilled nursing services 2-3 times that included weigh patient weekly on routine visits. Report weight gain of 4 pounds in 1 week or 2 pounds in 24 hours. Home visit observation and Interview on 2/5/24 at 11:30 AM with Patient #2, reported their mother helps with setting up their medications and the Lasix medication is set up a noon, so they remember to take the Lasix. Interview on 2/5/24 during home visit with Staff D, Licensed Practical Nurse (LPN), reported the Lasix and weight are monitored because of Patient #2’s swelling in their legs. a. Skilled nursing visit note, dated 12/29/23, documentation included Lasix not taken on Tuesday or Thursday. b. Skilled nursing visit note, dated 1/2/24, Patient #2’s weight 360.8 pounds, up 5 pounds 4 ounces. c. Skilled nursing visit notes, dated 1/15/24, Patient #2’s weight 363 pounds, up 3 pounds. The HHA failed to notify the physician when Patient #2 had missed taking Lasix as ordered and when Patient #2 had an increase in their weight. 3. Patient #6 had a start of care date of 10/19/23. Clinical record review revealed: Plan of Care, dated 10/19/23-12/18/23, included physician orders for skilled nursing services 1-2 times a week that included to check weight every visit. a. Skilled nursing visit note, dated 10/24/23, documentation lacked a weight. b. Skilled nursing visit note, dated 10/29/23, documentation lacked a weight. The HHA failed to notify the physician when Patient #6 weight was not obtained as ordered. 4. Patient #7 had a start of care date of 7/11/23. Clinical record review revealed: Plan of Care, dated 7/11/23-9/8/23, included physician orders for skilled nursing services 1-2 times a week that included to check weight every visit. Skilled nursing visit note, dated 7/31/23, documentation included assisted living staff weighed Patient #7, weight down 5 pounds. The HHA failed to notify the physician when Patient #7 weight had decreased. The above findings were reviewed with the Administrator and Staff B, Clinical Manager. The agency provided no further information prior to the end of the survey.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient’s plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 2 sampled patients with wounds (Patient #2). The agency reported a current census of 108 patients at the time of the survey, including 7 patients who had a wound. Including 102 patients receiving services from the parent office in Onawa and 6 patients receiving services from the Decatur, Nebraska Branch office at the time of the survey. The deficient practice was identified in the Onawa parent office. Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: According to the agency policy, titled Wound Assessment and Photography, dated 6/2020, wounds will be measured weekly and more often if wound deterioration is noticed. Do depth measurement first. Complete measurement with length and width. During an interview on 2/5/24 at 2:30 PM, Staff B, Clinical Manager, reported wound measurements should be completed weekly. The measurements include depth, length and width of the wound. The wound measurements would be documented in the clinical record under assessment. Patient #2 had a start of care date of 6/2/23. Clinical record review revealed: Plan of Care, dated 11/29/23-1/27/24 and 1/28/24-3/7/24, included physician orders for skilled nursing services 2-3 times a week that included wound care to left lower extremity. Home visit observation and Interview on 2/5/24 at 11:30 AM with Patient #2, reported they take a shower before the skilled nurse visit and removed the dressing on the wound when they shower. Interview during home visit with Staff D, Licensed Practical Nurse (LPN) reported wounds are measured at the first visit of the week a. Skilled nursing visit note, dated 12/11/23, documentation included a length and width of the wound, but lacked a depth measurement. b. Skilled nursing visit notes, dated 1/7/24 and 1/10/24, documentation did not include a length, width and depth of the wound. No wound measurements were completed for the week of 1/7/24. c. Skilled nursing visit note, dated 1/22/24, documentation included a length and width of the wound, but lacked a depth measurement. d. Skilled nursing visit note, dated 2/5/24, documentation included a length and width of the wound, but lacked a depth measurement. Home visit observation with Staff D, LPN, of wound measurements did not include a depth measurement. The agency RN/LPNs failed to follow their agency policy and measure wounds weekly. The above findings were reviewed with the Administrator and Staff B, Clinical Manager. The agency provided no further information prior to the end of the survey.”