Mercy Home Care

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on clinical record review, agency policy review, patient/family interview and agency staff interview, the agency: 1) failed to ensure all services, medications and/or treatments required by the patient to meet his/her needs were included on each patient’s Plan of Care (G574); 2) failed to promptly alert the relevant physician to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the plan of care should be altered (G590). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency’s 225 patients.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record review, staff interview, policy review, patient and family member interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including types of services required and patient-specific interventions to meet their needs for 1 of 3 sampled patients (Patient #2). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy, titled Catheter-Associated Urinary Tract Infection Prevention, dated 4/1/21, catheters are to be inserted using aseptic technique, sterile equipment and a health care worker who has shown competency in this procedure. Use the smallest bore catheter as possible, consistent with good drainage to minimize urethral trauma. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction. Assess for voiding within 6 hours of removal of catheter. According to the agency procedure from Mosby’s Nursing Skills reference, titled Male Catheter Insertion Technique, dated November 2022, an indwelling catheter is inserted through the urethral meatus, advance the catheter until urine flows through the tubing. Do not inflate the balloon until urine flow appears. Continue to advance the catheter to the bifurcation (splitting) of the tubing. Do not force the catheter against resistance. Notify the physician, if resistance to catheter insertion persists, the patient may have an enlarged prostate or a urinary abnormality. Patient #2 had a start of care date of 3/28/23 and a discharge date of 9/20/23. Clinical record review revealed: a. Plan of Care, dated 7/26/23 to 9/23/23, identified diagnoses encounter for fitting and adjustment of urinary device; retention of urine, unspecified; and benign prostatic hyperplasia without lower urinary tract symptoms; and included physician order for skilled nursing services 1 visit every month and 3 visits PRN (as needed) for indwelling foley catheter replacement/troubleshooting/management. b. Skilled nursing visit note, dated 9/19/23, from 12:13 PM to 1:34 PM, included documentation indwelling foley catheter removed and replaced with 14 French foley catheter with 10 milliliter balloon at 1:10 PM, was not a difficult insertion but there was no urine and/or blood returned. Foley catheter balloon was inflated prior to urine flow. During the nurse visit, Staff C, RN (registered nurse), had patient drink water and walk around, patient denied pain. Assessment included: lung sounds clear bilaterally, respirations unlabored, no cough or pain with inspiration, no complaints of shortness of breath or difficulty breathing, appetite: fair, fluids: inadequate, change in appetite: unchanged, diet type: regular, oral problems: no oral problems:, and nutritional concerns: dehydration. Staff C spoke with assisted living facility Director regarding foley change and no urine return, requested assisted living staff to keep an eye on patient output and report no urine output to Staff C. During an interview on 11/21/23 at 11:25 AM, Assisted Living Facility (ALF) Director reported talking with Staff C on 9/19/23, assisted living facility nurse was not available when the home health agency staff made their visit. ALF Director received a report the foley catheter had been changed during visit and assisted living facility staff needed to follow up with the patient regarding urine output. Director documented this information in the patient record for the assisted living facility nurse to read/review and reported no concerns with education and care coordination with the home health agency staff. The Director reported Staff C did not give specific instructions for follow up on urine output or timeframe for assisted living staff to contact the home health agency. The assisted living facility nurse was unavailable for interview as he/she was no longer employed with the assisted living facility. During an interview on 11/21/23 at 8:48 AM, Patient #2’s son, reported not being at the assisted living facility during the skilled nurse visit on 9/19/23. Patient #2’s son received a call from assisted living facility staff at approximately 8:00 PM. The ALF staff reported the foley catheter was changed earlier in the day and facility staff suspected blood was in the catheter. Patient #2’s son made a visit to the facility and found Patient #2 on the toilet, bleeding, blood in the catheter bag, patient sick to his/her stomach, had diarrhea, and complained the home care nurse changed the foley catheter and left him/her like that. Patient #2 was sent to the emergency room per the request of Patient #2’s son. During an interview on 11/21/23 at 2:17 PM, Patient #2 reported the foley catheter change in September 2023, the nurse took the old catheter out, not sure what happened but they wrecked the inside (referencing bleeding), had to go to the hospital to get fixed, bled immediately when the new catheter was put in, blood was squirting all over. During an interview on 11/29/23 at 2:36 PM, Staff C, RN reported Patient #2’s catheter insertion was routine without difficulty other than no urine return, patient voiced no complaints. Staff C instructed assisted living facility staff to check on patient later, push fluids due to the potential for dehydration and notify home health nurse if the patient had no urine return. Since no call was received, home health nurse assumed the Patient had urine return. Staff C reported she did not think to notify physician about no urine return, since Staff C felt it was a routine catheter insertion. During an interview on 11/29/23 at 2:23 PM, Administrator reported she was unable to speak to the policy or procedure in regards to catheterizations without reviewing the policy or procedures first. The Administrator provided the requested policies/procedures on 11/30/23. During an interview on 1/4/24 at 3:22 PM, Staff C, RN reported it is essential to have urine return after inserting a foley catheter and the physician should have been notified, however the physician was not notified. In the future she would notify the physician if there was no urine return after inserting a foley catheter. Patient #2 had no urine or blood in the catheter bag when Staff C left the patient home. Staff C reported the assisted living facility staff check on patients only at certain times throughout the day. Staff C was not aware of this on 9/19/23 when she spoke with the assisted living facility director and requested assisted living facility staff to push fluids due to potential for dehydration, check the patient’s urine output and call Staff C if no urine output. Staff C did not give a specific timeframe for the facility to check on patient and call nurse. Staff C reported in the future she will be more specific regarding times when requesting assisted living facility staff to check on patients. During an interview on 1/15/24 at 10:49 AM, Administrator reported agency staff are instructed to give assisted living facility nurses report on patients after they have been seen by agency staff. If the assisted living facility nurse is not available at the time of the home health visit, staff may give report to another staff member that may be available, even if not a nurse. The expectation is the report or message would be passed onto the assisted living facility nurse. The Administrator reported it would be expected for staff to follow the policy/procedure for catheterization. 3. Assisted Living Facility (ALF) documentation for Patient #2 included the following: a. entry dated 9/19/23 at 2:40 PM, included documentation the home care nurse changed the patient’s foley catheter today; b. entry dated 9/19/23 at 6:11 PM, included documentation certified medication aide (CMA) called assisted living facility nurse to report blood present in foley catheter drainage bag and patient complained of discomfort. CMA instructed to administer to Patient #2, as needed Tylenol dose, encourage patient to increase water intake, and for CMA to call back with update between 7:00 PM and 8:00 PM. c. entry dated 9/19/23 at 7:50 PM, included documentation CMA contacted assisted living facility nurse and reported patient continued with dark red urinary output and blood at catheter insertion site. Patient reported some relief from Tylenol but continued to have discomfort. Assisted Living facility nurse called home health on call nurse and informed that a home health visit would be made. Assisted living facility nurse called patient’s son and notified him that patient had dark red urinary output and blood at catheter insertion site and home health nurse was to be at the facility to make a visit and assess the patient. d. entry dated 9/19/23 at 8:26 PM, included documentation CMA contacted assisted living facility nurse and reported patient’s son had arrived to assisted living facility, refused to talk with assisted living facility nurse or wait for home health nurse to assess patient, requested to have patient sent to emergency room via ambulance. CMA instructed by assisted living facility nurse to send patient to emergency room. 4. Home Health Case Communication note, dated 9/19/23 at 7:44 PM, included documentation the on call nurse received a call from assisted living facility staff, patient had blood tinged urine in foley catheter bag. Blood around urinary meatus, patient denies pain, urine draining. On call nurse instructed the assisted living staff that a skilled nursing visit would be made, nurse was at least 30 minutes away and would need to finish with current skilled nursing visit before coming to assess patient at the assisted living. Nurse arrived at the assisted living facility at 8:56 PM and was informed patient had been sent to the emergency room per family request. 5. Emergency department provider note, dated 9/19/23 at 9:04 PM, included documentation patient arrived in emergency department with complaint to ambulance staff the foley catheter didn’t feel right. Patient had blood in urine but unsure when the blood started. Patient with history of benign prostatic hypertrophy (enlarged prostate) urinary retention and chronic foley catheter, pseudomonas bacteremia (infection), presented today with complaint of blood in urine. Foley catheter changed this morning and since that time has had bleeding noticed in catheter drainage bag as well as around the urinary catheter. Patient reported he did not feel foley catheter was placed correctly. Clinical laboratory results demonstrated leukocytosis with left shift of nonspecific etiology (high white blood cell count). Emergency department physician consulted with primary physician and decision made to change foley catheter. At 10:58 PM, emergency department nursing staff changed foley catheter successfully with urine output, no obvious microscopic hematuria (blood in urine), no significant bleeding in urinary catheter or around urinary catheter. Patient having no significant discomfort with this foley catheter placement. Clinical Impression, Final diagnoses: acute hypoxemic respiratory failure; hematuria, unspecified type; pneumonia of both lungs due to infectious organism; sepsis with acute hypoxic respiratory failure. Patient admitted to inpatient status. 6. Hospital discharge summary note, dated 9/26/23 at 9:02 AM, included documentation patient was admitted on 9/19/23 with an elevated white blood cell count and temperature. Given patient previous history of pseudomonas urinary tract infection patient was started on 2 antibiotics (there was concern for possible pneumonia as well). Antibiotics were later scaled back as the blood culture had grown e coli and the repeat blood culture was negative. 7 days of antibiotics were completed. Discharge exam revealed foley catheter in place draining clear urine. Staff C failed to follow standard of practice for catheter insertion. Staff C failed to replace or troubleshoot the foley catheter due to no urine output. Staff C failed to communicate specific instructions for Patient #2, to the assisted living staff when to contact the home health agency. The plan of care failed to identify patient-specific instructions regarding steps to take if foley catheter was problematic and/or uncomfortable. The agency provided no additional information prior to the end of the survey.”

“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, agency procedure review, patient/family interview 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 1 of 2 sampled patients with indwelling foley catheters. (Patient #2) Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings included: According to the agency policy, titled Catheter-Associated Urinary Tract Infection Prevention, dated 4/1/21, catheters are to be inserted using aseptic technique, sterile equipment and a health care worker who has shown competency in this procedure. Use the smallest bore catheter as possible, consistent with good drainage to minimize urethral trauma. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction. Assess for voiding within 6 hours of removal of catheter. According to the agency procedure from Mosby’s Nursing Skills reference, titled Male Catheter Insertion Technique, dated November 2022, an indwelling catheter is inserted through the urethral meatus, advance the catheter until urine flows through the tubing. Do not inflate the balloon until urine flow appears. Continue to advance the catheter to the bifurcation (splitting) of the tubing. Do not force the catheter against resistance. Notify the physician, if resistance to catheter insertion persists, the patient may have an enlarged prostate or a urinary abnormality. Patient #2 had a start of care date of 3/28/23. Clinical record review revealed: 1. Plan of Care, dated 7/26/23 to 9/23/23, included physician orders for skilled nursing services 1 time a month for indwelling foley catheter replacement and 3 as needed for foley catheter replacement/ troubleshooting/ management. 2. Skilled nursing visit note, dated 9/19/23, from 12:13 PM to 1:34 PM, included documentation indwelling foley catheter removed and replaced with 14 French foley catheter with 10 milliliter balloon at 1:10 PM, was not a difficult insertion but there was no urine and/or blood returned. Foley catheter balloon was inflated prior to urine flow. During the nurse visit, Staff C, RN (registered nurse), had patient drink water and walk around, patient denied pain. Assessment included: lung sounds clear bilaterally, respirations unlabored, no cough or pain with inspiration, no complaints of shortness of breath or difficulty breathing, appetite: fair, fluids: inadequate, change in appetite: unchanged, diet type: regular, oral problems: no oral problems, and nutritional concerns: dehydration (due to inadequate fluid intake and no urine output). Staff C spoke with assisted living facility staff regarding foley change and no urine return, requested assisted living staff to keep an eye on patient output. Staff C failed to notify the physician of no urine output upon insertion of foley catheter. Staff C failed to follow standard of practice for catheter insertion. During an interview on 11/21/23 at 8:48 AM, Patient #2’s son, reported not being at the assisted living facility during the skilled nurse visit on 9/19/23. Patient #2’s son received a call from assisted living facility staff at approximately 8:00 PM. The ALF staff reported the foley catheter was changed earlier in the day and facility staff suspected blood was in the catheter. Patient #2’s son made a visit to the facility and found Patient #2 on the toilet, bleeding, blood in the catheter bag, patient sick to his/her stomach, had diarrhea, and complained the home care nurse changed the foley catheter and left him/her like that. Patient #2 was sent to the emergency room per the request of Patient #2’s son. During an interview on 11/21/23 at 2:17 PM, Patient #2 reported the foley catheter change in September 2023, the nurse took the old catheter out, not sure what happened but they wrecked the inside (referencing bleeding), had to go to the hospital to get fixed, bled immediately when the new catheter was put in, blood was squirting all over. During an interview on 11/21/23 at 11:25 AM, Assisted Living Facility (ALF) Director reported talking with Staff C on 9/19/23, assisted living facility nurse was not available when the home health agency staff made their visit. ALF Director received a report the foley catheter had been changed during visit and assisted living facility staff needed to follow up with the patient regarding urine output. Director documented this information in the patient record for the assisted living facility nurse to read/review and reported no concerns with education and care coordination with the home health agency staff. The Director reported Staff C did not give specific instructions for follow up on urine output or timeframe for assisted living staff to contact the home health agency. The assisted living facility nurse was unavailable for interview as he/she was no longer employed with the assisted living facility. During an interview on 11/29/23 at 2:36 PM, Staff C, RN reported Patient #2’s catheter insertion was routine without difficulty other than no urine return, patient voiced no complaints. Staff C instructed assisted living facility staff to check on patient later, push fluids due to the potential for dehydration and notify home health nurse if the patient had no urine return. Since no call was received, home health nurse assumed the Patient had urine return. Staff C reported she did not think to notify physician about no urine return, since Staff C felt it was a routine catheter insertion. During an interview on 11/29/23 at 2:23 PM, Administrator reported she was unable to speak to the policy or procedure in regards to catheterizations without reviewing the policy or procedures first. The Administrator provided the requested policies/procedures on 11/30/23. During an interview on 11/30/23 at 1:00 PM, Administrator reported staff are to contact the physician if they have difficulty inserting a foley catheter or insert a foley catheter with no urine return. During an interview on 1/4/24 at 3:22 PM, Staff C, RN reported it is essential to have urine return after inserting a foley catheter and the physician should have been notified, however the physician was not notified. In the future this RN would notify the physician if there was no urine return after inserting a foley catheter. Patient #2 had no urine or blood in the catheter bag when Staff C left the patient home. 3. Assisted Living Facility (ALF) documentation included the following: a. entry dated 9/19/23 at 2:40 PM, included documentation the home care nurse changed the patient’s foley catheter today; b. entry dated 9/19/23 at 6:11 PM, included documentation certified medication aide (CMA) called assisted living facility nurse to report blood present in foley catheter drainage bag and patient complained of discomfort. CMA instructed to administer to Patient #2, as needed Tylenol dose, encourage patient to increase water intake, and for CMA to call back with update between 7:00 PM and 8:00 PM. c. entry dated 9/19/23 at 7:50 PM, included documentation CMA contacted assisted living facility nurse and reported patient continued with dark red urinary output and blood at catheter insertion site. Patient reported some relief from Tylenol but continued to have discomfort. Assisted Living facility nurse called home health on call nurse and informed that a home health visit would be made. Assisted living facility nurse called patient’s family member and notified them that patient had dark red urinary output and blood at catheter insertion site and home health nurse was to be at the facility to make a visit and assess the patient. d. entry dated 9/19/23 at 8:26 PM, included documentation CMA contacted assisted living facility nurse and reported patient’s son had arrived to assisted living facility, refused to talk with assisted living facility nurse or wait for home health nurse to assess patient, requested to have patient sent to emergency room via ambulance. CMA instructed by assisted living facility nurse to send patient to emergency room. 4. Home Health Case Communication note, dated 9/19/23 at 7:44 PM, included documentation the on call nurse received a call from assisted living facility staff, patient had blood tinged urine in foley catheter bag. Blood around urinary meatus, patient denies pain, urine draining. On call nurse instructed the assisted living staff that a skilled nursing visit would be made, nurse was at least 30 minutes away and would need to finish with current skilled nursing visit before coming to assess patient at the assisted living. Nurse arrived at the assisted living facility at 8:56 PM and was informed patient had been sent to the emergency room per family request. 5. Emergency department provider note, dated 9/19/23 at 9:04 PM, included documentation patient arrived in emergency department with complaint to ambulance staff the foley catheter didn’t feel right. Patient had blood in urine but unsure when the blood started. Patient with history of benign prostatic hypertrophy (enlarged prostate) urinary retention and chronic foley catheter, pseudomonas bacteremia (infection), presented today with complaint of blood in urine. Foley catheter changed this morning and since that time has had bleeding noticed in catheter drainage bag as well as around the urinary catheter. Patient reported he did not feel foley catheter was placed correctly. Clinical laboratory results demonstrated leukocytosis with left shift of nonspecific etiology (high white blood cell count). Emergency department physician consulted with primary physician and decision made to change foley catheter. At 10:58 PM, emergency department nursing staff changed foley catheter successfully with urine output, no obvious microscopic hematuria (blood in urine), no significant bleeding in urinary catheter or around urinary catheter. Patient having no significant discomfort with this foley catheter placement. Clinical Impression, Final diagnoses: acute hypoxemic respiratory failure; hematuria, unspecified type; pneumonia of both lungs due to infectious organism; sepsis with acute hypoxic respiratory failure. Patient admitted to inpatient status. 6. Hospital discharge summary note, dated 9/26/23 at 9:02 AM, included documentation patient was admitted on 9/19/23 with an elevated white blood cell count and temperature. Given patient previous history of pseudomonas urinary tract infection patient was started on 2 antibiotics (there was concern for possible pneumonia as well). Antibiotics were later scaled back as the blood culture had grown e coli and the repeat blood culture was negative. 7 days of antibiotics were completed. Discharge exam revealed foley catheter in place draining clear urine. The skilled nurse failed to notify the physician regarding the indwelling foley catheter insertion without urine return. This resulted in an approximately 9 hour delay in getting the patient the appropriate care. The above findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.”