Aveanna Healthcare

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on surveyor observation, staff interview, record review and policy review the home health agency: 1) failed to ensure the patient had a confidential clinical record (G438) 2) failed to address the discharge for cause (G462) 3) failed to make efforts to resolve the problem (G466) 4) failed to provide contact information for other services available (G468) 5) failed to document efforts to resolve problems (G470) The cumulative effects of these 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 143 current patients.”

“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 agency staff interview, clinical record review and agency policy review the agency: 1) failed to ensure staff promptly alert relevant physician of changes. (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 143 patients.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on agency staff interview and patient/caregiver interview, policy review, clinical record review and review of other applicable documents, the agency failed to honor patient rights to have a confidential record for 1 of 3 sampled patients who had intakes with no admission to home health care. (Patient #8). Failure to allow patients to have a confidential clinical record resulted in violation of the patient’s rights as allowed by agency policy, home health regulation and governing laws. Findings include: The agency policy, titled Patient Rights and Responsibilities, revised 1/23/23, stated all patients/clients will be informed of their rights and responsibilities in a language and manner that the individual understands including those with limited English proficiency and accessible to individuals with disabilities free of charge. The patient receives written information about rights and responsibilities during the initial evaluation visit, in advance of furnishing care to the patient and in accordance to law and regulation. A handout summarizing patient rights and responsibilities will be reviewed and given to all patient/families upon admission. Patient #8 had an intake date of 12/7/23 for possible admission for home health care services. Clinical record review included the following: The admission paperwork, dated 12/7/23, included electronic documentation the patient consented for pictures. The client coordination note report, dated 12/7/23, included documentation the nurse went to the patient’s home and reviewed the policies, rules and patient’s expectations with the patient. The patient agreed and signed the paperwork. The nurse completed the assessment and reviewed the patient’s medications. A family member entered the home and demanded the nurse leave the home. The nurse left the home and the Clinical Manager was notified. During an interview on 2/13/24 at 2:00 PM, the patients’ family member stated he/she came into the home and found Staff D, Registered Nurse (RN) in the patient’s room taking pictures on her own personal cell phone. Staff D stated the pictures were to make the medication list. The family member told her to leave the patient’s room and their home and did not wish to have services provided. During an interview on 2/14/24 at 11:00 AM the Administrator stated Staff D, RN was assigned to complete the admission for patient #8. Staff D went to patient #8’s home for the admission and identified a person, identified as a family member, entered the home after the admission process had started. Staff D was asked by the family member to leave the home. Staff D admitted she took pictures of the patient’s medications using her personal cell phone and had verbal permission from the patient. The Administrator further stated staff are not allowed to use their personal cell phone but are only to use their agency provided tablet to take pictures for security reasons. During an interview on 2/14/23 at 8:30 AM, Staff D, RN stated she received a referral from the Veterans Administration (VA) on 12/6/23 and made an appointment with the patient for 12/7/23. She stated she reviewed the policy book and he/she signed the paperwork. She asked him/her where the medications were and he/she showed her the medication/medication bottles were in the patient’s bedroom. She stated she asked the patient if she could take pictures of the medications and he/she said yes. She took pictures with her personal cell phone to reconcile with the VA at a later time and did not use the agency provided tablet. The patient’s brother came into the home and asked what she was doing. The patient’s brother stated they did not want the service and asked her to leave their home. She identified the pictures were deleted off her personal cell phone after the visit due to the patient not admitted for services. She stated she had not been aware she could not take pictures with her personal cell phone but only with the agency provided secure tablet. She further stated education had been provided and she knew to only take pictures with the agency provided secure tablet. During an interview on 2/15/24 at 9:40 AM Patient #8, stated he/she saw the nurse taking pictures in his/her room. It bothered him/her a little bit and he/she wondered what was going on. He/she stated verbal permission was not given to take pictures in the home and he/she did not put permission in writing. The above findings were reviewed with the Administrator.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to document the patient’s behaviors and circumstances that warranted patient’s discharge for cause and the agency’s efforts to resolve the problems prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #6) Failure to document the patient’s behaviors and circumstances that warranted the patient’s discharge prevented the patient from attempting to correct the issue prior to the involuntary discharge. Findings include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company’s policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. During an interview on 2/13/24 at 3:34 PM Staff C, Home Care Aide (HCA) stated she called the patient and the patient told her the Doctor wanted him/her to go to the Emergency Room. She stated she did not need a bath aide. Staff C offered services on another day and the patient said he/she did not need a bath aide. Staff C notified the Case Manager, Patient #6 did not want aide services. During an interview on 2/14/24 at 3:40 PM with Patient #6, the patient stated he/she had not been aware the agency was going to discharge him/her. He/she stated he/she had no aide service provided to him/her in the home and denied refusing aide services from the agency. During an interview on 2/14/23 at 8:30 AM, Staff E, RN stated Patient #6 called the on call service for clean up after soiling him/herself. Staff E explained to the patient the services the agency provided for patients and that staff could not go and assist the patient at any time. The patient was not satisfied and wanted more services. She could not recall anything regarding the patient refusing home health aide services. Staff E stated she told the patient she could go with other agencies and companies for services but didn’t have a name or contact information to give the patient. Staff E reported she did not know if she documented the conversations. During an interview on 2/14/24 at 4:20 PM with Staff B, Clinical Manager, she stated the care team had concerns about Patient #6’s safety in his/her home. She stated she called the patient’s Doctor and communicated the patient refused aide services and multiple falls in the home and called EMT services several times and had a wound on his/her bottom. The Doctor said the patient should go to the Emergency Room and if the agency thought it was not safe for the patient in the home, we could discharge him/her. She further expressed concerns for safety due to falls and wounds. She informed Patient #6, the Doctor requested for Patient #6 to go to the Emergency Room and concerns for safety due to falls and wound and the agency was going to discharge him/her from services. The patient did not agree with discharge and stated his/her roommate was not willing to help him/her. Interview on 2/15/24 at 9:12 AM with the patient’s primary physician, revealed on 10/19/23, he had a phone message from the agency the patient had declined, refused a skin assessment and the agency was not available to provide 24/7 care for him/her. He stated the agency filed a report with the Department of Health and Human Services (DHHS) feeling she was not safe in the home. The doctor explained the patient was strong willed and will let people know how it was going to work. The agency felt she needed a higher level of care. On 10/23/23 the patient missed a visit at his office. They were trying to get her into a higher level of care and he did recommend it. He stated he didn’t know if the agency attempted to find other facilities but it would have been hard to find another provider to provide services in the home. Patient #6 had a start of care date of 10/4/23 and was discharged by the agency on 10/23/23. Clinical record review and associated patient and staff interviews included the following: a. The Plan of Care (POC), dated 10/4/23-12/4/23, included physician orders for skilled nursing services one time a week, physical therapy services two times a week, occupational therapy services one time a week and effective 10/15/23 home health aide services one time a week. b. The care coordination note, dated 10/13/23, included a call to the doctor’s office at 12:00 PM to report the patient had fallen two times within the last two days without any injuries. They also reported occupational therapy reported a blood pressure of 122/45 without symptoms. c. The care coordination note, dated 10/17/23, documented a call to physician to report the patient was not safe in the home. The Doctor recommended the patient should go to the emergency room. d. The care coordination note, dated 10/17/23, documented the occupational therapist reported patient reported two falls since last week. They discussed with PTA, PT and nurse concerns and recommended skilled nursing facility. e. The care coordination note, dated 10/19/23, documented concerns for the patient being safe at home with collaboration from the home health agency care team. On admission the patient originally refused to allow nursing to complete a full skin assessment. Last week (week of 10/13/23) he/she had to have emergency medical services come to his/her home up to four times due to falling or slipping out of the chair and needing assistance with changing position in his/her chair. It is taking three people with maximum effort to move/position in the chair. He/she is unable to get to the bathroom and is sitting in his/her urine and feces. The physical therapy assistant assisted with changing the pad and noticed multiple pressure ulcers and some blood noted on the pad. Concerns for patient safety at home and self neglect. DHS report has been filed. Over the weekend the patient called and stated he/she had soiled his/herself and needed someone to come clean him/her up. Physician notified of home health agency concerns of patient safety. Spoke with patient about staff concerns about safety in the home. Expressed to patient that clinicians are concerned about his/her safety and do not feel he/she is safe, so will be unable to continue providing services. Doctor aware and agrees to discharge and patient should go to emergency room to get further assistance. f. The episode summary report (discharge summary), dated 10/23/24, documented the patient discharge to home or self care due to skilled services exceed what can safely be provided in home setting. She/He is dependent upon self care. The patient had falls and called EMT several times to help him/her get up and also called on weekends to ask if someone can go to him/her after had a bowel movement due to unable to clean self. The clinical record lacked documentation of the patient’s received contact notification of agencies who may have the ability to provide care prior to the patients’ discharge. The above findings were reviewed with the agency Administrator.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on agency staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to initiate any efforts to resolve problems presented by the patient’s behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #6). Failure to attempt to initiate any efforts to resolve problems denied the patient the ability to attempt to correct the issue prior to the involuntary discharge. Findings Include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company’s policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. Patient #6 had a start of care date of 10/16/2020 and was discharged by the agency for cause on 10/23/2023. See G0462 for additional information. The agency failed to attempt to resolve the issues prior to discharge. The above findings for Patient #6 were reviewed with the agency Administrator.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on agency staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to provide contact information for other agencies or providers who may be able to provide care prior to discharging the patient for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #6) Failure to provide contact information of other providers hindered the patient ability to attempt to contact other agencies or providers to assist prior to the involuntary discharge. Findings include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company’s policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. During an interview on 2/13/24 at 3:34 PM Staff C, Home Care Aide (HCA) stated she called the patient and the patient told her the Doctor wanted him/her to go to the Emergency Room. She stated she did not need a bath aide. Staff C offered services on another day and the patient said he/she did not need a bath aide. Staff C notified the Case Manager, Patient #6 did not want aide services. During an interview on 2/14/24 at 3:40 PM with Patient #6, the patient stated he/she had not been aware the agency was going to discharge him/her. He/she stated he/she had no aide service provided to him/her in the home and denied refusing aide services from the agency. During an interview on 2/14/23 at 8:30 AM, Staff E, RN stated Patient #6 called the on call service for clean up after soiling him/herself. Staff E explained to the patient the services the agency provided for patients and that staff could not go and assist the patient at any time. The patient was not satisfied and wanted more services. She could not recall anything regarding the patient refusing home health aide services. Staff E stated she told the patient she could go with other agencies and companies for services but didn’t have a name or contact information to give the patient. Staff E reported she did not know if she documented the conversations. During an interview on 2/14/24 at 4:20 PM with Staff B, Clinical Manager, she stated the care team had concerns about Patient #6’s safety in his/her home. She stated she called the patient’s Doctor and communicated the patient refused aide services and multiple falls in the home and called EMT services several times and had a wound on his/her bottom. The Doctor said the patient should go to the Emergency Room and if the agency thought it was not safe for the patient in the home, we could discharge him/her. She further expressed concerns for safety due to falls and wounds. She informed Patient #6, the Doctor requested for Patient #6 to go to the Emergency Room and concerns for safety due to falls and wound and the agency was going to discharge him/her from services. The patient did not agree with discharge and stated his/her roommate was not willing to help him/her. Interview on 2/15/24 at 9:12 AM with the patient’s primary physician, revealed on 10/19/23, he had a phone message from the agency the patient had declined, refused a skin assessment and the agency was not available to provide 24/7 care for him/her. He stated the agency filed a report with the Department of Health and Human Services (DHHS) feeling she was not safe in the home. The doctor explained the patient was strong willed and will let people know how it was going to work. The agency felt she needed a higher level of care. On 10/23/23 the patient missed a visit at his office. They were trying to get her into a higher level of care and he did recommend it. He stated he didn’t know if the agency attempted to find other facilities but it would have been hard to find another provider to provide services in the home. Patient #6 had a start of care date of 10/4/23 and was discharged by the agency on 10/23/23. Clinical record review included the following: a. The Plan of Care (POC), dated 10/4/23-12/4/23, included physician orders for skilled nursing services one time a week, physical therapy services two times a week, occupational therapy services one time a week and effective 10/15/23 home health aide services one time a week. b. The care coordination note, dated 10/13/23, included a call to the doctor’s office at 12:00 PM to report the patient had fallen two times within the last two days without any injuries. They also reported occupational therapy reported a blood pressure of 122/45 without symptoms. c. The care coordination note, dated 10/17/23, documented a call to physician to report the patient was not safe in the home. The Doctor recommended the patient should go to the emergency room. d. The care coordination note, dated 10/17/23, documented the occupational therapist reported patient reported two falls since last week. They discussed with PTA, PT and nurse concerns and recommended skilled nursing facility. e. The care coordination note, dated 10/19/23, documented concerns for the patient being safe at home with collaboration from the home health agency care team. On admission the patient originally refused to allow nursing to complete a full skin assessment. Last week (week of 10/13/23) he/she had to have emergency medical services come to his/her home up to four times due to falling or slipping out of the chair and needing assistance with changing position in his/her chair. It is taking three people with maximum effort to move/position in the chair. He/she is unable to get to the bathroom and is sitting in his/her urine and feces. The physical therapy assistant assisted with changing the pad and noticed multiple pressure ulcers and some blood noted on the pad. Concerns for patient safety at home and self neglect. DHS report has been filed. Over the weekend the patient called and stated he/she had soiled his/herself and needed someone to come clean him/her up. Physician notified of home health agency concerns of patient safety. Spoke with patient about staff concerns about safety in the home. Expressed to patient that clinicians are concerned about his/her safety and do not feel he/she is safe, so will be unable to continue providing services. Doctor aware and agrees to discharge and patient should go to emergency room to get further assistance. f. The episode summary report (discharge summary), dated 10/23/24, documented the patient discharge to home or self care due to skilled services exceed what can safely be provided in home setting. She/He is dependent upon self care. The patient had falls and called EMT several times to help him/her get up and also called on weekends to ask if someone can go to him/her after had a bowel movement due to unable to clean self. The agency failed to provide the patient with contact information for other agencies or providers. The above findings were reviewed with the agency Administrator.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient’s behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #6) Failure to document the problems and efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company’s policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. Pt #6 had an admission date of and discharge date of 10/23/23. See G0468. The agency failed to make attempts to resolve the problem. The above findings were reviewed with the agency Administrator.”

“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 agency staff interview and patient/caregiver interview, agency policy review and clinical record review, agency staff interview the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 10 sampled patients (Patients #6). Failure to communicate the patient’s status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Coordination of Care, dated 11/9/23, all providers of care are encouraged to maintain open communication to ensure their efforts effectively complement one another. All efforts should support and enhance patient care needs. Communication will be maintained through effective service coordination regarding changes in the patient’s needs, services or care goals. When a situation occurs that requires action by another provider of services, it is the responsibility of the agency staff to contact the other provider to assure awareness of the situation. This contact should be documented in the patient’s record. Patient #6 had a start of care date of 10/4/23. Clinical record review revealed the following: a. The Plan of Care, dated 10/4/23 to 12/2/23, included orders for skilled nursing, physical therapy and occupational therapy services. b. The occupational therapy (OT) visit note, dated 10/9/23, documented the patient reported feeling worse than last week, like his/her mobility was gradually getting worse and he/she had a fear of falling. The patient reported a pain scale rating of 3 (out of 0 to 10) with reported pain in the anal area and feet. c. The Client Coordination Note Report, dated 10/9/23, documented OT staff notified the nurse and physical therapy about the patient’s bowel movement Patient #6 reported the bowel movement had about 1/2 cup of blood in it and his/her anal area hurt. He/she also reported feeling like walking was more difficult in the last week. d. The client coordination note report, dated 10/20/23, documented a call received from the client asking about a Hoyer sling delivered to his/her home. He/she asked if someone could come and educate him/her and complained that the transportable oxygen had not arrived yet. Staff advised the patient to call his/her physician and reach out to the company that delivered the supplies to inquire about this. During an interview on 2/14/24 at 8:30 AM Staff D, RN stated she did not recall notification from the patient or occupational therapy that Patient #6 had blood with any bowel movement. She also stated she did not notify the physician of the patient report of bleeding. During an interview with the physician on 2/15//24 at 9:12 AM he stated he did not receive notification from the agency about the blood loss report but did identify the patient had a history of hemorrhoids. During an interview on 2/15/24 at 10:00 AM, Staff G, Team Coordinator stated she received a phone call from Patient #6 on 10/20/23. The patient reported, she received a Hoyer sling and asked if she could have some assistance with it. Staff G stated she didn’t think it was an expectation for staff to run over to the patient’s home and didn’t understand the expectation the patient had for staff to be available all the time. She could not recall if she contacted the nurse or documented contacting the nurse but would normally contact a nurse for a request that came into the office from a patient. She further stated the patient had also been upset the portable oxygen was not delivered yet but staff did not know what the agency could do about the oxygen. During an interview on 2/14/24 at 1:06 PM the Administrator stated she had not been aware of the patient’s reported blood loss. She would expect staff to notify the physician. Agency staff failed to notify the physician of reported patient changes in condition. The above findings were reviewed with the Administrator.”

“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 3 sampled patients with wounds (Patient #6). 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 Care management, dated 10/12/23, wound assessment and wound care can be completed by: Registered Nurses, Licensed Practical Nurses and Physical Therapists. Wounds are to be measured weekly, or as ordered by the physician, and for any significant change in wound condition. Patient #6 had a start of care date of 10/4/23 and date of discharge of 10/23/23. Clinical record review revealed: The Plan of Care, dated 10/4/23-12/2/24, included physician orders for skilled nursing services 1 time a week times 1, 2 times a week times 1 and 1 time a week times 7 weeks. a. The comprehensive assessment, dated 10/4/23, documented the patient refused a skin assessment. b. The occupational therapy note, dated 10/9/23, included documentation Patient #6 reported he/she had about 1/2 cup of blood with a bowel movement and the anal area hurt. The note included documentation the nurse was notified. c. The physical therapy assistant (PTA) note, dated 10/18/23, documented staff assisted the patient to stand and change the pad under the patient. A new pressure area was noted to the bottom of the gluteal cleft. Staff were not able to take a picture or measure the size due to the patient inability to stand for a period of time. The patient was advised to go the emergency room for treatment and advised the patient to go to a skilled nursing facility for higher level of care. During an interview on 2/14/24 at 8:30 AM, Staff D, Registered Nurse (RN) stated she did not recall a report to notify her Patient #6 had a wound on his/her bottom. She further stated she would normally check on the patient, ask about the sore and check it out. She would then call the doctor. She stated she would notify her supervisors and do an extra visit if needed to assess the wound. During an interview on 2/14/24 at 11:00 AM the Administrator stated if the nurse was made aware of a wound, the expectation for the nursed to assess the wound in 24 to 48 hours. During an interview on 2/14/24 at 11:20 AM, Staff F, PTA stated during a home visit, he did notice the patient had an active bleeding area from a wound. The patient’s physician and agency administration was notified. The patient educated to go to the emergency room for evaluation. The agency nurses failed to follow established agency policy and assess patients wounds. The above findings were reviewed with the Administrator.”