Saint Joseph VNA Home Care

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the accuracy of the medication profile for 1 of 2 home visit observations (Patient #3). Findings include: During a home observation on 7/12/2024 with Patient #3, licensed practical nurse (LPN) 2 compared Patient #3’s pill bottles with the medication list on their computer tablet. LPN 2 indicated the medication list had the same medications listed twice. The Clinical Manager, also at the visit, looked at the tablet and indicated they would need to discontinue one of the duplicate entries. The duplicate entries included amlodipine – benazepril (for high blood pressure), atorvastatin (for high cholesterol), metformin (for diabetes), low – dose aspirin (may reduce risk of heart attack and stroke), and metoprolol tartrate (for hypertension). The agency failed to ensure the accuracy of the medical record. During an interview on 7/12/2024 at 3:10 PM, LPN 2 indicated they did not know why the medications were listed twice or were not fixed at previous visits. LPN 2 indicated this was the first time they had seen the medications listed twice. During an interview on 7/12/2024 at 3:15 PM, the Administrator indicated the EMR duplicated the medications. When asked, the Alternate Clinical Manager indicated the nurse would see the medication already listed in the system and should have discontinued the duplicate. 410 IAC 17-15-1(a)(7)”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure assessments accurately reflected the patient’s current medical status in 1 of 4 active records reviewed of patients with wounds (Patient #2). Findings indicate: 1. Review of an agency policy titled “Wound Measurement Program” indicated utilizes the expertise of the Wound Ostomy Continence Nurse Society (WOCN) and wound care measurements should be done weekly to document wound progress. 2. Review of the WOCN recommendations for measuring wounds indicated the depth of a wound would usually be measured by inserting a Q-tip into the deepest part of the wound and determining how well a wound would be healing depends on consistent measurements and if different care team members measure it differently, it would result in inconsistency, errors, and treatment problems with the healing process. 3. Review of the registered nurse (RN) job description indicated the RN is to accurately assess patient’s condition and needs. 4. Review of the clinical record of Patient #2, start of care date 10/16/2023 with diagnosis, but not limited to, cancer of left breast. The wound record report included a baseline assessment of the left chest area cancer lesion completed on 10/16/2023 with wound depth measurement of 0.3 centimeters (cm). During a home visit on 07/12/2024 beginning at 9:00 AM, RN 2 removed the old dressings to a wound to the left chest area and observed a large wound protruding outward from the skin surface. Review of the wound care report for certification period 04/13/2024 – 06/11/2024 included the following depth measurements: on 05/13/2024 RN 2 documented 0.2 cm, on 05/20/2024 licensed practical nurse (LPN) 1 documented 0.1 cm, on 05/27/24 the clinical manager documented 13.0 cm, on 06/03/2024 RN 2 documented 0 cm, and on 06/10/2024 RN 2 documented 5 cm. Documentation failed to evidence an accurate depth measurement of the wound. Review of the wound care report for certification period 06/12/2024 – 08/10/2024 included the following depth measurements: on 06/17/2024 RN 2 documented 0.1 cm, on 06/24/2024 LPN 1 documented 0.1 cm, on 07/01/2024 RN 3 documented 7 cm, and on 07/08/2024 LPN 1 documented 0.1 cm. Documentation failed to evidence a consistent depth measurement of the wound. During an interview on 07/12/2024 at 12:12 PM, when asked how to measure the depth of the wound of Patient #2, RN 2 indicated the wound had changed and used to have a small section at the top of the wound with depth, and today during the home visit there was no open area. During an interview on 07/12/2024 at 2:50 PM, when asked about the depth measurement of 13 cm on 05/27/2024, the clinical manager indicated the wound sometimes had a small open area with depth and that the wound had never been 13 cm in depth, that was a mistake. During an interview on 07/12/2024 at 2:56 PM, when asked how to measure the depth of the wound of Patient #2, RN 3 indicated measures depth from the skin level outward, and with Patient #2 the depth measured would be how far the wound protrudes from the skin. During an interview on 07/12/2024 at 3:01 PM, when asked how to measure the depth of the wound of Patient #2, LPN 1 indicated when the wound had a small open area would measure the depth. 410 IAC 17-14-1(a)(1)(B)”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered by the physician and included in the plan of care (POC) for 1 of 5 active records reviewed (Patient #4). Findings include: 1. Review of an agency policy titled “Care Management and Plan of Care” indicated the agency provides the patient with the services according to the individualized POC that is developed. 2. Review of the registered nurse (RN) job description indicated the RN provides services as indicated in the POC. 3. Review of the medical record of Patient #4 included a POC for certification period 06/13/2024 – 08/11/2024 that included skilled nurse interventions at each visit for wound vac (removes the pressure over a wound, which helps to reduce swelling and helps clean the wound) dressing changes. Review of a physician order dated 06/17/2024 indicated the skilled nurse was to make five visits for one week to Patient #4 effective 06/16/2024. Review of the skilled nurse visits made the week of 06/16/2024 – 06/22/2024 indicated the RN made two visits that week, on 06/17/2024 and on 06/19/2024. Documentation failed to evidence the SN made five visits as ordered. During an interview on 07/12/2024 at 3:08 PM, when asked why 5 SN visits were not made the week of 06/16/2024 – 06/22/2024 as ordered, the administrator indicated the previous clinical manager must have approved the order before making the corrections.”