Pratt Regional Medical Center HHA

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on home visit observation, record review, and staff interview, it was determined the Home Health Agency (HHA) failed to follow acceptable standards of practice, including the use of standard precautions to prevent infections when performing wound care for 1 of 3 patient home visits (Patient 1). This failed practice of not adhering to standard precautions when providing wound care had the potential to place all patients receiving wound care services at a higher risk of infection and hospitalization. Findings Include: Patient 1 Review of Patient 1’s clinical record, indicated a Start of Care (SOC) date of 01/23/24 and a primary diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer and orders for skilled nursing to provide wound care to both of the patient’s legs using Mepilex AG (a soft spongey grey foam pad that has silver in it), Adaptic (a wound dressing that doesn’t stick to the wound), and Unna boots (compression dressing made by wrapping layers of gauze around the leg and foot). Observation during a home visit on 03/13/24 from 9:05 AM to 9:50 AM, Staff C, Registered Nurse (RN), was observed providing wound care to both of Patient 1’s legs. The RN established a clean field using a barrier under both feet, then supplies to be used during wound care on the barrier next to patient’s feet. The RN used scissors from the supply box present in the home but, failed to clean them prior to or after use. The RN removed the current dressings from the patient’s left leg, then changed her gloves prior to cleaning the wound however, she failed to use proper hand hygiene by applying hand sanitizer between glove changes. After cleaning the wound the RN removed her gloves again and failed to use hand sanitizer prior to applying new gloves. When performing wound care to the right leg the RN removed the current dressing, then removed her gloves and failed to use proper hand hygiene by applying hand sanitizer before applying new gloves. During an interview on 03/13/24 at 4:00 PM with Administrator, Staff A and Staff C, the RN observed during the home visit, both confirmed the nurse should have used hand hygiene after removing dirty gloves. Staff C also confirmed that she had failed to clean the scissors prior to using to cut the wound care supplies.”

“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, and staff interview, it was determined that the home health agency failed to ensure the plan of care was individualized to include interventions to manage patients’ primary diagnosis for 3 of 7 sample patients (Patient 1, 2, and 4). This failed practice had the potential to place all patient at risk for adverse outcomes as well as unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/23/24 and a Certification Period from 01/23/24 to 03/22/24. The Primary Diagnosis was listed as: Type 2 Diabetes Mellitus with Foot Ulcer. Orders, Treatments, and Interventions included on the Plan of Care were for skilled nursing to provide wound care to bilateral lower extremities, assess skin, and notify physician of “fasting blood sugar greater than 200 or less than 70 and random blood sugar greater than 300 or less than 70”. There were no written orders included for skilled nursing or the patient to check a blood sugar or check a blood sugar log therefore, no ability to notify the physician of blood sugars out of range. Patient 2 Review of Patient 2’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/24/23 and a current Certification Period from 01/20/24 to 03/19/24. The Primary Diagnosis was listed as: Type 2 Diabetes Mellitus with Hyperglycemia. Orders, Treatments, and Interventions included on the Plan of Care were for skilled nursing one time per week and PRN (as needed) for assessment and notify physician of fasting blood sugar greater than 200 or less than 70 and random blood sugar greater than 300 or less than 70. There were no written orders included for skilled nursing to check a blood sugar or to monitor a blood sugar log therefore, no ability to notify the physician of blood sugars out of range. Patient 4 Review of Patient 4’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/26/24 and a Certification Period from 01/26/24 to 03/25/24. The Primary Diagnosis was listed as: Type 2 Diabetes Mellitus with Foot Ulcer. Orders, Treatments, and Interventions included on the Plan of Care were for skilled nursing to provide wound care and notify physician of “fasting blood sugar greater than 250 or less than 70 and random blood sugar greater than 300 or less than 70”. There were no written orders included for skilled nursing to check a blood sugar or to monitor a blood sugar log therefore, no ability to notify the physician of blood sugars out of range. During an interview conducted on 03/13/24 at 3:50 PM, Staff A, Administrator confirmed the above findings of the agency not having an individualized Plan of Care with interventions to manage primary diagnosis.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to send a discharge summary to the physician within 5 business days of patient’s discharge in 1 of 7 sample patients (Patient 6). The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Patient 6 Review of Patient 6’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/19/24 and a Certification Period from: 01/19/24 to 03/18/24. Review of visit notes for the current certification period showed the patient was discharged from services on 02/14/24. However, there was no documented evidence of a discharge summary being sent to the physician. During an interview on 03/13/24 at 2:55 PM, Staff A, Administrator, confirmed the agency had not provided a Discharge Summary for the above patient.”