Elara Caring

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations during home visits, interviews, and record reviews, the agency failed to ensure the patient’s comprehensive assessment included a review of all medications the patient was currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications during subsequent home visits for 4 of 4 (#4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” revealed the following, in part: Purpose: To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications. Key Words/Definitions: Medications: includes all over the counter, prescription, regularly taken PRN medications, herbals, and nutraceuticals that the client takes in all places of residence. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/04/2023 and had a current Certification Period of 10/31/2023 to 12/29/2023. Patient #4 had diagnoses, which included Chronic Combined Systolic and Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Unspecified Cardiomyopathy. Further review revealed Patient #4 received Skilled Nursing Visits once weekly for nine weeks for Certification period of 10/31/2023 to 12/29/2023. A home visit was conducted with Patient #4 on 12/18/2023 at 1:00 p.m. with S7PT present in the home. Patient #4’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #4’s Current Medication Profile provided by the Home Health Agency: Fish Oil 1000 mg soft gel take one soft gel by mouth daily– present in the home and not on the Medication Profile Buspirone 5 mg tablet take one tablet by mouth three times daily – on the Medication Profile, but not present in the home Hydrocodone 7.5 mg-Acetaminophen 325 mg tablet take one tablet by mouth every 12 hours as needed for Pain – on the Medication Profile, but not present in the home An interview was conducted with Patient #4 during the home visit. She stated she managed her own medications. She stated she had been taking Fish Oil for at least 6 months and she stopped taking Hydrocodone about 5 months ago. She further stated it had been months since she had taken Buspirone. An interview was conducted with S7PT during the home visit on 12/18/2023 at 1:35 p.m. He stated the nurses should reconcile the patient’s medications every visit. S7PT said he only asked Patient #4 if she had any medication changes each visit and if she reported she did, he notified the agency’s office nurses with the changes to update the medication profile. S7PT verified the medications on Patient #4’s Medication Profile and what the patient was taking did not match and should have. Patient #5 Review of Patient #5’s Clinical Record revealed she began receiving services from the Home Health Agency on 10/07/2023 and had a current Certification Period of 12/06/2023 to 02/03/2024. Patient #5 had diagnoses, which included Pressure Ulcer of Other Site Stage 2, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Chronic Diastolic Congestive Heart Failure, Mixed Hyperlipidemia, and Primary Generalized Osteoarthritis. Further review revealed Patient #5 received Skilled Nursing Visits once weekly for one week and twice weekly for eight weeks for Certification period of 12/06/2023 to 02/03/2024. A home visit was conducted with Patient #5 on 12/18/2023 at 2:00 p.m. with S4LPN present in the home. Patient #5’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #5’s Current Medication Profile provided by the Home Health Agency: Albuterol Sulfate 2.5 mg/3 ml vial nebulizer take every 6 hours as needed, filled on 12/02/2023- present the in home and not on the Medication Profile Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg inhaler take one inhalation daily, filled on 12/02/2023 with 16 doses remaining – present in the home and not on the Medication Profile Atenolol 25 mg tablet take one tablet by mouth daily, filled on 12/11/2023 – present in the home and not on the Medication Profile Calcium 500 plus D 500 mg-5 mcg tablet take one tablet by mouth daily- on the Medication Profile and not present in the home Calcium 600 mg plus Vitamin D3 20 mcg tablet take one tablet by mouth daily- present in the home and not on the Medication Profile Metoprolol Succinate ER 25 mg tablet, Extended Release 24 hour – on the Medication Profile and not present in the home Pantoprazole 40 mg tablet take one tablet 30 minutes before breakfast, filled 12/11/2023 – present in the home and not on the Medication Profile Rosuvastatin 5 mg tablet take one tablet by mouth daily – on the Medication Profile and not present in the home Melatonin 10 mg tablet take one tablet by mouth at night – present in the home and not on the Medication Profile An interview was conducted with Patient #5 during the home visit. She stated her daughter filled her pill box weekly, but she knew what medications she was on. She stated she took Albuterol nebulizer treatments daily at 10:30 a.m. She stated she had been taking the Trelegy Ellipta inhaler for at least two weeks. She stated she took Atenolol daily but did not know where the Metoprolol bottle was or if she was still taking it. She stated she had been on taking Pantoprazole daily for months. She stated she had been out of her Rosuvastatin for a while. She stated she had been taking Melatonin almost every night for a while. A telephone interview was conducted with Patient #5’s daughter on 12/19/2023 at 4:48 p.m. She stated she assisted Patient #5 with her medications by filling her pill box weekly. She stated Patient #5 took Albuterol nebulizer treatments daily. She stated Patient #5 had been taking the Trelegy Ellipta inhaler for over a month as she had completed one 30 day inhaler and was now on a second inhaler. She stated Patient #5 began taking Atenolol on 12/11/2023. She stated Patient #5 was taking Pantoprazole daily. An interview was conducted with S4LPN during the home visit on 12/18/2023 at 2:10 p.m. She stated she had been seeing Patient #5 since 12/12/2023. S4LPN also reviewed Patient #5’s medications and confirmed the above discrepancies. S4LPN stated Patient #5’s medications should have been reconciled every skilled nursing visit. S4LPN confirmed Patient #5’s current Medication Profile should have been up to date and it was not. Patient #6 Review of Patient #6’s Clinical Record revealed he began receiving services from the Home Health Agency on 09/26/2022 and had a current Certification Period of 11/20/2023 to 01/18/2024. Patient #6 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Unspecified Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Further review revealed Patient #6 received Skilled Nursing Visits once weekly for three weeks and twice weekly for six weeks. A home visit was conducted with Patient #6 and his spouse on 12/19/2023 at 9:00 a.m. with S5RN present in the home. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #6’s Current Medication Profile provided by the Home Health Agency: Pepcid 20 mg tablet take one tablet by mouth daily – on the Medication Profile and spouse stated Patient #6 was not taking Vitamin D3 50 mcg soft gel take one soft gel daily – present in the home and not on the Medication Profile Zinc 50 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile Magnesium Extra Strength 400 mg soft gel take one soft gel by mouth daily – present in the home and not on the Medication Profile Vitamin B12 5000 mcg take one quick dissolve tablet by mouth daily – present in the home and not on the Medication Profile An interview was conducted with Patient #6’s spouse during the home visit. She stated she managed Patient #6’s medications. She stated Patient #6 had not taken Pepcid for four to five months. She stated Patient #6 had been taking the above supplements for a long time. An interview was conducted with S5RN on 12/19/2023 at 9:45 a.m. She stated Patient #6’s medications should have been reconciled every visit. She reviewed Patient #6’s medications and Medication Profile and confirmed the above discrepancies. She confirmed the Medication Profile and the medications Patient #6 was taking should match and did not. Patient #7 Review of Patient #7’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/02/2023 and had a current Certification Period of 11/28/2023 to 01/26/2024. Patient #7 had diagnoses, which included Lymphedema, Major Depressive Disorder, Personal History of Pulmonary Embolism, and Peripheral Vascular Disease. Further review revealed Patient #7 received Skilled Nursing Visits twice weekly for eight weeks and once weekly for one week for Certification period of 11/28/2023 to 01/26/2024. A home visit was conducted with Patient #7 on 12/19/2023 at 11:00 a.m. with S6RN present in the home. Patient #7’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #7’s Current Medication Profile provided by the Home Health Agency: Escitalopram 10 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile Aspirin 81 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile An interview was conducted with Patient #7 during the home visit. She stated she had been taking Escitalopram daily for about one year. She stated she had been taking Aspirin daily for a couple months. An interview was conducted with S6RN on 12/19/2023 at 11:20 a.m. She stated medications were reconciled by looking at the medication bottles on admit and recertification. She reviewed Patient #7’s medications and confirmed the above discrepancies. She confirmed the Medication Profile and the medications the patient was taking should match and did not. An interview was conducted with S1ADM on 12/19/2023 at 11:50 a.m. She was notified of the medication discrepancies found during the home visits for Patient #4, #5, #6 and #7. She stated each patients’ medications should have been reconciled every nursing visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on interviews and record review, the agency failed to communicate an elevated Potassium level with the Physician for 1 (#4) of 4 (#4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Management” revealed the following, in part: Purpose: To reduce errors and improve quality of care and promote safety throughout the home care program. Monitoring Effects of Medications 4. Laboratory values will be evaluated as ordered and other clinical responses noted in the record and reported to the physician or allowed practitioner as indicated. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/04/2023 and had a current Certification Period of 10/31/2023 to 12/29/2023. Patient #4 had diagnoses, which included Chronic Combined Systolic and Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Unspecified Cardiomyopathy. Further review revealed Patient #4 received Skilled Nursing Visits once weekly for nine weeks for Certification period of 10/31/2023 to 12/29/2023. Review of Patient #4’s current Medication Profile provided by the Home Health Agency revealed the following, in part: Start date: 07/11/2022 – Potassium Chloride ER 20 MEQ Tablet, Extended Release- take one tablet by mouth daily as needed on days she takes Lasix Start date: 05/18/2023 – Furosemide 40 mg tablet take one tablet as needed for weight gain greater than 2 pounds Review of Patient #4’s Physician Orders dated 12/01/2023 revealed the following, in part: Obtain labs at next Skilled Nurse Visit Comprehensive Metabolic Panel Review of Patient #4’s Laboratory Results dated 12/11/2023 revealed the following, in part: Potassium 5.5 mEq/L High, Reference Range (3.5-5.1) Review of Patient #4’s Nurses’ Notes dated December 2023 revealed no documented evidence the physician was notified or the agency followed up regarding Patient #4’s elevated potassium results on 12/11/2023. A home visit was conducted with Patient #4 on 12/18/2023 at 1:00 p.m. She stated the home health nurse drew her labs last week, but she had not heard back from the agency or the doctor with the results. She stated she had a history of abnormal electrolytes. She stated she was mildly short of breath and had gained 2.5 pounds on 12/17/2023 and took a dose of Furosemide and Potassium. A telephone interview was conducted with S3LPN on 12/20/2023 at 8:40 a.m. She stated on 12/11/2023, she reviewed and faxed Patient #4’s laboratory results to the patient’s physician. She confirmed the laboratory results revealed an elevated Potassium level of 5.5. She stated she was aware Patient #4 was prescribed Potassium Chloride as needed. She confirmed she did not follow up with Patient #4 or the physician regarding the elevated Potassium level. She stated at this point she would have expected a response and new orders from the physician. She stated she did not communicate Patient #4’s Potassium level of 5.5 to S2RN. An interview was conducted with S2RN on 12/20/2023 at 9:22 a.m. She stated she was aware S3LPN faxed laboratory results for Patient #4 on 12/11/2023 to the physician. She stated S3LPN did not notify her of Patient #4’s elevated Potassium level of 5.5. She stated at this point she would have expected a response or new orders from the physician. She confirmed there was no documentation of the agency staff having communicated or followed up with Patient #4’s physician regarding the Potassium level of 5.5. She confirmed Patient #4 had not had a skilled nurse visit since the labs were drawn on 12/11/2023. She confirmed a Potassium level outside of therapeutic range could be life threatening. An interview was conducted with S1ADM on 12/20/2023 at 8:30 a.m. She stated S3LPN reviewed and faxed Patient #4’s laboratory results to the physician on 12/11/2023. She confirmed there was no documentation the agency staff communicated or followed up with Patient #4’s physician regarding the Potassium level of 5.5. She stated a patient with an elevated Potassium level would warrant a follow up phone call from the agency to the physician. She confirmed a Potassium level outside of therapeutic range could be life threatening.”