Vitalcaring Group

“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 observation, record review, and interview, the agency failed to ensure patients had an accurate medication reconciliation for 2 (Patient #2 and Patient #4) of 4 (Patient #1, Patient #2, Patient #3, and Patient #4) sampled patients observed during home visits. Findings: Patient #2 Review of Patient #2’s Home Health Certification and Plan of Care for certification period of 01/27/2024 through 03/26/2024 revealed Patient #2 was to receive skilled nursing services once a week for one week, twice a week for one week, then alternating weekly the following: four times a week for one week and then three times a week for one week for the remainder of the certification period. Observation on 03/05/2024 at 11:45 a.m. revealed Patient #2 had the following medications available in the home for use, in part, Lantoprost (medication used to treat eye conditions) 125 micrograms (mcg) per 2.5 milliliter (ml) administer one drop to the left eye every night; Dorzolamide Hydrochloride/Timolol Maleate (medication used to treat eye conditions) 22.3 milligrams (mg)/6.8mg/ml administer one drop to the left eye twice a day; and Methotrexate (medication used to treat psoriasis flare ups) 2.5 mg administer eight pills once a week. In an interview on 03/05/2024 at 11:45 a.m., Patient #2 stated he had been prescribed and had been taking the above medications for months. Review of Patient #2’s Physician Progress Note/Referral dated 01/25/2024 revealed, in part, Patient #2 was prescribed, in part, Dorzolamide Hydrochloride 2%/Timolol Maleate 0.5% ophthalmic solution as directed, and Methotrexate 2.5 mg administer one tablet orally every 24 hours. Review of Patient #2’s Client Medication Record revealed no documented evidence and the agency presented no documented evidence of Lantoprost 125 mcg per 2.5 ml administer one drop to the left eye every night; Dorzolamide Hydrochloride/Timolol Maleate 22.3 mg/6.8mg/ml administer one drop to the left eye twice a day; and Methotrexate 2.5 mg administer eight pills once a week had been reconciled on the Client Medication Record. In an interview on 03/08/2024 at 12:42 p.m., S2Branch Director (BD)/Director of Nursing (DON) stated the nurse should have reviewed the medication against the admit paperwork, and should be checking medications every visit. S2BD/DON stated the agency had no documented evidence for the reason as to why the above mentioned medications were not properly reconciled on admit. Patient #4 Review of Patient #4’s Home Health Certification and Plan of Care for certification period of 12/25/2023 through 02/22/2024 revealed Patient #4 was to receive skilled nursing services once a week for nine weeks. Review of Patient #4’s Client Medication Record, provided to the surveyor on 03/04/2024 at 3:16 p.m. as the current medication record, revealed the following medications were listed as current medications for Patient #4 Atorvastatin 40 mg administer one tablet by mouth daily; Duloxetine 30 mg administer one tablet by mouth daily; Finasteride 5 mg administer one tablet by mouth daily; Gabapentin 100mg administer one tablet by mouth three times daily; and Metoprolol Succinate ER 25 mg administer one half of a tablet daily. Observation on 03/05/2024 at 12:21 p.m. revealed Patient #4 had the following medications available in the home for use Duloxetine (medication used to treat depression) 30 mg administer one tablet twice a day with a filled date of 02/14/2024, and Gabapentin (medication used to treat nerve pain) 300 mg administer one tablet by mouth three times a day with a filled date of 02/29/2024. Further observation revealed no evidence of the following medications were in Patient #4’s home Atorvastatin (medication used to treat elevate cholesterol); Finasteride (medication used to treat enlarged prostate); and Metoprolol Succinate Extended Release (ER) (medication used to treat elevated blood pressure). Review of Patient #4’s Physician Progress Note/Referral dated 02/27/2024 revealed, in part, Atorvastatin; Finasteride; and Metoprolol Succinate ER were not listed as current medications. Further review revealed Gabapentin 100mg administer one tablet by mouth three times daily and Duloxetine 30 mg administer one tablet by mouth daily were listed as current medications. In an interview on 03/05/2024 at 12:21 p.m., S3Registered Nurse (RN) stated Patient #4’s caregiver was in charge of his medication and was not always present for home visits and therefore was not completing an accurate medication reconciliation at the visits the caregiver was not present. In an interview on 03/08/2024 at 12:47 p.m., S2BD/DON stated the nurse should have reconciled the medications each visit and communicated with both the caregiver and any physicians any time a discrepancy was identified.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview the facility failed to ensure: 1. the agency communicated with the patient’s physician on abnormal lab results for 1 (Patient #7) of 3 (Patient #6, Patient #7, and Patient #10) sampled patients with lab orders; 2. the agency contacted the physician to clarify which orders to follow when a patient could not afford an ordered medication for 1 (Patient #7) of 1 (Patient #7 ) sampled patients who were not following physician’s orders; 3. the agency contacted the physician when the physician did not respond to faxed concerns within a timely manner for a patient with urinary discomfort for 1 (Patient #10) of 5 (Patient #1, Patient #7, Patient #8, Patient #9, and Patient #10 ) sampled patients reviewed for a change in condition; and 4. the agency contacted the physician to clarify orders when skilled nurse orders were not authorized for 1 (Patient #10) of 2 (Patient #8 and Patient #10) sampled patients with skilled nurse services that were not authorized. Findings: Patient #7 Review of Patient #7’s Physician Order dated 01/30/2024 revealed the skilled nurse was to obtain a complete blood count (CBC) and comprehensive metabolic panel (CMP) via venous puncture (process where the nurse draws blood from the vein) the week of 02/04/2024. Review of Patient #7’s record revealed the CBC and CMP were obtained on 02/05/2024 and results on 02/05/2024 at 6:53 p.m. with the following values being outside of normal limits, in part: Chloride (test to monitor health conditions with heart and kidneys) elevated at 113 millimoles per liter (mmol/L) (normal range of 95-110 mmol/L); Blood Urea Nitrogen (BUN, a test to monitor kidney function) elevated at 26 milligrams per deciliter (mg/dL) (normal range of 8-23 mg/dL); Albumin (test to monitor kidney function) lower than normal limits at 3.4 grams per deciliter (g/dL) (normal range of 3.5-5.2 g/dL); Red Blood Cell count lower than normal limits at 3.4 milli-international units per liter (M/uL) (normal range of 4.0-5.4 M/uL); Hemoglobin (test to monitor the oxygen carrying capacity of red blood cells) lower than normal at 9.4 g/dL (normal range of 12-16 g/dL); and Hematocrit (test used to measure the volume/percentage of red blood cells) lower than normal at 30.4% (normal range of 27-48.5%). Review of Patient #7’s record revealed no documented evidence and the agency presented no documented evidence the skilled nurse nor the agency staff had communicated with the physician regarding the above mentioned CBC and CMP results to ensure the physician was aware of the above mentioned abnormal lab results. Review of Patient #7’s Client Coordination Note Report dated 02/11/2024 revealed, in part, Patient #7 stated to the nurse she could not afford and would not pay for the above mentioned medication. Further review the nurse notified the physician to the above to please advise. The physician responded with “agree” on 02/14/2024, but no mention as to what was meant as to what the physician was agreeing to. There was no documented evidence and the agency did not present any documented evidence of agency staff contacting Patient #7’s physician to clarify if the physician was aware of the above mentioned abnormal lab results or of Resident #7 not being able to afford and/or was not going to pay for the above mentioned Eliquis medication. In an interview on 03/08/2024 at 1:00 p.m., S2Branch Director/Director of Nursing (BD/DON) stated the agency did not have any documented evidence of the nurse or agency having followed up with the physician on the abnormal labs, or to clarify what the physician wanted to do regarding Patient #7’s Eliquis. S2BD/DON further stated the nurse and agency staff should have followed-up with the physician to ensure no new orders were needed and the labs had been reviewed. Patient #10 Review of Patient #10’s Home Health Certification and Plan of Care for certification period of 12/29/2022 through 02/26/2023 revealed the skilled nurse was to provide services once a week for four weeks. Review of Patient #10’s Client Coordination Note Report dated 01/09/2023 revealed Patient #10 reported urinary discomfort, lower abdominal pain and frequency. Review revealed the agency requested to obtain a urinalysis with culture and sensitivity. Further review revealed Patient #10’s physician did not respond until 01/11/2023 with an answer of yes to obtaining the urinalysis with culture and sensitivity. Review of Patient #10’s record revealed no documented evidence and the agency presented no documented evidence of the agency having followed-up with Patient #10’s physician between 01/09/2023 when the urinary discomfort started until 01/11/2023 when the order was finally received. In an interview on 03/08/2024 at 1:10 p.m., S4Alternate Branch Director stated the agency had not documented a reason as to why staff did not follow-up with the physician when the physician did not respond back timely. Review of Patient #10’s Client Coordination Note Report dated 01/10/2023 from the previous Director of Nursing to the authorization department revealed, in part, the previous DON had documented a missed visit for the skilled nurse due to no authorized visits. Further review revealed Patient #10 was having urinary tract infection symptoms. Review of Patient #10’s record revealed no documented evidence of Patient #10’s physician was notified Patient #10 had a missed skilled nurse visit due to authorization issues, nor any documented evidence of a physician’s order to miss the skilled nurse visit. In an interview on 03/08/2024 at 1:10 p.m., S4Alternate Branch Director stated the agency had no documented evidence the physician was notified of the missed visit nor any documented evidence of a physician order to miss the skilled nurse visit. In an interview on 03/08/2024 at 1:11 p.m., S2Branch Director/Director of Nursing stated the agency should have contacted the physician for an order to change the frequency of the skilled nurse visit instead of completing a missed visit in the system.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview the agency failed to coordinate care to ensure a patient received a urinalysis timely for 1 (Patient #10) of 1 (Patient #10) sampled patients reviewed for urinary tract infection signs and symptoms. Findings: Review of Patient #10’s Home Health Certification and Plan of Care for certification period of 12/29/2022 through 02/26/2023 revealed the skilled nurse was to provide services once a week for four weeks. Review of Patient #10’s Client Coordination Note Report dated 01/09/2023 revealed Patient #10 reported urinary discomfort, lower abdominal pain and frequency. Review revealed the agency requested to obtain a urinalysis with culture and sensitivity. Further review revealed Patient #10’s physician responded on 01/11/2023 with an answer of yes to obtaining the urinalysis with culture and sensitivity. Review of Patient #10’s record revealed the urinalysis was not obtained until 01/16/2023. Further review revealed no documented evidence and the agency presented no documented evidence for the reason as to why the urinalysis was not obtained until 01/16/2023. Review of Patient #10’s Urinalysis obtained on 01/16/2023 revealed the urinalysis was abnormal with elevated white blood cells (cells present in urine when a urinary tract infection was present) and bacteria present. In an interview on 03/08/2024 at 1:10 p.m., S2Branch Director/Director of Nursing stated the agency did not have any documented evidence for the reason as to why the urinalysis was delayed. S2Branch Director/Director of Nursing stated due to Patient #10 having urinary discomfort the urinalysis should have been obtained as soon as the order was approved.”