VNA of Eastern Massachusetts

“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 observation, policy review, and interview, the agency staff failed to ensure infection control guidelines were maintained during the home visit observations of wound care for three patients (#3, #4 and #2), out of a total sample of 4 patient home visits. Findings include: 3. For Patient #2, RN #1 failed to follow accepted standards of practice while monitoring an incision and assessing for ankle edema (condition where excess fluid accumulates in the body’s tissues, causing swelling). Patient #2 was admitted to the agency in September 2025 and had a diagnosis of surgical aftercare following surgery on the circulatory system. Review of physician orders, dated 9/17/25, indicated the following: *Skilled observation and assessment of incision line, S/SX (signs/symptoms) infection, call for wt (weight) gain of 2lbs (pounds)/day or 5lbs net per week. On 9/23/25 at 12:45 P.M., a home visit was conducted with RN #1. At 12:58 P.M., RN #1 donned a pair of gloves to assess the patient’s sternal incision line palpating (to examine by touch) the surrounding skin. RN #1 doffed her gloves and disposed of them. She proceeded to measure the patient’s incision line without performing hand hygiene first. RN #1 then performed hand hygiene, donned gloves, and assessed the patient’s ankles for edema. RN #1 doffed her gloves and weighed the patient. RN #1 did not perform hand hygiene after doffing her gloves and prior to weighing the patient. During an interview on 9/23/25 at 1:30 P.M., RN #1 said she should have performed hand hygiene after removing her gloves. Review of the agency policy, titled Universal Precautions, revised October 2000, indicated the following: Policy: It is the policy of the Agency that Universal Precautions and Body Fluid Precautions will be utilized in the area of all patients in which exposure to blood and body fluids may occur. Procedure: Hand washing is essential in preventing the spread of an infection agent. *Gloves should be worn for touching blood or body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Hands should always be washed immediately after gloves are removed. Review of the agency policy, titled Hand Washing Technique, revised October 2000, indicated the following: Considerations for hand washing: *After each contact with a patient (even when gloves are worn), hands should always be washed after gloves are removed, even if the gloves appear to be intact. *After touching patient excretions (feces, urine or materials soiled with them). *After touching secretions from wounds and skin infection. 1. For Patient #3, Registered Nurse (RN) #2 failed to follow accepted standards of practice while performing wound care. Patient #3 was admitted to the agency in August 2025 with a diagnosis of Acute Cystitis with hematuria (inflammation of the bladder accompanied by blood in the urine). Review of the Physician order, dated 8/6/25, indicated the following: *Open butt wound: Normal Saline (NS) cleanse, cover with Mepilex (a bordered foam gauze dressing). On 9/24/25 at 10:00 A.M., a home visit was conducted with RN #2. At 10:15 A.M., RN #2 prepared Patient #3 for his/her wound dressing change. RN #2 washed her hands and donned (put on) gloves and proceeded to prepare for the treatment. She gathered all her supplies and placed them on a clean barrier on the bed. Prior to initiating the wound treatment, she moved the dirty trash bucket over next to the patient. She then proceeded to remove the old dressing from the affected body area and cleansed the wound. RN #2 did not doff (take off) her gloves and perform hand hygiene after touching and moving the dirty trash bucket, causing concern for potential risk for cross contamination. After completing the cleansing of the wound, RN #2 proceeded to apply a new dressing to the wound. RN #2 did not doff her gloves, perform hand hygiene, and don new clean gloves prior to applying the new dressing, causing concern for the potential risk of cross contamination. During an interview on 9/24/25 at 11:00 A.M., RN #2 said she probably should have changed her gloves after touching the trash bucket and said she should have performed hand hygiene and changed her gloves after cleaning the wound. 2. For Patient #4, RN #3 failed to follow accepted standards of practice while performing wound care. Patient #4 was admitted to the agency in September 2025 with a diagnosis of acute tubule-interstitial nephritis (inflammatory condition of the kidneys) and non-pressure chronic ulcer of the left ankle with unspecified severity. Review of the Physician orders, dated 9/22/25 indicated the following: *Incision/Wound care (left lower extremity): NS wash, Santyl/calcium alginate AG (medicated ointment that removes dead tissue from wound so it can heal), 4x4/ABD/Kling/Sock/Ace. On 9/24/25 at 11:00 A.M., a home visit was conducted with RN #3. At 11:30 A.M., RN #3 prepared Patient #4 for his/her wound dressing change. RN #3 washed her hands and donned gloves. She removed the old dressing from the left lower extremity. RN #3 doffed her gloves and performed hand hygiene. She applied new gloves and proceeded to cleanse the wound. After cleansing the wound, RN #3 applied the wound ointment to the wound and applied a new clean dressing. RN #3 did not doff her gloves and perform hand hygiene after cleaning the wound, causing concern for potential risk of cross contamination. During an interview on 9/24/25 at 12:05 P.M., RN #3 said she should have changed her gloves and performed hand hygiene after cleaning the wound and prior to applying the new clean dressing.”

“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 record review and interview, the agency failed to ensure clinical documentation was complete, and appropriately authenticated and dated in accordance with currently accepted standards of practice for four patients (#6, #9, #10 and #3), out of a total sample of 11 patients. Findings include: 4. Patient #3 was admitted to the agency in August 2025 with a diagnosis of Acute Cystitis with hematuria (inflammation of the bladder accompanied by blood in the urine). Review of the Physician ordered POC for certification period 8/6/25 through 10/4/25 indicated the following: -SN visit two times a week for one week (8/6/25-8/9/25), and then three times a week for eight weeks (8/10/25-10/4/25). Review of the clinical record indicated the following SN visit notes were not dated/signed within 24 hours of the skilled visit: *8/8/25 visit, note completed on 8/11/25. *8/15/25 visit, note completed on 8/17/25. *8/20/25 visit, note completed on 8/22/25. *8/22/25 visit, note completed on 8/25/25. *8/25/25 visit, note completed on 8/27/25. *9/1/25 visit, note completed on 9/5/25. *9/3/25 visit, note completed on 9/6/25. *9/6/25 visit, note completed on 9/9/25. During an interview on 9/24/25 at 2:00 P.M. the Licensed Practical Nurse (LPN) Supervisor said that all clinical notes should be completed and documented in the clinical record within 24 hours of the skilled visit. 3. Patient # 10 was admitted to the agency in January 2025 with a diagnosis of pneumonia. Review of the physician ordered POC, dated 1/28/25 through 3/28/25, indicated the following: -SN visit: twice a week for 3 weeks and once a week for 6 weeks. Review of the clinical record indicated the following SN visit notes were not dated and signed within the required timeframe: *2/4/25 visit, note completed on 2/9/25. *2/7/25 visit, note completed on 2/9/25. *2/12/25 visit, note completed on 2/14/25. *2/25/25 visit, note completed on 2/27/25. Review of the facility policy entitled, Documentation and Data Transmission, revised May 2021, indicated the following: *All visits must be documented on the day of the visit and submitted electronically within 24 hours of the visit. 1. Patient #6 was admitted to the agency in July 2025 with a diagnosis of left hip osteoarthritis (flexible protective tissue at the end of bones wears down). Review of the Physician ordered Plan of Care (POC) for certification period 7/31/25 through 9/28/25 indicated the following: Skilled Nurse (SN) visit-once a week for one week, twice a week for three weeks, once a week for 6 weeks. Review of the clinical record indicated the following SN visit notes that were not signed/dated within 24 hours of the skilled visit: *8/18/25 visit, note completed on 8/20/25. *8/27/25 visit, note completed on 8/29/25. *9/3/25 visit, note completed on 9/8/25. 2. Patient #9 was admitted to the agency in May 2025 with a diagnosis of idiopathic aseptic necrosis of the right femur (a condition where the bone tissue of the the ball-shaped bone at the top of the thigh dies due to a lack of blood supply). Review of the Physician ordered POC for certification period 5/14/25 through 7/12/25 indicated the following: SN visit-twice a week for one week, twice a week for six weeks, once a week for one week. Physical Therapy (PT) visit-twice a week for five weeks, once a week for four weeks. Review of the clinical record indicated the following SN visit notes that were not signed/dated within 24 hours of the skilled visit: *5/23/25 visit, note completed on 5/25/25. *5/27/25 visit, note completed on 5/29/25. *6/17/25 visit, note completed on 6/19/25. Review of the clinical record indicated the following PT visit notes that were not signed/dated within 24 hours of the skilled visit: *5/22/25 visit, note completed on 5/26/25. *5/27/25 visit, note completed on 6/4/25.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care and services were provided in accordance with the plan of care (POC) for two patients (#6 and #11), out of a total sample of 11 patients. Findings include: Review of the facility policy entitled, Clinical Treatment Plan Guidelines, revised January 2021, indicated the following: *Content of the Plan of Care: The orders on the plan of care must specify the service type and frequency of the services to be provided to the member, and the type of professional who must provide them....... 1. Patient #6 was admitted to the agency in July 2025 with a diagnosis of left hip osteoarthritis (flexible protective tissue at the end of bones wears down). Review of the Physician ordered Plan of Care (POC) for certification period 7/31/25 through 9/28/25 indicated the following: Physical Therapy (PT) visit-once a week for one week, twice a week for nine weeks. Review of the clinical record indicated a PT visit was not provided for the week of 8/31/25 through 9/6/25 and the POC was not followed. 2. Patient #11 was admitted the the agency in August 2025 with a diagnosis of orthopedic aftercare of surgical amputation. Review of the Physician ordered POC for certification period 8/7/25 through 10/5/2025 indicated the following: PT visit-once a week for one week, twice a week for nine weeks. Review of the clinical record indicated a PT visit was not provided for the week of 8/31/25 through 9/6/25 and the POC was not followed. During an interview on 9/24/25 at 1:30 P.M, the Licensed Practical Nurse (LPN) Supervisor said PT visits were not provided for Patients #6 and #11 for the week of 8/31/25 through 9/6/25 as per POC. She further said the agency did not make an attempt to reschedule the missed PT visits.”