Well Care Home Health of the Triad Inc.

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the skilled nurse failed to assess a new wound/do wound care for 1 of 1 discharged patient with a wound [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30 pm. The policy stated, “Based on the assessment and conclusions, the individualized plan of care will include, but not be limited to...All patient care orders from all physicians involved in the individualized plan of care...Specific services and treatments to be provided...” Patient # 1 had a Start of Care [SOC] date of 3/3/23 and admitting diagnoses of venous insufficiency [a condition that occurs when the valves in veins do not work properly, making it harder for veins to move blood back to the heart], non-pressure chronic ulcer other part of left lower leg with fat layer exposed, and chronic kidney disease. Review of the Plan of Care [POC] for the certification period 7/1/23-8/29/23 included orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week, 2 as needed visits for change in condition and “lower leg wound-left lateral- clean with soap and water, 2 times per week, clean with gauze with soap and water, wipe wound and peri wound using clean gauze...apply zinc oxide ointment to wound edges, spray antibiotic solution and set for 5 minutes...moisten Prisma cover wound bed then cover with hydrofera blue...” Review of the clinical record revealed the patient was seen at _______ [name of wound center] on 8/18/23. Review of the wound center’s notes revealed the wound center had identified a new wound noted on the right gluteus [buttock area]. The wound center had given the following order, “Gluteus; Right-clean wound with anasept and wound cleanser 1 time per day. Apply aquacel ag rope to wound bed; cover with abd pad and secure with tape. Review of the clinical record revealed the patient received a SN visit on 8/28/23. Further review of the clinical record revealed no evidence the wound on the right gluteus was assessed or the wound care was completed on 8/28/23. The patient had a return visit to the wound center on 8/31/23. The wound center provided new orders related to the area on the right gluteus which was identified on 8/18/23. The new order was, “...Location-Right gluteus-clean with sound cleanser...pack with packing strips moistened in Dakin’s solution, cover with abd pad. Change dressing 2 times per day...” The patient received SN visits on 9/8/23 and 9/10/23. The clinical record revealed no evidence the new wound care was completed or the area to the right gluteus was assessed. During an interview with the branch director on 5/16/24 at approximately 3:30 pm, the director confirmed the wound was not assessed or the wound care completed”

“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 agency policy, clinical record review, and staff interviews the skilled nurse failed to change an indwelling catheter as ordered by the physician in the plan of care for 1 of 1 discharged patient with an indwelling catheter [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30 pm. The policy stated, “Based on the assessment and conclusions, the individualized plan of care will include, but not be limited to...All patient care orders from all physicians involved in the individualized plan of care...Specific services and treatments to be provided...” Patient # 1 had a Start of Care [SOC] date of 3/3/23 and admitting diagnoses of venous insufficiency [a condition that occurs when the valves in veins do not work properly, making it harder for veins to move blood back to the heart], non-pressure chronic ulcer other part of left lower leg with fat layer exposed, and chronic kidney disease. Review of Plan of Care [POC] for the certification period 3/3/23-5/1/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, and 3 PRN [as needed for change in condition/catheter issues/signs of UTI [urinary tract infection] and “Skilled nurse for insertion of foley catheter maintenance with catheter # 18 with 10 cc balloon, change every month around the 13th and PRN dislodgement or stoppage...” Review of the clinical record revealed the foley catheter was changed on 3/24/23. There was no documented evidence of the foley catheter being changed in April 2023. Review of the Plan of Care for the certification period 7/1/23-8/29/23 included orders for “skilled nurse for insertion of foley catheter; maintenance with catheter size of 18 French with 5-10 cc balloon. Change foley every month and as needed...” The next foley catheter change was documented completed on 8/7/23. There was no evidence the foley catheter was changed during the month of July 2023. During an interview with the agency director on 5/16/24 at approximately 3 pm, the director confirmed the foley catheter was not changed in accordance with the POC.”