Bayada Home Health Care, 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 review, clinical record review and staff interviews the SN [skilled nurse] failed to assess the PICC [peripherally inserted central line catheter used to access large veins to prevent repeated sticks for medications] line site for 2 of 2 patients with a PICC line [#10,14] and failed to obtain wound measurements for 1 of 5 [#10] patients with a wound. The findings included: The agency procedure guide, PICC [peripherally inserted central line catheter used to access large veins to prevent repeated sticks for medications] Line Management [no date], was provided by employee # 4 on 4/10/24 at 8:30 am. The procedure stated, “…Verify that external length visible outside corresponds to initial placement measurement. If it does not, notify physician before continuing use…Assess for signs of infection, including redness, swelling, inflammation, tenderness, or exudate. Assess for catheter migration. Observe the external catheter length and compare it to the insertion record…” The policy, Wound Care-Assessment and Treatment [9/9/21], was provided by employee # 4 on 4/10/24 at 8:30 am. The policy stated, “…Wounds should be measured in centimeters [cm] once per week and/or as physician’s order…” 1. Patient # 10 had a Start of Care date of 3/11/24 and admitting diagnoses of infection/inflammation reaction due to internal left knee prothesis, methicillin resistant staphylococcus [type of bacteria] infection causing diseases classified elsewhere, and encounter for adjustment and management of VAD [vascular access device- a device which allows repeated and long-term access to the bloodstream for frequent or regular administration of drugs]. Review of the Plan of Care for the certification period 3/11/24-5/9/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 4 weeks, 2 times a week for 1 week and “PICC [peripherally inserted central line catheter used to access large veins to prevent repeated sticks for medications] care as follows: …cleanse PICC site with alcohol/betadine swab sticks…provide dressing change weekly…” Review of the clinical record revealed the patient received SN visits on 3/18/24, 3/25/24, and 4/1/24. Further review of the clinical record revealed no PICC line assessment was completed. During an interview with employee # 1 on 4/10/24 at approximately 12:30 pm, employee # 1 confirmed the PICC line should have been assessed with each visit. 2A. Patient # 14 had a Start of Care date of 3/4/24 with admitting diagnoses of encounter for change or removal of surgical wound dressing, encounter for orthopedic aftercare following surgical amputation, and acquired absence of other right toe. Review of the Plan of Care for the certification period 3/4/24-5/2/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week and “SN will apply negative pressure wound therapy to right 5th toe amputation site…set device at 125 mmHg …change 3 times per week…educate and monitor for signs and symptoms of infection.” Review of the clinical record revealed the patient had an inpatient stay from 3/18/24-3/26/24. The patient was discharged home with a PICC [peripherally inserted central line catheter used to access large veins to prevent repeated sticks for medications] line. The resumption of care [ROC-assessment after patient is admitted inpatient for at least 24 hours] visit was completed on 3/27/24 by RN # 3. Review of the ROC orders included the following orders “skilled nurse will collect/perform blood sample via venipuncture/PICC line…perform IV site care with PICC supplies using aseptic technique weekly and prn [as needed] …” RN # 3 obtained PICC line measurements during the ROC visit. Review of the clinical record revealed the patient received 5 SN visits from 3/27/24-4/8/24. Review of the visit documentation revealed no PICC line assessment was completed for 3 of the 5 SN visits. During an interview with employee # 1 on 4/10/24 at approximately 2 pm, employee # 1 confirmed the PICC line should be assessed/measured with each visit to prevent complications. 2B. Patient # 14 had a Start of Care date of 3/4/24 with admitting diagnoses of encounter for change or removal of surgical wound dressing, encounter for orthopedic aftercare following surgical amputation and acquired absence of other right toe. Review of the Plan of Care for the certification period 3/4/24-5/2/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week and “SN will apply negative pressure wound therapy to right 5th toe amputation site…set device at 125 mmHg …change 3 times per week…educate and monitor for signs and symptoms of infection.” Review of the clinical record revealed the amputation site measured 5.5 cm x 4 cm x 1.5 cm on 3/4/24. LPN # 2 made routine visits the week of 3/11/24. The clinical record revealed no wound measurements for that week. The patient was hospitalized from 3/18/24-3/26/24 with the resumption of care [ROC-assessment after patient is admitted inpatient for at least 24 hours] visit completed on 3/27/24 by RN # 3. RN # 3 documented wound measurements of 3.5 cm x 0.5 cm x 0.2 cm on 3/27/24. Further review of the clinical record revealed LPN # 2 conducted a routine visit on 4/1/24 and 4/8/24. RN # 3 conducted a PRN visit on 4/1/24. No wound measurements were obtained for any of those visits. During an interview with employee # 1 on 4/10/24 at approximately 10:30 am, employee # 1 stated, “Wounds are to be measured weekly. The patient should have at least 1 RN visit each week so they could have obtained the wound measurements.” During the interview, employee # 1 confirmed the patient’s wound was not measured weekly.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review and staff interview the SN [skilled nurse] failed to document communication with physician in the clinical record regarding administration of an enema for 1 of 1 patient with an order for an enema [#1]; failed to document communication with the physician regarding bleeding around a G [gastrostomy] tube site for 1 of 1 patient with a G tube [#1]; failed to document communication with the physician regarding an order to discontinue a wound vac for 1 of 1 patient with a wound vac [#14]; failed to document communication with the physician regarding change in a wound for 1 of 5 patients with a wound [#14]. The findings included: 1A. Patient # 1 had a Start of Care date of 8/4/23 and admitting diagnoses of Ileus [obstruction in part of the intestines] and dysphagia [difficulty swallowing] following cerebral infarction [stroke]. Review of the Plan of Care for the certification period 8/4/23-10/2/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks, 1 time every 2 weeks for 4 weeks, 1 time a week for 1 week. Review of the clinical record revealed a physician’s verbal order dated 8/11/23 to “…assist client with enema due to constipation to be followed by impaction removal if enema is unsuccessful.” RN # 5 conducted a routine visit on 8/11/23 and documented, “Family states patient had a bowel movement prior to my visit use of enema…” Further review of the clinical record revealed no evidence the physician was notified that the RN did not administer the enema. During an interview with RN # 5 on 4/10/24 at approximately 1:15 pm, the RN stated she did notify the physician, however, she failed to document the notification in the client’s record. 1B. Patient # 1 had a Start of Care date of 8/4/23 and admitting diagnoses of Ileus [obstruction in part of the intestines] and dysphagia [difficulty swallowing] following cerebral infarction [stroke]. Review of the Plan of Care for the certification period 8/4/23-10/2/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks, 1 time every 2 weeks for 4 weeks, 1 time a week for 1 week. Review of the clinical record revealed a coordination note dated 8/12/23 entered by RN # 5. The coordination note stated, “Returned call to patient’s daughter regarding bleeding from G tube [gastrostomy]. Noted patient is on blood thinner and explained to daughter the tube can rub the tissue and it will cause bleeding. Instructed daughter to keep watch and let me know if it continues and a visit can be made to assess.” Further review of the clinical record revealed no evidence the RN advised the physician of the bleeding around the G tube site. During an interview with RN # 5 on 4/10/24 at 1:15 pm, the RN stated she had called the physician about the bleeding, but “forget to document it”. 2A. Patient # 14 had a Start of Care date of 3/4/24 with admitting diagnoses of encounter for change or removal of surgical wound dressing, encounter for orthopedic aftercare following surgical amputation and acquired absence of other right toe. Review of the Plan of Care for the certification period 3/4/24-5/2/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week and “SN will apply negative pressure wound therapy to right 5th toe amputation site…set device at 125 mmHg …change 3 times per week…” Review of the clinical record revealed LPN # 2 conducted a routine visit on 3/13/24 and documented the following information, “…Per PT [patient], wound vac discontinued and pt is now doing daily wet to dry dressings…” Review of the clinical record revealed no physician’s order to discontinue the negative pressure wound therapy. During an interview with LPN # 2 on 4/10/24 at approximately 2:30 pm, the LPN confirmed there was no order to discontinue the wound vac but reported, “I called and spoke with the physician and he did actually give that order. I just failed to note that in the clinical record.” 2B. Patient # 14 had a Start of Care date of 3/4/24 with admitting diagnoses of encounter for change or removal of surgical wound dressing, encounter for orthopedic aftercare following surgical amputation and acquired absence of other right toe. Review of the Plan of Care for the certification period 3/4/24-5/2/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week and “SN will apply negative pressure wound therapy to right 5th toe amputation site…set device at 125 mmhg …change 3 times per week…educate and monitor for signs and symptoms of infection. “Review of the clinical record revealed LPN # 2 conducted a routine visit on 8/3/24 and documented, “…wound care was provided as ordered. Redness around wound as well as on right leg, warmth noted a well…called to report to doctor’s office. Spoke directly to Doctor ______ [name] who states patient has been recently on a large regiment of antibiotics and he is not concerned about an infection. LPN made a visit on 3/11/24 and documented, “Pt continues to have redness around wound. Pt states that his doctor prescribed abx [antibiotic] for possible infection to wound site…” LPN completed a routine visit on 3/15/24 and documented, “Wound care was provided as ordered. Pt continues to have redness around wound. Some drainage from suture site. Pt has another appointment with wound dr. on Monday to evaluate wound…” Review of the clinical record revealed no evidence the LPN notified the physician of her findings on 3/11/24 or 3/15/24. The patient was admitted to _____ [name of hospital] on 3/18/24 for an abscess located at the suture site. During an interview with LPN # 2 on 4/10/24 at approximately 2:30 pm, the LPN stated, “I called the physician and told him about my concerns related to the wound, I just didn’t document the call.””