Bayada Home Health Care, Inc.

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to ensure OASIS [Outcome and Assessment Information Set-comprehensive assessment] question NO415 [high risk drug classes-use and indication] was answered accurately for 7 of 17 patient records reviewed [#2, 7, 8, 9, 11, 1, and 17]. The findings included: A policy, Chart Data Requirements and Format - Home Health Practice, was provided by the agency director on 11/8/23 at 11:00 a.m. The policy stated, “The Assessment…includes…A review of the client’s medications to identify any potential adverse effects and drug reactions, including…high risk drug factors.” 6. Patient #1 was admitted on 1/13/23 with diagnoses of aftercare following joint replacement surgery, presence of left artificial knee joint, and long-term current use of aspirin (antiplatelet medication). The initial assessment was conducted on 1/13/23 by the physical therapist. The patient was not identified as taking an antiplatelet medication in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care for 1/13/23-3/13/23 included orders for aspirin 81 mg twice daily. An interview was conducted with the agency director on 11/8/23 at 12:00 p.m. The agency director confirmed that the OASIS was not coded accurately. 7. Patient #17 was admitted on 10/19/23 with a diagnosis of age-related osteoporosis with pathological fracture of the right ankle. The initial assessment was conducted on 10/19/23 by the physical therapist (PT). The patient was not identified as taking antiplatelet and opioid medications [type of pain medication). The Plan of Care for 10/19/23-12/17/23 included orders for aspirin 81 mg twice daily (antiplatelet) and oxycodone (opioid) 5 mg every eight hours as needed for pain, and tramadol (opioid) 50 mg every eight hours as needed for pain. An interview with PT #14 was conducted on 11/8/23 at approximately 2:00 p.m. The PT confirmed that the OASIS was not coded accurately 1. Patient # 2 had a Start of Care [SOC] date of 3/7/23 and admitting diagnoses of enterocolitis [inflammation of the intestines] due to clostridium difficile [bacteria that causes diarrhea] and type 2 diabetes mellitus without complications. Review of the clinical record revealed PT [physical therapist] # 4 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 3/7/23. Review of the OASIS documentation [NO415] did not include the use of Aspirin as an antiplatelet. Review of the medication revealed the patient was ordered Aspirin 81 mg each day. Further review of the OASIS revealed PT # 4 indicated the patient was not a diabetic. PT # 4 was not available for interview. An interview was conducted with employee # 3 on 11/8/23 at approximately 9 am. During the interview, employee # 3 confirmed the OASIS was not accurate. 2. Patient # 7 had a Start of Care [SOC] date of 9/20/23 and admitting diagnoses of unspecified open wound left lesser toe and non-pressure chronic ulcer of other part of left foot. Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 9/20/23. Review of the OASIS documentation [NO415] indicated the patient did not have an opioid [pain medication] prescribed at admission. Review of the Plan of Care revealed the patient had Morphine 15 mg immediate release ordered every 4 hours as needed for pain and MS Contin 30 mg extended release ordered two times per day. During an interview with RN # 10 on 11/8/23 at approximately 9:45 am, the RN confirmed the OASIS was inaccurate. 3. Patient # 8 had a Start of Care [SOC] date of 9/16/23 and an admitting diagnosis of type 2 diabetes with other specified complications. Review of the clinical record revealed RN # 7 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 9/16/23. Review of the OASIS documentation [NO415] did not include the use of Aspirin as an antiplatelet. Review of the Plan of Care revealed the patient was ordered Aspirin 81 mg each day. During an interview with RN # 7 on 11/8/23 at approximately 10 am, the RN confirmed the OASIS was not accurate. 4. Patient # 9 had a Start of Care [SOC] date of 9/17/23 and admitting diagnoses of multiple sclerosis [disease of the central nervous system] and urinary tract infection. Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 9/17/23. Review of the OASIS documentation [NO415] indicated the patient was prescribed an antipsychotic medication at the time of admission. Further review of the clinical record revealed no antipsychotic medication. During an interview with RN # 10 on 11/8/23 at 9:45 am, the RN stated, “I counted Remeron [antidepressant] as the antipsychotic medication.” The RN confirmed the OASIS was not accurate. 5. Patient # 11 had a Start of Care [SOC] date of 10/6/23 and admitting diagnosis of Alzheimer’s Disease. Review of the clinical record revealed PT [physical therapist] # 15 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 10/6/23. Review of the OASIS documentation [NO415] did not include the use of Cephalexin 500 mg as an antibiotic. During an interview with PT # 15 on 11/8/23 at approximately 9:30 am, the PT confirmed the OASIS was not accurate and stated, “I missed that.””

“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 and protocol, clinical record documentation and staff interviews the Registered Nurse failed to document PICC [peripherally inserted central catheter-device inserted through a vein for long term use of medications] line measurements for 1 of 1 patient with a PICC line [#8]; failed to obtain wound measurements for 2 of 8 patients with a wound [ #7 and 9 ]; the registered nurse changed a perineal urinary catheter in which she had not demonstrated competency (#6). The findings included: A policy, Competency Assessments (revised 1/27/22), was provided by the agency director on 11/8/23 at 9:55 a.m. The policy stated, “…has adopted Elsevier to provide evidence-based direction on performance of clinical procedures…When clinical procedures are performed, the procedure outlined in Elsevier or the linked [home health agency] procedure or policy is to be followed.” 4. Patient #6 was admitted on ­­­8/12/23 with diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and dementia. The Plan of Care (POC) for 8/12/23-10/10/23 included orders for skilled nursing visits weekly for two weeks, then every other week for eight weeks. The POC also included orders for urinary catheter changes every four weeks. The initial assessment was conducted on 8/12/23 and identified the presence of a urinary catheter. On 8/28/23, RN #12 conducted a visit and documented “insertion site for catheter is in the perineum [area between the scrotum and anus]. A coordination note stated that on 8/30/23 at 8:30 a.m. the patient’s urinary catheter was out. The agency was unsure if the patient pulled it out. The assisted living was requesting a nurse visit to assess. RN #6 conducted a visit on 8/28/23 at 1:08 p.m. The visit note stated, “16french [sic] [size of catheter] foley [indwelling] catheter placed using aseptic technique. Hematuria [blood in urine] noted. Provider, [provider name], notified.” A care coordination noted on 8/31/223 by RN #6 stated, “Nurse spoke with provider at community [assisted living facility] to notify of admission to [name of hospital]. Community provider stated that someone in community told memory care staff to monitor client for urination after catheter was removed. Client has catheter for urinary retention. Nobody is able to specify how long client’s catheter was out before [home health agency] was notified.” A Complaint Report was provided by the agency on 11/6/23 at 10:31 a.m. The report stated, “Daughter called…She wanted to be sure our RN that did dad’s cath care has proper education..” An interview with RN #12 was conducted on 11/8/23 at 12:54 p.m. The RN stated that she had not seen a catheter inserted into the perineum prior to the 8/28/23 visit. She stated that she changed the urinary catheter bag during the visit. An interview with RN #6 was conducted on 11/7/23 at 2:15 p.m. The RN stated that she had never seen a urinary catheter inserted into the perineum prior to the 8/30/23 visit. She stated that the catheter insertion site was discussed with the clinical manager prior to insertion. The RN stated that she inserted the catheter and there was blood return in the catheter. She notified the provider. The provider told her the patient had a history of hematuria and to monitor. An interview was conducted with the case manager on 11/8/23 at approximately 9:15 a.m. The interview revealed the clinical manager had not seen a catheter inserted into the perineum. The case manager confirmed there was no competency for this type of dressing change. The best practice policy [no title or date] was provided by the agency administrator on 11/6/23 at 11 am. The policy stated, “…Assess for catheter migration…compare to insertion record…” The policy, Wound Care and Assessment [revised 9/20/21] was provided by the agency administrator on 11/8/23 at 11 am. The policy stated, “…A weekly in-person comprehensive assessment of all wounds by a Registered Nurse is required. The assessment is to include wound measurements and staging and is to be documented…” 1. Patient # 8 had a Start of Care [SOC] date of 9/16/23 and an admitting diagnosis of type 2 diabetes with other specified complications and encounter for adjustment and management of VAD [vascular access device [provides access to veins for intravenous medications and or the ability to obtain lab work]. Review of the Plan of Care [POC] for the certification period 9/16/23 to 11/14/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 7 weeks and “skilled nurse to observe and assess IV access site and response to medication and provide skilled teaching regarding infusion procedure, care of infusion line…” Review of the RN # 7’s visit note dated 9/16/23 indicated 0 cm of the PICC [peripherally inserted central catheter-device inserted through a vein for long term use of medications] line catheter was exposed. RN # 7 completed 4 routine visits from 9/18/23 to 10/2/23. There were no PICC line measurements for 3 of the 4 visits. During an interview with RN # 7 on 11/8/23 at approximately 10:15 am, the RN stated, “The measurements are supposed to be documented with each visit. I don’t actually measure the line, I just “eyeball” the line. I can tell if the line length has increased or decreased, I have been a nurse for 30 some years.” 2. Patient # 7 had a Start of Care [SOC] date of 9/20/23 and admitting diagnoses of unspecified open wound left lesser toe and non-pressure chronic ulcer of other part of left foot. Review of the Plan of Care [POC] for the certification period 9/20/23 to 11/18/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “skilled nursing to perform wound care to nonpressure [sic] ulcer left foot 5th digit by cleansing with normal saline, apply hydrofiber to wound bed and cover and secure with abd pad…” Review RN # 10’s visit note dated 9/20/23 revealed a wound measurement of the wound to the left foot of 2.5 cm x 0.5 cm x 0.2 cm. Further review of the SN visit notes revealed no wound measurement for the visit made by RN # 10 on 10/24/23. The RN documented “unable” to measurement in the visit note. During an interview with RN # 10 on 11/8/23 at 9:45 am the RN stated, “I don’t know why I didn’t document the wound measurement.” 3. Patient # 9 had a Start of Care [SOC] date of 9/17/23 and admitting diagnoses of multiple sclerosis [disease of the central nervous system] and urinary tract infection. Review of the Plan of Care [POC] for the certification period 9/17/23 to 11/15/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks; PT [physical therapy] 1 time a week for 4 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed PT [physical therapy] # 9 made a routine visit on 10/17/23 and documented the following information, “Noted pressure areas with scant blood to left posterior heel...and right lateral plantar foot area. PT contacted _____ [name of RN] and advised paid CG [caregiver] to cover it will [sic] mepilex dressing and RN will assess next visit.” Further review of the clinical record revealed RN # 8 conducted a routine visit on 10/19/23 and documented the following information, “…skilled nursing performed wound care to left and right heel and right plantar unstageable pressure injury…” The SN visit note did not include any wound measurements or wound assessment for 10/19/23. On 10/24/23, RN # 8 conducted a routine visit and documented, “New pressure areas due to her foot drop boots…” Further review of the visit note dated 10/24/23 did not include any wound measurements or assessment from the new wound identified on 10/24/23 or the new areas addressed on 10/19/23. During an interview with the agency director on 11/8/23 at approximately 12:15 pm, the director confirmed there were no wound measurements or wound assessments related to the 10/19/23 and 10/24/23 SN visit notes.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, clinical record review, direct observation and staff and patient/caregiver interviews the Plan of Care [POC] failed to include all/correct medications the patient was taking for 2 of 7 patients with home visits [#12 and 13]; and failed to include the frequency for wound care for 1 of 8 patients with a wound [#8];and failed to include the frequency for PICC [peripherally inserted central catheter-device inserted through a vein for long term use of medications] line care for 1 of 1 patient with a PICC line [#8]. The findings included: The policy, Chart Data Requirements [revised 1/1/23] was provided by the agency administrator on 11/8/23 at 11 am. The policy stated, “…All home health clients will have a medication list…the medication list is used when we are assessing, monitoring and teaching medications in the home…” 1. Patient # 12 had a Start of Care date of 8/7/23 and admitting diagnoses of epilepsy [a neurological disorder associated with seizure activity], type 2 diabetes with hyperglycemia [high blood sugar] and anoxic brain damage [brain damage caused by inadequate oxygen to the brain]. Review of the Plan of Care for the certification period 10/6/23 to 12/4/23 included orders for PT [physical therapy] 1 time a week for 6 weeks. On 11/7/23 at approximately 11 am, a joint visit was conducted with PT 16. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Acetaminophen 325 mg [over the counter pain medication] 1-2 tablets every 12 hours as needed for pain. During an interview with the caregiver during the visit, the caregiver reported this was changed on 10/25/23 to Acetaminophen 500 mg take every 6 hours as needed for pain. Aspirin 81 mg was not included on the medication profile. During an interview with the caregiver, he presented a bottle of Aspirin 81 mg and stated the patient has been taking 1 tablet per day “since she came home from the hospital before admission to the agency”. The medication profile listed 70/30 insulin. Take 30 units at breakfast and 27 units at bedtime. The caregiver stated this dose was changed on 10/25/23 and the patient was taking 30 units 2 times per day. During an interview with PT # 16 on 11/7/23 at approximately 12:30 pm, the PT confirmed the Plan of Care did not include the correct medications. 2. Patient # 13 had a Start of Care date of 9/26/23 with an admitting diagnosis of pressure ulcer of right buttock, stage 2 [the ulcer has broken through the top layer of skin and part of the layer below]. Review of the Plan of Care [POC] for the certification period 9/26/23 to 11/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks. On 11/7/23 at 1:30 pm a joint visit was conducted with RN # 7. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Bacitracin [antibiotic ointment] 500 unit/gram was listed on the medication profile with directions to apply topically daily as needed. There was no indication for the medication. During an interview with RN # 7 on 11/7/23 at approximately 2 pm, the RN stated that the “patient did not use the medication any longer and had not used it for a couple weeks.” 3A. Patient # 8 had a Start of Care date of 9/16/23 and an admitting diagnosis of type 2 diabetes mellitus with other specified complication, inflammatory conditions of jaws and encounter for adjustment and management of VAD [vascular access device [provides access to veins for intravenous medications and or the ability to obtain lab work]. Review of the Plan of Care [POC] for the certification period 9/16/23-11/14/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 7 weeks and “Skilled nursing to perform wound care and instruct client/caregiver to perform wound care. Perform wound care to right mandible [jaw]. Clean with NS [normal saline] …Client/caregiver to perform wound care in the absence of skilled nurse…” The POC did not include a frequency for the wound care to be performed. During an interview with RN # 7 on 11/8/23 at approximately 10 am, RN # 7 confirmed the POC failed to include the frequency of the wound care. 3B. Patient # 8 had a Start of Care date of 9/16/23 and an admitting diagnosis of type 2 diabetes mellitus with other specified complication, inflammatory conditions of jaws and encounter for adjustment and management of VAD [vascular access device [provides access to veins for intravenous medications and or the ability to obtain lab work]. Review of the Plan of Care [POC] for the certification period 9/16/23-11/14/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 7 weeks and “…Skilled nurse to maintain IV access via right subclavian duel [sic] lumen PICC [peripherally inserted central catheter-device inserted through a vein for long term use of medications] line…Perform IV site care using change [sic] and aseptic technique…” The POC failed to include the frequency for the IV site dressing changes/care. During an interview with RN # 7 on 11/8/23 at approximately 10 am, the RN confirmed the POC failed to include a frequency for the IV site dressing changes.”

“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 direct observation, clinical record review and staff interviews the agency provided wound care without an order for 1 of 8 patients who received a home visit [#13]. The findings included: Patient # 13 had a Start of Care date of 9/26/23 with an admitting diagnosis of pressure ulcer of right buttock, stage 2 [the ulcer has broken through the top layer of skin and part of the layer below]. Review of the Plan of Care [POC] for the certification period 9/26/23 to 11/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks. On 11/7/23 at approximately 1:30 pm a joint visit was conducted with RN # 7. During the visit, RN # 7 applied Vicks Vapor Rub [topical ointment] to the patient’s toe nails on bilateral feet. The RN was also noted to apply Betadine [topical antiseptic] to the 3rd toe on the right foot. During an interview with the RN on 11/8/23 at approximately 10 am, the RN confirmed there were no physician’s orders for either of the treatments. The RN stated, “I have worked with podiatrists for a long time and that is what they do for fungus.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to notify the physician of a new wound for 1 of 8 patients with a wound [# 9]; failed to notify the physician of a decline in wound status for 1 of 8 patients with wounds (#14). Findings included: A policy, Client Care Coordination, was provided by the agency director on 11/8/23 at 11:00 a.m. The policy stated, “Care coordination will include…Assuring coordination of care delivery meets the client’s needs…” A policy, Chart Data Requirements and Format - Home Health Practice, was provided by the agency director on 11/8/23 at 11:00 a.m. The policy stated, “Clinical documentation is completed in the electronic medical record and should including…Documentation of communication with the physician…” A policy, Wound Care - Assessment and Treatment, was provided by the agency director on 11/8/23 at 11:00 a.m. The policy stated, “Document…Communication with physician regarding client progress, response, or recommended need to change in treatment as needed…” 2. Patient #14 was admitted on 9/19/23 with diagnoses of varicose veins left lower extremity with ulcer of the ankle, venous insufficiency, non-pressure chronic ulcer of left calf with fat layer exposed, and peripheral vascular disease. The Plan of Care (POC) for 9/19/23-11/17/23 included orders for skilled nursing twice weekly for wound care. RN #6 conducted a visit on 9/19/23. The RN noted the left mid-calf skin tear had 0-25% eschar. On 9/22/23, RN #6 conducted a visit and documented 0-25% eschar (dried, dead tissue) on the wound. On 9/25/23, RN #6 conducted a visit. The visit note revealed the left mid-calf skin tear had soft black eschar that covered 51-75% of the wound. There was no evidence the physician was notified of the increase in eschar presence on the wound. On 9/28/23, the patient had increased confusion and discomfort and was sent to the hospital. The resumption of care assessment on 10/7/23 stated, “Client was recently hospitalized due to increased confusion and wound complications.” In an interview with RN #6 on 11/7/23 at 2:15 p.m., the RN stated that she had notified the physician but failed to document the conversation. The RN stated that the physician said to continue to observe for changes. 1A. Patient # 9 had a Start of Care [SOC] date of 9/17/23 and admitting diagnoses of multiple sclerosis [disease of the central nervous system] and urinary tract infection. Review of the Plan of Care [POC] for the certification period 9/17/23 to 11/15/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks; PT [physical therapy] 1 time a week for 4 weeks, 1 time a week for 5 weeks. Review of the clinical record revealed PT [physical therapy] # 9 made a routine visit on 10/17/23 and documented the following information, “Noted pressure areas with scant blood to left posterior heel...and right lateral plantar foot area. PT contacted _____ [name of RN] and advised paid CG [caregiver] to cover it will [sic] mepilex dressing and RN will assess next visit.” During an interview with PT # 9 on 11/8/23 at approximately 10:30 am, the PT stated that she did not contact the physician to obtain an order for the wounds. “I just called the nurse, because I knew the patient had had wounds in the past.” 1B. Patient # 9 had a Start of Care [SOC] date of 9/17/23 and admitting diagnoses of multiple sclerosis [disease of the central nervous system] and urinary tract infection. Review of the Plan of Care [POC] for the certification period 9/17/23 to 11/15/23 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks. On 10/24/23, RN # 8 conducted a routine visit and documented, “New pressure areas due to her foot drop boots and chronic spasms. Aske [sic] family to decrease use that [sic] style boot…” There was no evidence the RN notified the physician of the new skin breakdown. During an interview with RN # 8 on 11/8/23 at 11 am, RN # 8 stated, “If I called the doctor, it will be in the coordination notes.””

“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 direct observation, clinical record review and staff interviews the RN failed to provide wound care as ordered in the Plan of Care of 1 of 7 patients who received a home visit [#13]. The findings included: Patient # 13 had a Start of Care date of 9/26/23 with an admitting diagnosis of pressure ulcer of right buttock, stage 2 [the ulcer has broken through the top layer of skin and part of the layer below]. Review of the Plan of Care [POC] for the certification period 9/26/23 to 11/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “SN to perform wound care to right buttock. Clean with normal saline. Apply Vaseline gauze to wound bed and cover and secure with foam…” On 11/7/23 at approximately 1:30 pm a joint visit was conducted with RN # 7. During the visit, the RN completed wound care to the right buttock by cleaning the area with skin prep. The RN then applied a dry dressing. During an interview with the RN on 11/8/23 at approximately 10 am, the RN stated, “I didn’t have any Vaseline gauze anyway.” The RN confirmed she did not follow the physician’s order related to wound care.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on direct observation, clinical record review and staff interviews, the RN failed to reinforce patient/caregiver teaching regarding a physician’s order for the frequency of a dressing change for 1 of 2 patients with a home visit who received a dressing change [#13]. The findings included: Patient # 13 had a Start of Care date of 9/26/23 with an admitting diagnosis of pressure ulcer of right buttock, stage 2 [the ulcer has broken through the top layer of skin and part of the layer below]. Review of the Plan of Care [POC] for the certification period 9/26/23 to 11/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “SN to perform wound care to right buttock. Clean with normal saline. Apply Vaseline gauze to wound bed and cover and secure with foam. Change dressing 2 times per week…caregiver to perform wound care in the absence of the skilled nurse…” On 11/7/23 at approximately 1:30 pm a joint visit was conducted with RN # 7. During the visit, the RN completed wound care to the right buttock by cleaning with skin prep and applying a dry dressing. During the visit, the caregiver stated, “We are not changing that dressing between your visits. If the dressing stays in place we just leave it.” The nurse stated, “That’s fine.” There was no discussion related to the physician’s order to do the dressing change 2 times per week. During an interview with the RN on 11/8/23 at approximately 10 am, the RN stated, “Yes, I am aware the order is for 2 times per week, but as you saw the wound is almost better, so the weekly changes are sufficient.””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on direct observation, clinical record review and staff interviews the RN documented a wound measurement not obtained during the visit and documented a treatment not performed for 1 of 2 patients with a wound who received a home visit [#13]. The findings included: Patient # 13 had a Start of Care date of 9/26/23 with an admitting diagnosis of pressure ulcer of right buttock, stage 2 [the ulcer has broken through the top layer of skin and part of the layer below]. Review of the Plan of Care [POC] for the certification period 9/26/23 to 11/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “SN to perform wound care to right buttock. Clean with normal saline. Apply Vaseline gauze to wound bed and cover and secure with foam…” On 11/7/23 at approximately 1:30 pm a joint visit was conducted with RN # 7. RN # 7 did not clean the wound bed with normal saline or apply Vaseline gauze. The RN cleaned the wound with skin prep and applied a dry dressing. The RN did not measure the wound on the right buttock. A review of the visit note dated 11/7/23 completed by RN # 7 revealed the RN had documented she cleaned the wound in accordance with the order for a Vaseline gauze. The RN also had entered a wound measurement into the patient’s chart. The RN documented the wound on the right hip measured 1 cm x 0.5 cm x 0.1 cm. [During an interview on 11/7/23 at approximately 10 am, RN # 7 stated she did not measure the wound, she “eye balled the wound for the measurements. The RN stated, “I didn’t have any Vaseline gauze anyway”. During an interview with the agency director [who had been present during the interview with RN # 7] on 11/8/23 at 10 am, the director confirmed the RN had documented a wound measurement that had not been obtained during the visit and had documented wound care that was not completed during the visit.”