Adventhealth Home Health

“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 clinical record review, direct observations during home visits and interviews with staff, the RN failed to follow proper infection control procedures during wound care for 1 of 3 patients who received wound care during a home visit [#3]. The findings included: Patient # 3 had a Start of Care date of 8/20/24 and a diagnosis of pyonephrosis [infection in the kidneys]. Review of the Plan of Care [POC] for the certification period 8/20/24-10/18/24 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 4 weeks. Review of the clinical record revealed a supplemental order for wound care to a sacral wound to “Cleanse with normal saline/soap and water and apply Vaseline and Silvadene. Cover with bordered foam dressing...” On 9/10/24 at approximately 9 am a joint visit was made with RN # 17 to observe wound care. During the wound care, the RN placed a gloved finger in a container identified as Vaseline [patient reported the Silvadene was mixed with the Vaseline]. The RN then used the gloved finger to spread the ointment all over the buttocks. The RN then placed the gloved finger back into the container and removed more ointment to spread over the buttocks. The RN did not use a swab/tongue depressor etc. to get the ointment out of the container and place on the buttocks. During an interview with employee # 2 on 9/11/24 at approximately 11:30 am, employee # 2 confirmed the RN should not have placed a gloved finger in the container and then spread the ointment onto the buttocks.”

“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 clinical record review and staff interviews the RN failed to measure wounds weekly for 2 of 11 patients with wounds [#3, 10]. The findings included: 1. Patient # 3 had a Start of Care date of 8/20/24 and a diagnosis of pyonephrosis [infection in the kidneys]. Review of the Plan of Care [POC] for the certification period 8/20/24-10/18/24 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 4 weeks. Review of the clinical record revealed a supplemental order for wound care to a sacral wound to “Cleanse with normal saline/soap and water and apply Vaseline and Silvadene. Cover with bordered foam dressing...” Review of the clinical record revealed RN # 15 completed the SOC visit on 8/20/24 and documented a wound measurement of 1.4 cm x 1.6 cm. The patient received 4 SN visits after 8/20/24. There were no wound measurements obtained in 4 of 4 visits. During an interview with employee # 2 on 9/11/24 at 3:30 pm, employee # 2 confirmed the wound should have been measured at least weekly. 2. Patient # 10 had a Start of Care [SOC] date of 12/1/23 and admitting diagnoses of encounter for change or removal of non-surgical wound dressing and type 2 diabetes with other specified complication. Review of the Plan of Care [POC] for the certification period 12/1/23 to 1/29/24 included orders for SN [skilled nursing] 1 time a day for 1 day, 3 times a week for 3 weeks, 3 times a week for 4 weeks. Review of the SOC documentation revealed the patient had 2 wounds. Wound 1 was documented as a diabetic ulcer on the left heel and wound 2 was documented as left leg pretibial area. The POC also included the following nursing interventions dated 11/25/23: “Skilled nurse and caregiver to perform dressing change to wounds on left front shin and left heel...Dressing to consist of “…cleanse wound with wound cleanser, soak iodoform in 0.25 % dakins and pack wound lightly, then cover with gauze and abd pad...change dressing every morning and evening”. The POC included a nursing invention dated 12/1/23 for “SN to perform wound care to left foot...clean with normal saline or wound cleanser...apply silver alginate and wrap with 3-layer wrap 3 times per week...” RN # 21 documented the following wound measurements to the left pretibital leg 4 cm x 1 cm x 0.1 cm. The RN also included a wound description for the left pretibial leg. Further review of the clinical record revealed no wound measurements for the left heel nor wound description. LPN # 8 completed a routine visit on 12/4/23 and 12/6/23. The LPN documented a wound assessment on the left pretibial area; however, the wound assessment did not include any wound measurements for the left pretibial wound. She did not document wound measurements or address the wound to the left heel. Further review of the clinical record revealed the patient received 5 SN visits from 12/11/23-12/29/23 [SN discharged date]. None of the visits included wound measurements or assessments to the area on the left heel. During an interview with employee # 2 on 9/11/24, employee # 2 confirmed the SN’s failed to assess and measure both wounds consistently.”

“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 and staff interviews, the Plan of Care [POC] failed to include current/correct medications the patient was taking for 6 of 17 records [#1, 2, 3, 8, 13 and 6]; and the POC included interventions no longer applicable to the patient for 2 of 17 patients [#8 and 1]. The findings included: 7. Patient #6 was admitted on 08/23/24 with diagnoses of venous insufficiency, non-pressure ulcer of other part of left lower leg, and type 2 diabetes. The plan of care for 08/23/24 to 10/21/24 had orders for skilled nursing 1 time a week for 1 week, 3 times a week for 4 weeks, and 2 times a week for 3 weeks. A home visit with the registered nurse was observed on 09/10/24 at 10:30 AM. The medication review during the home visit revealed the following discrepancy: famotidine 20 mg (milligrams) 1 tablet by mouth every night for heartburn. Interview with the patient confirmed he stopped taking this medication several years ago. The policy, Clinical Record [reviewed 1/24], was provided by employee # 1 on 9/11/24 at 4:08 pm. The policy stated, “...The record will include services provided directly by the employees of the home care agency...all medications the patient is taking...” 1. Patient # 1 had a Start of Care date of 8/30/24 with an admitting diagnosis of dislocation of internal left hip. Review of the Plan of Care [POC] for the certification 8/30/24-10/28/24 included orders for PT [physical therapy] 1 time a day for 1 day [admission], 2 times a week for 3 weeks. On 9/9/24 at approximately 1 pm, a joint visit was made with PT # 13. 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 Welchol [cholesterol] 625 mg. Take 1 tablet in the am, take 1 at noon and 1 in the pm. During an interview with the patient, the patient advised she takes 3 tablets 2 times a day. The patient reported, “I have been taking my cholesterol medicine like that for a long time”. During an interview with employee # 1 on 9/11/24 at approximately 10 am, employee # 1 confirmed the POC was not correct. 2. Patient # 2 had a Start of Care date of 8/17/24 with an admitting diagnosis of COPD [chronic obstructive pulmonary disease-lung condition]. Review of the Plan of Care [POC] for the certification period 8/17/24-10/15/24 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 1 week, 1 time a week for 4 weeks. On 9/9/24 at approximately 3 pm a joint visit was made with LPN # 8. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Mucinex [expectorant] 600 mg every 12 hours. During an interview with patient # 2 she stated, “I don’t take that. It made me cough more than I did when I wasn’t taking anything.” An interview with employee # 1 on 9/11/24 at 10 am confirmed the POC was incorrect related to medications. 3. Patient # 3 had a Start of Care date of 8/20/24 and a diagnosis of pyonephrosis [infection in the kidneys]. Review of the Plan of Care [POC] for the certification period 8/20/24-10/18/24 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 4 weeks. The POC also included an intervention for all clinicians to “review prescriptions and over the counter medications at each visit”. On 9/10/24 at approximately 9 am a joint visit was conducted with RN # 17. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient presented a bottle of Trazodone[antidepressant] 50 mg. Take 1.5 tablets at bedtime. The patient advised he had been using this medication for “a long time”. The trazodone was not listed on the medication profile. The medication profile listed Oxybutynin [bladder spasms] 5 mg. Take 1 tablet at noon and 1 at bedtime. The patient stated he only takes the medication 1 time per day and that is how he has taken the medication since before he became a home health patient. During an interview with employee # 1 on 9/11/24 at approximately 3:30 pm, employee # 1 confirmed the medication on the POC was incorrect. 4A. Patient # 8 had a Start of Care date of 7/9/23 with an admitting diagnosis of pressure ulcer of sacrum [base of spine], stage 2 [skin wears away, often forming a crater like sore]. Review of the Plan of Care [POC] for the certification period 7/9/23-9/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 1 time a week for 4 weeks. Further review of the POC [medication section] revealed an entry for Novolog Insulin 100 unit/1 ml. Take 12-14 units in the morning, take 12-14 units at lunch, take 12-14 units each evening. The medication profile did not include the blood sugar results so the patient would know whether to take 12, 13 or 14 units of insulin. During an interview with employee # 2 on 9/11/24 at approximately 3:30 pm, the employee confirmed the insulin order was incomplete. 4B. Patient # 8 had a Start of Care date of 7/9/23 with an admitting diagnosis of pressure ulcer of sacral region [bottom of the spine], stage 2 [skin wears away, often forming a crater like sore]. The Plan of Care [POC] for the certification period 7/9/23-9/6/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 1 time a week for 4 weeks. The POC also included the following intervention, “Skilled nurse to continue wound care to sacrum once weekly and PRN [as needed] ...Cleanse w normal saline or Vash...apply duoderm to wound...” Further review of the clinical record revealed the patient was seen at the wound clinic on 7/24/23 and the physician stated, “will try zinc”. An intervention was added to the POC dated 7/24/23 for “SN to clean open area with normal saline or Vash and apply desitin or sensicare to wound...home health to apply weekly”. Further review of the POC included both interventions for the wound care. During an interview with employee # 2 on 9/11/24 at approximately 3:30 pm, employee # 2 stated, “The first intervention should have been ended.” 5. Patient # 13 had a Start of Care date of 8/14/24 with admitting diagnoses of intraspinal abscess and encounter for adjustment and management of vascular access device [a device that provides access to the bloodstream for the administration of fluids, medication and other therapies]. Review of the Plan of Care [POC] for the certification period 8/14/24-10/12/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. The POC included an intervention for “SN to assess and maintain central IV [intravenous] catheter...flush with 10 ml of saline...” Review of the POC revealed normal saline was not included in the medication section of the POC. During an interview with RN # 2 on 9/11/24 at 3:30 pm, employee # 2 confirmed the saline should have been included on the POC. 6A. Patient # 1 had a Start of Care date of 8/30/24 with an admitting diagnosis of dislocation of internal left hip. Review of the Plan of Care [POC] for the certification 8/30/24-10/28/24 included orders for PT [physical therapy] 1 time a day for 1 day [admission], 2 times a week for 3 weeks; OT [occupational therapy] 1 time a week for 2 weeks. Review of the POC included an intervention for nursing dated 8/30/24. The intervention was related to wound care to left hip. The intervention stated, “SN to change dressing to left hip 7 days post op (9/4/24).” Further review of the clinical record revealed no physician’s order for nursing. During an interview with employee # 2 on 9/11/24 at approximately 3:30 pm, employee # 2 confirmed the POC should not have included an intervention for nursing. 6B. Patient # 1 had a Start of Care date of 8/30/24 with an admitting diagnosis of dislocation of internal left hip. Review of the Plan of Care [POC] for the certification 8/30/24-10/28/24. Further review of the POC included the following intervention “Assess vital signs...notify MD if vitals fall outside these parameters...blood sugar less than 70 or greater than 240...” Review of the clinical record revealed the patient had no diagnosis related to diabetes. During an interview with employee # 2 on 9/11/24 at approximately 11:30 am, employee # 2 advised, “The clinicians usually always add blood sugar parameters to the most of the POCs to ensure when there is a diabetic the blood sugars are monitored.””

“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 agency policy, clinical record review, and staff interviews the agency provided/educated patient on wound care for 2 of 11 patients with a wound [#1 and 16]. The findings included: 2.Patient #16 was admitted on 05/20/24 with diagnoses of pressure ulcer of right heel, urinary tract infections, unspecified Escherichia coli, and retention of urine. The plan of care for 07/18/24-09/16/24 had orders for skilled nursing 3 times a week for 9 weeks. Review of the skilled nursing note on 09/06/24 revealed the nurse told the caregiver to put antibiotic ointment on the wound and cover with a band aid. No order for that wound care was in the record. An interview with Employee #2 on 09/11/24 at 2:58 PM revealed the nurse called to get the order but hadn’t put the order in the computer. Review of policy, “Clinical Record”, revised 02/2024, was received from the agency staff on 09/11/24 at 4:08 PM. The policy stated”, …documentation of all physician orders …” 1. Patient # 1 had a Start of Care date of 8/30/24 with an admitting diagnosis of dislocation of internal left hip. Review of the Plan of Care [POC] for the certification 8/30/24-10/28/24 included orders for PT [physical therapy] 1 time a day for 1 day [admission], 2 times a week for 3 weeks. Review of the clinical record revealed PT # 13 conducted routine visit on 9/5/24. PT # 13 documented the patient had a skin tear noted on the left buttock measuring 2 cm x 3 cm x 0.1 cm. Further review of the clinical record revealed the PT advised/suggested the patient apply “a barrier cream such as desitin to the skin tear daily”. Review of the clinical record revealed no physician’s order for desitin to the skin tear. During an interview with employee # 1 on 9/11/24 at approximately 3:30 pm, employee # 1 confirmed the physician was not notified prior to the PT recommending use of the barrier cream.”

“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 clinical record review and staff interviews the agency failed to notify the physician of vital signs outside parameters for 5 of 17 patients with vital signs outside given parameters [#1, 2, 3, 13, 7]. The findings included: 5. Patient #7 was admitted on 08/11/24 with diagnoses of pressure ulcer stage 3, manic episode, and long standing atrial fibrillation. The plan of care (POC) for 08/11/24-10/09/24 included orders for home occupational therapy 1 time a week for 1 week, 2 times a week for 3 weeks; physical therapy 1 time a week for 1 week, 1 time a week for 3 weeks; skilled nursing 1 time a week for 1 week, 2 times a week for 2 weeks. Orders for skilled clinicians were to assess vital signs and notify the physician of significant changes, and if vital signs fall outside of these parameters: Pulse less than 60 or greater than 90 Review of the clinical record on 09/10/24 revealed a physical therapy visit was conducted on 08/14/24 with a heart rate (pulse) of 122. No documentation was in the record that the physician was notified of the pulse outside of parameters. An interview with Employee #4 on 09/11/24 at 2:50 PM revealed “the heart rate is outside of parameters- it doesn’t specifically say the heart rate outside of parameters was called to the physician”. 1. Patient # 1 had a Start of Care date of 8/30/24 with an admitting diagnosis of dislocation of internal left hip. Review of the Plan of Care [POC] for the certification 8/30/24-10/28/24 included orders for PT [physical therapy] 1 time a day for 1 day [admission], 2 times a week for 3 weeks. Review of the clinical record revealed PT # 13 conducted a routine visit on 9/5/24. PT # 13 documented the patient had a skin tear noted on the left buttock measuring 2 cm x 3 cm x 0.1 cm. There was no evidence the PT notified the physician of the skin tear. During an interview with employee #2 on 9/11/24 at approximately 3:35 pm, employee # 2 confirmed there was no evidence the MD was notified. 2. Patient # 2 had a Start of Care date of 8/17/24 with an admitting diagnosis of COPD [chronic obstructive pulmonary disease-lung condition]. Review of the Plan of Care [POC] for the certification period 8/17/24-10/15/24 included orders for PT [physical therapy] 1 time a day for 1 day, 1 time a week for 6 weeks. The POC also included an intervention for all skilled professionals to “Assess vital signs...notify MD if vital signs fall outside the following parameters...respirations less than 12 or greater than 25...pulse less than 50 or greater than 90...” Review of the clinical record revealed the following documented vital signs: 8/28/24 PT # 16 recorded a pulse of 105; On 8/30/24, OT # 20 documented a pulse of 114 and respirations of 40; On 9/3/24, PTA # 11 documented a heart rate [pulse] of 110 and respirations of 30; On 9/4/24 RN # 21 documented respirations of 30; On 9/5/24 OT # 20 documented a pulse of 109. Review of the clinical record revealed no evidence the physician was notified of the vital signs being outside the given parameters. 3. Patient # 3 had a Start of Care date of 8/20/24 and a diagnosis of pyonephrosis [infection in the kidneys]. Review of the Plan of Care [POC] for the certification period 8/20/24-10/18/24 included orders PT [physical therapy] 1 time a day for 1 day, 2 times a week for 3 weeks, 1 time a week for 4 weeks. Review of the clinical record revealed PT # 5 completed the PT evaluation on 8/21/24 and documented the patient walked 20 feet and his oxygen saturation dropped to 84 %. Review of the clinical record revealed no evidence the PT notified the physician of the drop in oxygen saturation. 4. Patient # 13 had a Start of Care [SOC] date of 8/14/24 with admitting diagnoses of intraspinal abscess and encounter for adjustment and management of vascular access device [a device that provides access to the bloodstream for the administration of fluids, medication and other therapies]. Review of the Plan of Care [POC] for the certification period 8/14/24-10/12/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. The POC included an intervention to “...assess vital signs...notify MD if vitals fall outside these parameters...systolic [top number] less than 50 or greater than 90...diastolic [bottom] less than 60 or greater than 110...” RN # 7 completed the SOC visit on 8/14/24 and recorded a blood pressure reading of 178/110. RN # 7 made a routine visit on 8/20/24 and documented a blood pressure of 158/100. Review of the clinical record revealed no evidence the physician was notified of either blood pressure reading being outside the given parameter. During an interview with employee # 1 on 9/11/24 at 3:30 pm, employee # 1 stated, “There is no specific documentation the either nurse told the doctor about the blood pressure.””

“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 clinical record review and staff interviews the RN failed to perform wound care for 1 of 3 patients who received wound care during home visits [#3]; and failed to obtain weekly vascular access device [a device that provides access to the bloodstream for the administration of fluids, medication and other therapies] measurements for 1 of 1 patient with a vascular access device [#13]. The findings included: 1. Patient # 3 had a Start of Care date of 8/20/24 and a diagnosis of pyonephrosis [infection in the kidneys]. Review of the Plan of Care [POC] for the certification period 8/20/24-10/18/24 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 4 weeks. Review of the clinical record revealed a supplemental order for wound care to a sacral wound to “Cleanse with normal saline/soap and water and apply Vaseline and Silvadene. Cover with bordered foam dressing...” On 9/10/24 at approximately 9 am a joint visit was made with RN # 17 to observe wound care. The RN completed the wound care but did not place a bordered foam dressing over the area. During an interview with employee # 2 on 9/11/24 at approximately 11:00 am, employee # 2 confirmed the RN failed to complete wound care as ordered. 2. Patient # 13 had a Start of Care date of 8/14/24 with admitting diagnoses of intraspinal abscess and encounter for adjustment and management of vascular access device [a device that provides access to the bloodstream for the administration of fluids, medication and other therapies]. Review of the Plan of Care [POC] for the certification period 8/14/24-10/12/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. The POC included an intervention for “SN to assess and maintain central IV [intravenous] catheter...change dressing and cap every 5-7 days...measure length of line at insertion site and document with each dressing change...” Review of the clinical record revealed the no measurement of the central catheter line at the time of admission. The patient received SN visits for central line catheter changes on 8/16/24, 8/20/24, 8/27/24 and 9/3/24. There was no central line measurements obtained.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on clinical record review and staff interviews the clinical record failed to include vital signs for 6 of 17 patients [#9, 10, 13, 5, 12, 15]. The findings included: 4. Patient #5 was admitted on 08/29/24 with diagnoses of acute cystitis with hematuria (urinary tract infection with blood), frequent falls, and acute kidney failure. The plan of care for 08/29/24-10/27/24 had orders for occupational therapy 1 time a week for 7 weeks, physical therapy 1 time a week for 1 week, and 2 times a week for 3 weeks, and 1 time a week for 3 weeks. Review of the occupational therapy evaluation on 09/04/24 revealed no vital signs were documented in the visit note. An interview with Employee #1 on 09/11/24 at 11:07 AM revealed “the clinician stated the computer was glitching and didn’t save all of his information and wasn’t sure what information was lost”. 5. Patient #12 was admitted on 12/04/23 with diagnoses of other retention of urine, encounter for fitting and adjustment of urinary device, alzheimer’s disease and essential hypertension. The plan of care for 12/04/23-02/02/24 had orders for occupational therapy 1 time a week for 4 weeks, 2 times a week for 3 weeks; physical therapy 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 1 week; skilled nursing 1 time a week for 3 weeks. Review of the clinical record revealed the following visits were missing all vital signs: -physical therapy assistant visit on 12/11/23 -occupational therapy visit on 01/12/24 -physical therapy assistant on 01/17/24 -occupational therapy visit on 02/01/24 Further review of the record revealed the following visit(s) were missing blood pressures: -physical therapy and occupational therapy on 01/25/24 were missing blood pressure -physical therapy assistant was missing blood pressures on 02/16/24 and 02/19/24 An interview with Employee #1 on 09/11/24 at 11:07 AM revealed “the clinician(s) had computer issues and weren’t sure what information was saved or lost”. 6. Patient #15 had a start of care on 08/15/24 with diagnoses of cerebral infarction (stroke), pressure ulcer of left heel, essential hypertension, and type 2 diabetes. The plan of care for 08/15/24-10/13/24 had orders for physical therapy 1 time a week for 7 week; skilled nursing 1 time a week for 4 weeks, occupational therapy 1 time a week for 1 week and home health aide 1 time a week for 8 weeks. Review of the clinical record revealed the blood pressure was missing from the physical therapist assistant visit note on 09/04/24. An interview with Employee #1 on 09/11/24 at 11:07 AM revealed “the clinician(s) had computer issues and weren’t sure what information was saved or lost”. 1. Patient # 9 had a Start of Care date of 10/10/23 and an admitting diagnosis of encounter for other orthopedic aftercare. Review of the Plan of Care [POC] for the certification period 10/10/23-12/8/23 included orders for PT [physical therapy] 1 time a day for 1 day, 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks and “Skilled clinicians assess vital signs...” Review of the clinical record revealed PTA [physical therapy assistant] # 9 completed a routine visit on 10/26/23. Review of the documentation revealed no documented blood pressure. During an interview with employee # 1 on 9/11/24 at approximately 3:30 pm, employee # 1 stated the clinician told her she had trouble with her device. 2. Patient # 10 had a Start of Care date of 12/1/23 and admitting diagnoses of encounter for change or removal of non-surgical wound dressing and type 2 diabetes with other specified complication. Review of the Plan of Care [POC] for the certification period 12/1/23 to 1/29/24 included orders for OT [occupational therapy] 1 time a day for 1 day, 1 time a week for 4 weeks. The POC included an intervention for all skilled clinicians to “Notify MD if vital signs fall outside given parameters...” OT # made a visit on 12/5/23. Review of the documentation revealed no blood pressure. During an interview with employee # 1 on 9/11/24 at approximately 3:30 pm, employee # 1 confirmed the OT failed to document the blood pressure in accordance with the POC. 3. Patient # 13 had a Start of Care [SOC] date of 8/14/24 with admitting diagnoses of intraspinal abscess and encounter for adjustment and management of vascular access device [a device that provides access to the bloodstream for the administration of fluids, medication and other therapies]. Review of the Plan of Care [POC] for the certification period 8/14/24-10/12/24 included orders for SN [skilled nursing] 1 time a week for 8 weeks. The POC included an intervention to “...assess vital signs...” Review of the clinical record revealed RN # 19 made a routine visit on 9/3/24. Review of the clinical record revealed no documentation of the blood pressure.”