Health Care Bridge, Inc.

“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 record review, policy review, and staff interview, the agency failed to alert the physician of changes in the patient’s condition for one of three patient records reviewed (Patient #3). This could affect all patients receiving services from the agency. The census was 166. Findings include: Review of the undated agency policy titled, “Monitoring Patient’s Response/Reporting to Physician,” revealed the patient’s physician will be contacted on the same day when significant changes in the patient’s psychosocial status, inability to achieve goals within specified time frame, changes that have occurred regarding medications and when there is a problem implementing the plan of care. All communications with the physician will be documented in the medical record. The nurse will immediately notify the Clinical Manager regarding any problems encountered. Review of Patient #3’s medical record and physician ordered plans of cares dated 10/22/23, 12/21/23 and 02/19/24 revealed a start of care date of 03/01/22 and diagnoses of cerebrovascular disease, high blood pressure and major depressive disorder. The skilled nurse (SN) was to visit once a week to observe and assess medication compliance and to teach the patient on the dose, schedule, purpose, possible side effects, importance to comply and consequences of noncompliance. The goal listed was Patient #3 will comply with prescribed medications. Further review of the plans of care dated 10/22/23 and 12/21/23 revealed Patient #3 had orders for Seroquel Extended Release (used to treat schizophrenia, bipolar disorder, and depression) 50 milligrams (mg) two times a day and 200 mg at bedtime. Review of the 60-day Clinical Summaries revealed the patient was non-complaint with oral medications. Review of the skilled nurse visit sheet dated 12/13/23 Staff A documented Patient #3 was very depressed. There was no documentation the physician had been notified of this change in Patient #3. Review of the Patient Communication Log revealed a complaint documented 01/10/24, where Patient #3 notified the nurse that she was out of Seroquel. The nurse asked when was the last time they saw the doctor? Patient #3 replied they will have a virtual visit with the doctor on 01/22/24. Review of an unsigned, undated statement revealed on 01/10/24 Patient #3 stated they were not sleeping well. When asked why, Patient #3 informed the nurse they were out of Seroquel and had a virtual doctor’s appointment on 01/22/24. There was no documentation the physician was notified the patient was out of her medication prior to her doctor’s appointment. Interview on 02/27/24 at 9:20 AM with Staff A revealed the goal to comply with prescribed medications was the same on the plans of care dated 10/22/23, 12/21/23 and 02/19/24 and stated there was no change in Patient #3’s progress. Patient #3 was always non-compliant with taking medications. Staff A confirmed there was no documentation that the physician had been notified of Patient #3 being non-compliant with medications or her inability to achieve this goal. Staff A stated Patient #3’s medications were with Exact Pac where they were all placed in individual pouches and the patient must tear off the pouch to take all medications daily. Staff A stated only the Seroquel at bedtime came in a pill bottle and not in the Exact Pac. She did not know why, and she did not question it. Sometimes Patient #3 took more than prescribed and ran out, then the pharmacy issued extra until Patient #3’s next doctor’s appointment. Sometimes Patient #3 could not find the Seroquel bottle. Staff A confirmed this was not documented and the physician was not notified that Patient #3 took more Seroquel than prescribed and was now out of this medication. Further interview with Staff A on 02/27/24 at 9:50 AM revealed the undated, unsigned statement was her statement written sometime in February 2024. Staff A confirmed she could have done better at monitoring for medication compliance. This deficiency represents non-compliance investigated under Substantial Allegation 104268.”