Complete Home Health of Western Oklahoma

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. the skilled nurse notified the physician of blood pressure levels outside the ordered parameters for one (Patient #1) of seventeen patients. 2. the skilled nurse addressed oxygen use as ordered for three (Patient’s #1, 2, and 3) of seventeen patients. Patient #1 A POC dated 08/08/23 to 10/06/23 showed an order for the physician to be notified of diastolic blood pressure less than 60. Skilled nurse assessments dated 08/24/23 and 09/07/23 documented a diastolic blood pressure of 54 and 50 with no physician notification. Patient #1 A POC dated 08/08/23 to 10/06/23 showed an order for oxygen for inhalation at 3 L/Min (liters per minute) continuous. A skilled nurse assessment dated 10/06/23 documented oxygen use, continuous at 2 LPM (liters per minute. Patient #2 A POC dated 09/07/23 to 11/05/23 showed an order for oxygen at 2 liters continuous. A review of the clinical record showed the following: A SN assessment dated 09/12/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. A SN assessment dated 09/15/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. A SN assessment dated 09/20/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. Patient #3 A POC dated 08/23/23 to 10/21/23 showed an order for oxygen at 4 L/Min (liters per minute) intermittently. A review of the clinical record showed the following: A SN assessment dated 08/31/23 documented oxygen use as intermittent at 3 LPM (liters per minute). A SN assessment dated 09/07/23 documented oxygen use as intermittent at 3 LPM (liters per minute). A SN assessment dated 10/19/23 documented oxygen use as intermittent at 3 LPM (liters per minute). On 11/08/23 at 10:29 a.m., Staff B stated: 1. there was no documentation of physician notification of the diastolic blood pressures being out of parameters for Patient #1. 2. the orders for administering the oxygen were not followed as documented in the POC for Patients #1, 2, and 3. 1. Patient #1 A POC dated 08/08/23 to 10/06/23 showed an order for the physician to be notified of diastolic blood pressure less than 60. Skilled nurse assessments dated 08/24/23 and 09/07/23 documented a diastolic blood pressure of 54 and 50 with no physician notification. 2. Patient #1 A POC dated 08/08/23 to 10/06/23 showed an order for oxygen for inhalation at 3 L/Min (liters per minute) continuous. A skilled nurse assessment dated 10/06/23 documented oxygen use, continuous at 2 LPM (liters per minute. Patient #2 A POC dated 09/07/23 to 11/05/23 showed an order for oxygen at 2 liters continuous. A review of the clinical record showed the following: A SN assessment dated 09/12/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. A SN assessment dated 09/15/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. A SN assessment dated 09/20/23 documented oxygen use as intermittent at 2 LPM (liters per minute) and on room air. Patient #3 A POC dated 08/23/23 to 10/21/23 showed an order for oxygen at 4 L/Min (liters per minute) intermittently. A review of the clinical record showed the following: A SN assessment dated 08/31/23 documented oxygen use as intermittent at 3 LPM (liters per minute). A SN assessment dated 09/07/23 documented oxygen use as intermittent at 3 LPM (liters per minute). A SN assessment dated 10/19/23 documented oxygen use as intermittent at 3 LPM (liters per minute). On 11/08/23 at 10:29 a.m., Staff B stated: 1. there was no documentation of physician notification of the diastolic blood pressures being out of parameters for Patient #1. 2. the orders for administering the oxygen were not followed as documented in the POC for Patients #1, 2, and 3.”

“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 record review and interview, the agency failed to ensure an individualized plan of care for three (Patient #9, 10 and 15) of 17 patients. Patient #9 A review of the plan of care dated 08/15/23 to 10/13/23 showed a primary diagnosis of Alzheimer’s disease with interventions which included teaching the patient to use wheelchair or walker when ambulating, educating the patient to stop and rest when tired and educating when to use their emergency necklace. Documentation showed no evidence the patient was capable of learning/being taught the interventions Patient #10 A review of the plan of care dated 08/20/23 to 10/18/23 showed a primary diagnosis of hypertensive chronic kidney disease with no interventions for monitoring of weight or instruction of weight gain or weight loss. Patient #13 A review of the plan of care dated 08/19/23 to 10/17/23 showed a primary diagnosis of hypertensive heart with heart failure with no interventions for monitoring of weight or instruction regarding weight gain or weight loss. On 11/08/23 at 11:20 am, staff B stated the care plans for Patient #9, 10 and 13 should have been developed in regards to the primary disease process.”

“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 and interview, the agency failed to ensure physician notification of significant change in wound for one (Patient #17) of 17 patients. Patient #15 A review of the plan of care dated 04/20/23 to 06/18/23 showed a diagnosis of Alzheimer’s disease with a skilled nurse frequency of one visit per week for eight weeks. A review of medical record showed the following: A skilled nurse visit dated 04/26/23 documented a stage II pressure area to the right hip with a measurement of 0.6 centimeters long by 0.6 centimeters wide by 0.1 centimeters deep. A skilled nurse visit dated 04/28/23 documented a stage II pressure area to the right hip with a measurement of 3 centimeters long by 2 centimeters wide by 0.1 centimeters deep, with no physician notification of a significant deterioration of the wound. A skilled nurse visit dated 05/01/23 documented a stage II pressure area to the right hip with a measurement of 7 centimeters long by 3.5 centimeters wide by 0.1 centimeters deep, with no physician notification of a significant deterioration of the wound. On 11/08/23 at 11:10 am, Staff B stated the physician should have been notified of the change in the wound status.”

“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 record review and interview, the agency failed to ensure PT evaluation for treatment was conducted for one (Patient #3) of seventeen patients. Patient #3 A POC dated 08/23/23 to 10/21/23 showed an order for a PT to evaluate and treat. Documentation showed no PT evaluation was conducted, no patient/caregiver refusal of the PT evaluations, no physician notifications and no changes in orders. On 11/08/23 at 10:35 a.m., Staff B confirmed there was no documentation of PT visits and stated a PT evaluation should have been conducted.”