Dfw Home Health

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure a patient’s right to be free from neglect by an agency employee in one of three patient records reviewed (Patient 1/Intake 1082417) in that: Patient 1 was allergic to seven antibiotics (medications that kills germs) and at high-risk for an allergic reaction to new antibiotics. On 04/09/2026, RN A administered the first dose of a newly ordered antibiotic, Meropenem, into Patient 1’s blood vessel that resulted in an anaphylactic reaction (severe and life-threatening allergic event) to the antibiotic. RN A then administered the wrong dose of an emergency medication used to treat the anaphylactic reaction into Patient 1’s muscle, Epinephrine. RN A neglected Patient 1 by administering the first dose antibiotic in the home setting to a patient with multiple drug allergies and using the wrong dose of the emergency medication. This failure resulted in Patient 1 suffering a severe medical event requiring transportation to the hospital by EMS services (medical personnel that respond to emergencies) and hospitalization for 4 nights. Findings included: According to the Infectious Diseases Society of America, November 13, 2018: The most serious concern about administering the first dose of an antimicrobial at home is the ability to manage an immediate reaction or anaphylaxis, conditions that can be life threatening. Due to concerns about patient safety and to ensure the appropriate management of anaphylaxis, it is recommended that the first dose be administered in a supervised healthcare setting before allowing administration at home. It is reasonable to administer the first dose of an antibiotic in a patient’s home under the supervision of a competent healthcare worker in patients with no prior history of allergy to antibiotics in the same medication class (groups of drugs with similar chemical structures). https://www.idsociety.org/practice-guideline/outpatient-antimicrobial-parenteral-therapy/?utm According to Drugs.com, last updated 10/23/2025: The usual dose for adult anaphylaxis is Epinephrine 0.3-0.5 milligrams administered into a muscle with a needle. The maximum dose per injection is 0.5 milligrams. https://www.drugs.com/dosage/epinephrine.html#Usual_Adult_Dose_for_Anaphylaxis Record review of the Texas Unified Licensing Information Portal (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) included a self-reported incident (Intake #1082417) in which the Area Adm reported to the Health and Human Services Commission Complaint and Incident Intake on 04/10/2026. The report included an allegation of Neglect of Patient 1 by RN A. The report read in part, “… On 04/09/2026, at 1:00 PM, [RN A] was scheduled to administer a first dose Meropenem antibiotic [classified as a carbapenem antibiotic, which is a subclass of β-lactam antibiotics] and verified [Patient 1’s] allergies. She also verified the patient has an anaphylaxis kit (includes medications used for emergency response to severe allergic reactions) in the home. After the nurse administered the Meropenem antibiotic, the patient did have a reaction to the medication with severe swelling. She could not breathe and she started gasping. [RN A] opened the anaphylaxis kit and misread the instructions. The instructions state to pull (.3ml) of epinephrine into a 3ml syringe (device used to inject fluids into or withdraw them from something). The nurse pulled (3ml) into the syringe and administered it intramuscular (into a muscle). The nurse called 911. EMS transported the patient to [Hospital]… On 04/10/2026, [Family Member]… informed the agency that the patient’s hospital diagnosis is epinephrine overdose. The patient is still in the hospital at this time. There is no known hospital discharge date…” Record review of Patient 1’s electronic health record included a plan of care dated 03/19/2026-05/17/2026 with a start of care date of 11/19/2025 that was electronically signed by RN B on 03/17/2026. The plan of care included a diagnosis of Kidney (blood-filtering organs that form and excrete urine) infection and orders for the nurse to visit the once a week for eight weeks. The plan of care included seven antibiotics Patient 1 was allergic to, including three in the drug classification of β-lactam antibiotics (most widely used antibiotics): Cefpodoxime; Cephalexin; and Penicillin. The record included a physician order dated 04/07/2026 for a new antibiotic that read in part, “… IV (administers fluids, medications and nutrients directly into a blood vessel) medication Meropenem (drug classification subclass of β-lactam antibiotics; the same classification of three of the seven antibiotics Patient 1 was allergic to: Cefpodoxime; Cephalexin; and Penicillin) 1000 mg Q 8 hrs x 2 weeks – FIRST DOSE…” The record included a document titled, “…HomeCare… Mixing Report… [Pharmacist] ” dated 04/08/2026 that included orders for the Anaphylactic Kit that read in part, “…Fill Date: 04/08/2026… [Patient 1]… Anaphylactic Kit… Epinephrine (Adrenaline) 1mg/1ml… Adrenaline 1 mg/1 ml… withdrawl (sic) Epinephrine with a 3 ml syringe and inject IM using the appropriate needle… filled by [Pharmacist]…” The record included a nurse visit note conducted by RN A on 04/09/2026 that was signed by RN A on 04/13/2026. The note included in-home time from 10:54 AM – 11:56 AM that read in part, “… Pulse (heart rate) 98… 10:58 AM… Blood Pressure 124/74… 10:58 AM (force of blood against the walls of blood vessels; the normal blood pressure for adults is generally considered to be 120/80)… currently yellow on the stoplight tool (a visual aid used to help patients understand their condition and the steps they need to take to manage it effectively. It typically categorizes symptoms into different zones, such as green, yellow, and red, indicating the severity of the condition and the actions required to address it)… due to patient reporting feeling anxious due to getting new antibiotic that she has never received before… medication allergy list reviewed with patient prior to starting a new medication… new medication started Meronepem. 10 minutes into initiating medication, patient started to puff up on her arms and hands started turning red. Patient reported feeling nauseated (Feeling of needing to throw up). Epi (epinephrine) given per instructions listed on medication packet from pharmacy. 911 called (emergency telephone number). EMS arrived within 10 minutes. Patient transported to ER via EMS…” The record included an EMS report from EMS dated 04/09/2026 that read in part, “… [Patient 1]… Primary Impression Allergic Reaction… Allergic Reaction/Anaphylaxis… Signs & Symptoms Swelling… Time… 11:49 [AM]… BP 210/92… 11:57 [AM]… BP 193/68… 12:02 [PM]… BP 156/116… 12:07 [PM]… BP 183/84… 12:12 [PM]… BP 161/65… 12:17 [PM]… BP 224/107… Treatment… 12:00 [PM]… Diphenhydramine (medication used for allergic reactions)… 25 Milligrams (mg); Intramuscular (administered into a muscle using a needle); Patient Response: Improved… 12:13 [PM]… Diphenhydramine 25 Milligrams (mg); IV; Patient Response: Improved… dispatched for an allergic reaction… arrived on scene of a residence without incident to find a 52 year old female sitting upright in a chair… Home health nurse stated that she gave the pt an antibiotic and the pt started having some swelling to the area so she gave 3mg of Epi prior to EMS arrival. Pt stated that she was shaken and had been nauseous (Feeling of needing to throw up) with a rash starting to form. Vitals were obtained as charted and pt was moved from her chair to the stretcher with assistance and pt was secured via seatbelts and guard rails and moved to MICU for further assessment and treatment. Benadryl was given as charted and vitals were obtained as charted. Transport to [Hospital] was initiated and pt was continuously monitored... Pt stated her arms started feeling itchy and another dose of Benadryl was given as charted… arrived at [Hospital] without incident and pt was moved to ER room…” The record included a daily progress note from Hospital dated 04/12/2026 at 8:54 AM with a hospital admission date of 04/09/2026 that read in part, “… Feels anxious this morning because of her pain… BP 115/67… Epinephrine overdose… hypertensive urgency [high blood pressure]… Patient with chest pain… Patient needs continued hospital level of care because of epinephrine overdose with hypertensive urgency… Due to ongoing acute medical conditions as outlined above, need for intensive services in the hospital, inpatient setting for close clinical monitoring and adverse outcomes if not monitored, it is expected that this patient will remain in the hospital inpatient status greater than 2 midnights…” The record included a daily progress note from Hospital dated 04/12/2026 at 10:07 PM with a hospital admission date of 04/09/2026 that read in part, “… Diagnosis: Organ damage, organ injury, anaphylaxis, allergic reaction, medication reaction… 04/09/2026… Pt is now complaining of chest pain according to nursing staff… final diagnoses Hypertensive emergency … Allergic reaction… chest pain… Patient apparently received an excessive dose of epinephrine yesterday by a home health nurse following which she developed chest pain, generalized shaking and elevated blood pressure. She was given epinephrine 3 mg IV instead of 0.3 mg by the home health nurse…” The record included a record from Pharmacy titled, “BlastFax” (scans a document and transmits it electronically to another fax machine or online service, producing a copy of the original at the recipient’s end) sent to the agency dated 04/07/2026 that read in part, “… Telemedicine Visit Date of service: 03/17/26 [Patient 1]… Drug allergies… Bactrim… Cefpodoxime… Cephalexin… Ciprofloxacin… Clindamycin… Doxycycline… Penicillins… [antibiotics]” The record included a record from Pharmacy titled, “BlastFax” sent to the agency dated 04/07/2026 that read in part, “… Subject: Doctor Order… IV Meripenem (sic) 1000 mg Q 8 hrs x 2 wks… HH to do… first dose…” The record included drug allergies with a moderate severity/reaction to 7 antibiotics: Bactrim… Cefpodoxime… Cephalexin… Ciprofloxacin… Clindamycin… Doxycycline… Penicillins…” During an interview with RN A on 04/13/2026 at 2:16 PM, RN A stated: Patient 1 was allergic to certain antibiotics and she was getting the first dose of Meropenem in her home, which was in the same family of other antibiotics the patient was allergic to. The patient and Family Member asked for a nurse to be in the home for the first dose. RN A located the anaphylactic kit in the home and read the instructions. RN A started the IV antibiotic administration and about 10 minutes later, Patient 1 said, “Look at my arms.” Patient 1’s arms had started to puff up, her hands turned red and she stated she was having trouble breathing, was nauseous. RN A then re-read the instructions on the anaphylactic kit and I understood them the same way as the first time she read them. RN A prepared and administered Epinephrine 3 mg by giving Patient 1 a shot into a muscle. The paper from the Pharmacy read the dose of Epinephrine was 3 milligrams and to withdraw the Epinephrine into a 3ML syringe and administer to the patient and then call 911 and EMS arrived. RN A later looked online to see what the Epinephrine dose should have been and realized too much was administered and that RN A had made a mistake. RN A stated on 04/09/2026, she took a screenshot of the pharmacy orders included in the anaphylactic kit that was in the Patient 1’s home. RN A stated she followed the directions on the orders when she administered the Epinephrine. The surveyor requested the screenshot to be sent to the surveyor. The screenshot was received via text message from RN A on 04/13/2026 at 4: 38 PM and read in part, “… Fill Date: 04/08/2026… [Patient 1]… Adrenalin 1 gm/1 ml… withdrawl (sic) Epinephrine with a 3 ml syringe and inject IM using the appropriate needle… filled by [Pharmacist]…” RN A further stated she worked in hospitals as an RN from 2017 through September 2025 and her only prior experience with administering Epinephrine was while working in a hospital and she administered Epinephrine as an IV titration drip (careful adjustment of an intravenous infusion rate to achieve a desired therapeutic effect while minimizing side effects). During an interview with RN A on 04/14/2026 at 9:23 AM, RN A stated she was not sure what the normal administration dose was for IM Epinephrine for anaphylactic reactions, so she followed the instructions from Pharmacy and administered Epinephrine 3 mg/3 ml IM. RN A further stated before administering the first dose in the home, she did not consult with the pharmacy or ordering physician regarding the first dose of the new antibiotic in the home or her history to allergies to multiple antibiotics. During an interview with the Adm/DON and Alt Adm/ADON on 04/14/2026 at 11:00 AM, the Adm/DON stated the normal dose of Epinephrine for an anaphylactic reaction was 0.3 mg into a muscle. The Adm/DON stated first-dose antibiotics are not supposed to be administered in the home setting for patients with multiple allergies to antibiotics. The Adm/DON stated she or the Alt Adm/ADON should have reviewed the orders and Patient 1’s allergies before sending an employee to the home and it should have been caught beforehand. The Adm/DON further stated before the first dose antibiotic was administered in Patient 1’s home, the agency did not consult with the pharmacy or ordering physician regarding the first dose of the new antibiotic in the home or Patient 1’s allergy history to multiple antibiotics. During a joint interview with Patient 1 and Family Member on 04/14/2026 at 4:14 PM, Family Member stated: Patient 1’s doctor ordered new IV antibiotic, Meropenem, that Patient 1 had never taken before and the doctor wanted a home health nurse to be present for the first-dose administration of the medication. An anaphylactic kit and the Meropenem was delivered to their house. The anaphylactic kit was in case Patient 1 had an allergic reaction to the Meropenem since she was allergic to many other antibiotics. On 04/09/2026, RN A started the IV Meropenem and Patient 1 had an anaphylactic reaction. RN A gave Patient 1 a shot of Epinephrine and called 911. Patient 1 was hospitalized from 04/09/2026-04/13/2026 (4 nights). Family Member and Patient 1 were waiting so see if there was permanent heart damage. During a joint interview with Patient 1 and Family Member on 04/14/2026 at 4:14 PM, Patient 1 stated: After her anaphylactic reaction started on 04/09/2026, her left arm started puffing up (where the IV was located), she broke out in a rash, her blood vessels started turning purple, and she started itching. RN A gave her a shot of Epinephrine and she immediately started feeling bad with uncontrolled shaking and it felt like her heart would beat out of her chest. EMS arrived in an ambulance and took her vital signs. Her blood pressure was bad and the paramedics said she needed to go to the ER. Patient 1 stated she was discharged home on 04/13/2026 and still had pain in her chest when she moved and walked. During an interview with the Adm/DON and Alt Adm/ADON on 04/14/2026 at 2:30 PM, the Adm stated it was a slip-up that agency policies were not followed. Agency policy titled, “PATIENT ABUSE, EXPLOITATION, AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING (TEXAS ONLY)… 2.1.005T” with a last revised date of 11/01/2024 read in part, “… Neglect Failure to provide one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services…” Agency policy titled, “PATIENT RIGHTS, RESPONSIBILITIES AND CONDUCT REQUIREMENTS (TEXAS ONLY)… 1.001T” with a last revised date of 12/01/2021 read in part, “… The patient has the right to be free from… Neglect… by an agency employee, volunteer, or contractor…” Agency policy titled, “ANAPHYLAXIS FOLLOWING MEDICATION ADMINISTRATION… 10.030” with a last revised date of 12/01/2019 read in part, “… PURPOSE: To provide information to assist the nurse in recognizing allergic, adverse or anaphylactic reactions to medications and to provide the information necessary to perform immediate and effective treatment in the event an allergic, adverse, or anaphylactic reaction occurs in the home. Policy Once an allergic or anaphylactic reaction has been established, using the anaphylaxis kit supplied by the IV supplier or agency, the nurse will begin treatment according to protocol of the agency or specific orders of the patient’s prescribing physician. Definitions: Anaphylaxis: A sudden onset of severe, acute systemic reactions triggered by the massive release of histamine. Symptoms are characterized by urticaria, respiratory distress as dyspnea, wheezing, choking, cyanosis, vascular collapse in the form of hypotension, chills, sweating, weakness or anxiety, dizziness, nausea and vomiting, diarrhea, or abdominal cramping… Procedure… 1. For medications administered intravenously, stop the infusion immediately… 3. Administer Epinephrine 1: 1000 subcutaneous or intramuscular into anterolateral aspect of thigh as ordered… Recommended doses: Epinephrine… Adults > 65 lbs… milder reaction 0.3 mg… severe reaction… 0.5 mg…” Agency policy titled, “FIRST DOSE THERAPY IN THE HOME SETTING… 10.29” with a last revised date of 07/01/2010 read in part, “… PURPOSE: To provide guidelines for appropriate therapies and patient criteria which should be met before the first… intramuscular (IM) or intravenous (IV) dose of any medication is administered to a patient in a home setting… POLICY: Since the first dose of any… Intramuscular (IM), or Intravenously (IV) medications presents an increased risk for severe allergic or anaphylactic reaction, the first dose of… IM, or IV medications may be administered in the home only after consultation among the patient, ordering physician, pharmacist, and the agency’s nurse… Procedure… Administration of the first dose of medication in the home is the joint responsibility of the pharmacist, nurse, nursing director/supervisor and ordering physician… Administration of the first dose of medication in the home will only be performed when anaphylaxis allergic reaction orders and an anaphylaxis reaction kit are present in the home… Medical, allergy and drug history along with consultation between the patient, ordering physician, nurse and pharmacist must be documented in the patient’s chart prior to initiation of a first home dose administration is given…””

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on observation, record reviews and interviews, a Patient had the right to be free from neglect for 1 (Patient #18) of 3 discharged patient charts reviewed who received skilled nursing services with aftercare following surgery. The registered nurse (RN ) A failed to follow physician orders (leave wound vac in place) and provided treatment (removed the wound vac and removed staples causing the cadaver graft to come off) without an order. This failure placed Patient #18 at risk of complications of an open wound, infection and caused delayed healing and delayed a scheduled surgery. FINDINGS INCLUDE: Review of the Consumer Rights and Services Incident Investigation Worksheet included a self-report received date 10/8/2024. The report included the following allegations: Patient Neglect. Review of TULIP (a database utilized by the State of Texas to maintain licensing, demographic information, complaints and self-reported incidents on home health and hospice agencies) included a facsimile received from the HHA that included form 3613-provider investigation report and the agency background search and licensure verification for the alleged perpetrator, RN A. The provider investigation report undated, faxed to CII on 10/10/24 read in part,…”Incident category Neglect…When 10/4/2024…Location patient’s home, Description of the Allegation RN performed home health admission changed wound vac (vacuum-assisted closure: a medical device that uses of suction to help health difficult wounds by gently pulling fluid and bacteria out of the wound site by creating negative pressure around the wound area) and removed staples without physician orders. Referral stated to leave wound vac in place until patients follow up surgery on 10/7. RN removed cadaver graft (tissue taken from a donor who has died and used to treat patients) when he removed staples…Individual or Patient name Patient #18…Diagnosis and Pertinent History Vascular Disease (conditions that affect the blood vessels and veins), DM (diabetes mellitus is a chronic disease that occurs when the body can’t regulate blood sugar levels), hospital diagnosis: Right SFA-DPA bypass (SFA-superficial femoral artery-a major artery in the thigh, DPA-deep femoral artery, a branch of the femoral artery that supplies blood to the thigh muscles., bypass graft: A surgical construct, usually made from a vein take from the patient’s leg, that redirects blood flow around the blocked areas.) with composite vein graft (stitching together pieces of veins to create a longer graft to reroute blood around a blocked artery) for critical RLW ischemia (right lower extremity severe blockage in the arteries which markedly reduces blood flow). Superficial necrosis of right thigh saphenectomy (a surgery used to remove damaged veins and prevent complication) wound…Alleged Perpetrator…RN A…Alleged Perpetrator Confirmed (the allegation)…Injury or adverse affect- Yes, Assessment Date 10/3/2024, Time 4:00 PM, Description of injury and Assessment RN A removed wound vac and staples without a physician’s order and in the process removed cadaver graft from right femoral leg wound. Treatment provided Yes, Treatment or Transfer Date-10/4/24, HH (home health) agency sent RN A to assess wound at MD request…Agency Immediate Response- Executive Director immediately removed RN A from all patient care on 10/4 when mistake was discovered. ED notified surgeon’s office and spoke with PA for surgeon. ED called and notified head of CM of Harris Hospital as patient was scheduled for surgery on 10/7 that would have to be cancelled. ED called and notified patient’s MPOA of situation. ED emailed risk management and HR department and filed incident report. ED and area admin met with RN A on TEAMS (a collaboration platform that allows users to communicate through instant messaging, hold video meetings, share files, and work together on projects within organized teams, all within a single interface) who stated he didn’t properly read referral before admitting patient. RN A stated he changed the wound vac because the MPOA stated she thought the vac was due to be changed. RN A stated he seen there were staples in the wound and removed them and consequently removed the cadaver graft and silver dressing. RN A then replaced wound vac. On Monday 10/7 ED, area admin and HR met with employee and terminated employee. ED reported employee to BON on 10/8/24. ED reported to TULIP the following day…Investigation Findings confirmed. Agency action post investigation RN A terminated, reported to BON and TULIP. All clinicians that provide direct patient care attended annual skills check off session at local training center 10/8 and 10/10 with special attention to wound vacs education will be provided at weekly case conference week of 10/21 on: proper wound vac care, managing grafts, and properly reading referral orders.” 1/28/25 at 1:30 pm surveyor called Patient #18. Patient #18’s MPOA answered the phone. Surveyor explained that I would like to visit with Patient #18. Patient #18’s MPOA explained that her father was in the hospital and had surgery again on the same leg today. Surveyor explained I would like to see the patient in the morning if he was up to it. Patient #18’s MPOA explained that she did not want Patient #18 asked questions while on pain medicine unless she was present. Surveyor asked if between 9-9:30 in the morning would be ok for her to be there for my visit. Patient #18’s MPOA said yes, she could be there. Surveyor asked what hospital and room. Patient #18’s MPOA said Facility A in downtown Fort Worth in room 801. 1/28/25 at 2:09 pm surveyor attempted to call RN A, alleged perpetrator. No answer. Message indicated number called belonged to RN A. Surveyor left message requesting return call. 1/29/25 at 9:00 am surveyor conducted a face- to- face interview with Patient #18 and Patient #18’s MPOA. Surveyor asked Patient #18 what happened when RN A admitted you to home health. Patient #18 stated, “My daughter can get you up to date.” Surveyor asked Patient #18’s MPOA what RN A did during the home visit. Patient #18’s MPOA said, “The nurse took the wound vac off and removed some staples. Patient #18’s graph came off. There was blood everywhere, the nurse was using gauze to mop all of it up. Then he kept cutting the black foam and piecing it like a puzzle. After he left, the black foam kept clogging up the wound vac. Surveyor asked did you know what the nurse was supposed to do for you. Patient #18 said, “We didn’t know, but he changed the wound vac and removed some staples.” Patient #18 record review revealed a POC dated 10/3/24 to 12/1/24 with a start of care date of 10/3/24. The primary diagnosis was listed ad Encounter for other specified surgical aftercare. Skilled nursing was ordered 2 times a week for 1 week, 3 times a week for 8 weeks, physician therapy 1 time a week for 1 week effective 10/13/24 and occupational therapy 1 time a week for 1 week effective 10/6/24. The record contained the referral orders that read as follows: Postop note: Patient is s/p debridement, cadaver skin placement, and wound vac placement to the right thigh. Keep right thigh wound vac dressing clean dry and intact. Wound vac settings 175 mmHg high continuous suction. To be changed by burn team only. Plan: obtain home vac then discharge to home with home wound vac. Will arrange outpatient surgery for patient next week likely on Monday. Wound vac to stay on until return to OR. If unable to arrange outpatient vac will plan on inpatient surgery next Monday. Please call/text/email me for any questions or concerns. Signed by MD A 10/1/24 at 0030. Record review of the Patient episode coordination notes report. Entry 10/3/24, entered by RN A read in part…”RLE/Thigh wound/wound vac in place and active @ 175 continuous negative pressure R/T infected superficial injury of right thigh, S/P bypass (a surgical procedure that creates a new route for blood or other body fluids to flow around an obstacle) and S/P debridement (the process of carefully cleaning a wound by removing dead or infected tissue) with cadaver (dead human body) skin/silverlon placement. Applied/stapled to (7X25 cm, 175 SQ cm, full thickness, wound bed.” Picture of wound taken during SOC on 10/3/24 and uploaded by RN A. Name: 10-03-24 7.38.20PM Timestamp: 2024-10-04T00:38:23 is a picture of a right thigh, open wound, beefy red wound bed. No staples or graft noted, no wound vac covering wound. Entry on 10/6/24 by Administrator/Supervising Nurse that read, “ED was notified on Friday 10/4 by PCMA and PCM that it appears patients wound vac was changed at SOC even though orders in referral state to leave vac in place. SOC still not turned in. ED reached out and spoke with RN A. RN A stated that he did change vac and also used staple removers to remove staples in wound bed and subsequently removed graft. PCM called and notified PA B of situation. ED also called and spoke with PA B. ED sent PA B picture of the wound and ED and PA B both confirmed graft was no longer in place. Patient was scheduled to have surgery on 10/7 that will now be cancelled. PA B instructed HH Agency to perform wound vac changes 3X weekly until appointment on Wednesday 10/9 where patient will be seen in clinic and evaluated. ED called and notified head of CM at Facility A of situation. Ed called and spoke with patient’s MPOA and explained situation. MPOA upset but willing to let nurse come out. RN E went to evaluate patient. Wound vac changed on Thursday 10/3 and will be changed on 10/7 by RN E. 1/29/25 at 11:42 am 2nd attempt to reach RN A. Surveyor called, phone rang 2 times and was disconnected with no opportunity to leave a message. Surveyor redialed and left a message requesting a return call. 1/31/25 at 1:10 pm 3rd attempt to reach RN A. Surveyor called, no answer, left message requesting a return call. An interview was conducted on 1/31/25 1:10 pm with the Alternate Administrator/Alternate Supervising Nurse. Surveyor, the agency policy reviewed with Alternate Administrator/Alternate Supervising Nurse: Physician Orders stated no treatment will be administered without an order. Surveyor reviewed that RN A removed the wound vac and staples without orders and didn’t follow the order for the wound vac to remain until 10/7/2024. Alternate Administrator/Alternate Supervising Nurse nodded yes. Surveyor asked how not following orders and providing treatment without an order could affect patient care. Alternate Administrator/Alternate Supervising Nurse stated, “It can be very detrimental, cost him (the patient) money, he (the patient) had to have another skin graft, against his rights, and he could have gotten an infection. Agency policy: Patient Abuse, Exploitation, and Neglect: Assessment, Identification and Reporting (Texas Only) Policy Number: 2.1.005 T Revised Date: 11/1/24 read in part…”PURPOSE: To identify, assess, and report victims of actual or suspected abuse, exploitation and/or neglect. POLICY:…B. Neglect Failure to provided one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretake to provide such goods or services.”…”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide the NOMNC written notice at least two days in advance of terminating on-going care in 2 (Patient #14 & #15) of 5 discharged records reviewed whose reason for discharge was goals met. The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patient from exercising their right to appeal the discharge decision, if they chose to appeal. Findings include: Patient 14: The record contained a POC dated 8/16/24-10/14/24 with a SOC date of 4/18/24. The record contained a discharge OASIS [HC(1] assessment dated 10/10/24 and signed by RN B. The discharge summary indicated reason for discharge as goals met. The record failed to contain a NOMNC. Patient 15:The record contained a POC dated 9/19/24-11/17/24 with a SOC date of 5/22/24. The record contained a discharge OASIS assessment dated 11/11/24 and signed by RN C. The discharge summary indicated reason for discharge as goals met. The record failed to contain a NOMNC. An interview was conducted on 1/31/2025 with the Alternate Administrator/Alternate Supervising Nurse. The surveyor explained that Patient #14 and Patient #15 did not receive the NOMNC. The surveyor reviewed regulations related to discharge notices NOMNC notice no less than 2 days prior to discharge. Alternate Administrator/Alternate Supervising Nurse said, “We put a buddy code for the visit before discharge so the nurse will give the discharge notices.” The surveyor asked Alternate Administrator/Alternate Supervising Nurse how a patient not receiving a discharge notice could affect patient care. Alternate Administrator/Alternate Supervising Nurse said, “The patient may get discharged without having time to appeal it and have a gap in care if they still need home health.” Agency policy: Notice of Non-Coverage, Expedited Determination and Reconsideration for Discharge 1.003 last revised 12/1/21 read in part:…”POLICY The agency will adhere to the Benefits and Improvement Act (BIPA) and will be liable for continued services until two calendar days (or more stringent state requirement frames indicated in table below) after a Medicare beneficiary receives a Notice of Medicare Provider Non-coverage….PROCEDURE… 3. The notice will be issued no later than two calendar days before the proposed end of services for all states except those listed below with more stringent notification timelines.”…”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on record review and interview the agency failed to report findings immediately in accordance with state law. When the agency had cause to believe a Patient had been neglected by an agency employee, RN A, the agency failed to report the information within 24 hours to HHSC in 1 (Patient #18) of 1 self-reported incident of potential neglect (Intake 536532) of a Patient. This failure potentially placed Patients at further risk of abuse, neglect or exploitation. Findings include: Record review of intake 536532, Incident Investigation Worksheet: Review showed the “Date Received was identified as 10/8/24 at 1:19 pm. The intake indicated “Date facility first learned of incident” as 10/4/24 at 2:15 pm” with information about an allegation of neglect of Patient #18 by RN A. There was no evidence the agency reported the ANE allegation to HHSC no later than 10/5/24; there were no other intake in TULIP which showed the agency reported the ANE allegation within 24 hours. An interview was conducted on 2/6/25 at 10:45 am with the Administrator/Supervising Nurse. The surveyor reviewed the agency policy for Self Reported Incidents of ANE. The surveyor stated the agency became aware of the neglect on 10/4/24 and reported it to HHSC on 10/8/24. The Administrator/Supervising Nurse stated, “I wasn’t aware of the 24 hour rule at the time. The surveyor asked how not reporting allegations of ANE could affect Patient Care. The Administrator/Supervising Nurse stated, “Patient safety would be at jeopardy.” Agency Policy: Patient Abuse, Exploitation, and Neglect: Assessment, Identification and Reporting (TEXAS ONLY) last reviewed 11/1/24 read in part…”PURPOSE; To identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect…POLICY:…If an agency has cause to believe that a client served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, within 24 hours, The Health and Human services Commission (HHSC) Complaint and Incident Line at 1-800-458-9858 or through the secure website https://txhhs.force.com/TULIP/s/ for all cases;”…”

“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 record review and interview the agency failed to provide treatments in accordance with the orders of a physician in 1 (Patient #18) of 3 discharged client charts reviewed with primary diagnosis of aftercare following surgery. RN A failed to follow the physician order to leave wound vac in place, RN A removed the wound vac and staples causing cadaver graft to fall off with an order. This failure cause Patient #18 to have a delay in scheduled surgery and delayed healing with increased risk of wound infection and/or complications. Findings include: Patient #18 record review revealed a POC dated 10/3/24 to 12/1/24 with a start of care date of 10/3/24. The primary diagnosis was listed ad Encounter for other specified surgical aftercare. Skilled nursing was ordered 2 times a week for 1 week, 3 times a week for 8 weeks, physician therapy 1 time a week for 1 week effective 10/13/24 and occupational therapy 1 time a week for 1 week effective 10/6/24. The record contained the referral orders that read as follows: Postop note: Patient is s/p debridement (the process of carefully cleaning a wound by removing dead or infected tissue), cadaver (dead human body) skin placement, and wound vac (vacuum-assisted closure: a medical device that uses of suction to help health difficult wounds by gently pulling fluid and bacteria out of the wound site by creating negative pressure around the wound area) placement to the right thigh. Keep right thigh wound vac dressing clean dry and intact. Wound vac settings 175 mmHg high continuous suction. To be changed by burn team only. Plan: obtain home vac then discharge to home with home wound vac. Will arrange outpatient surgery for patient next week likely on Monday. Wound vac to stay on until return to OR. If unable to arrange outpatient vac will plan on inpatient surgery next Monday. Please call/text/email me for any questions or concerns. Signed by MD A 10/1/24 at 0030. Record review of the record contained Client episode coordination notes report. Entry 10/3/24, entered by RN A read in part…”RLE/Thigh wound/wound vac in place and active @ 175 continuous negative pressure R/T infected superficial injury of right thigh, S/P bypass (a surgical procedure that creates a new route for blood or other body fluids to flow around an obstacle) and S/P debridement (the process of carefully cleaning a wound by removing dead or infected tissue) with cadaver (dead human body) skin/silverlon placement. Applied/stapled to (7X25 cm, 175 SQ cm, Full thickness, wound bed.” Picture of wound taken during SOC on 10/3/24 and uploaded by RN A. Name: 10-03-24 7.38.20PM Timestamp: 2024-10-04T00:38:23 is a picture of a right thigh, open wound, beefy red wound bed. No staples or graft noted, no wound vac covering wound. Entry on 10/6/24 by Administrator/Supervising Nurse that read, “ED was notified on Friday 10/4 by PCMA and PCM that it appears patients wound vac was changed at SOC even though orders in referral state to leave vac in place. SOC still not turned in. ED reached out and spoke with RN A. RN A stated that he did change vac and also used staple removers to remove staples in wound bed and subsequently removed graft. PCM called and notified PA B of situation. ED also called and spoke with PA B. ED sent PA B picture of the wound and ED and PA B both confirmed graft was no longer in place. Patient was scheduled to have surgery on 10/7 that will now be cancelled. PA B instructed HH Agency to perform wound vac changes 3X weekly until appointment on Wednesday 10/9 where patient will be seen in clinic and evaluated. ED called and notified head of CM at Facility A of situation. Ed called and spoke with patient’s daughter and explained situation. Daughter upset but willing to let nurse come out. RN E went to evaluate patient. Wound vac changed on Thursday 10/3 and will be changed on 10/7 by RN E. RN A failed to provide care only per physician orders. 1/29/25 at 11:42 am 2nd attempt to reach RN A. Surveyor called, phone rang 2 times and was disconnected with no opportunity to leave a message. Surveyor redialed and left a message requesting a return call. 1/31/25 at 1:10 pm 3rd attempt to reach RN A. Surveyor called, no answer, left message requesting a return call. An interview was conducted on 1/31/25 1:10 pm with the Alternate Administrator/Alternate Supervising Nurse. Surveyor, the agency policy reviewed with Alternate Administrator/Alternate Supervising Nurse: Physician Orders stated no treatment will be administered without an order. Surveyor reviewed that RN A removed the wound vac and staples without orders and didn’t follow the order for the wound vac to remain until 10/7/2024. Alternate Administrator/Alternate Supervising Nurse nodded yes. Surveyor asked how not following orders and providing treatment without an order could affect patient care. Alternate Administrator/Alternate Supervising Nurse stated, “It can be very detrimental, cost him (the patient) money, he (the client) had to have another skin graft, against his rights, and he could have gotten an infection. Agency Policy Physician orders revised 10/1/23 read in part:…”POLICY: No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner.”…”