Vitalcaring Group

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to reassess the patient within 48 hours of the patient’s return to home from a hospital admission of 24 hours or more in 1 out of 3 patient records reviewed (Patient 2). The agency failed to conduct a Resumption of Care reassessment visit for Patient 2 after the patient returned home from a five day hospital admission. This failure resulted in the patient not being seen for 11 days after being discharged from the hospital, which put the patient at risk for further decompensation and risk of rehospitalization due to not having a nurse reassess their changed condition after discharge and not receiving home health for 11 days. Findings included: Review of the agency’s policy titled, “Reassessment/Recertification,” last revised 12/2024, revealed a document that read in part: “Each patient will be reassessed using a comprehensive OASIS assessment tool for the review and revision of the plan of care when: … The patient returns home after an inpatient admission lasting twenty-four (24) hours or longer for any purpose other than diagnostic testing.” Review of the document titled, “Outcome and Assessment Information Set OASIS-E Manual”, updated 1/1/2024, under the heading ‘1.5.3 When is OASIS Completed? (Time Points)’, revealed the following OASIS requirement for completing an assessment: “Time Point: Resumption of Care (ROC); Reasons for Assessment: Resumption of Care (after inpatient stay), Assessment Timeframe “Withing 2 calendar days of the facility discharge date or knowledge of the patient’s return home.” (https://www.cms.gov/files/document/oasis-emanual2024-update.pdf ) Record review of the document, “Patient Calendar Report,” dated for the period of 2/5/26 - 3/16/26, revealed Patient 2 had an “RN Resumption of Care” visit on 3/3/26. Record review of the document titled, “Order Number: 1128912” dated 2/13/26, showed that a hospital hold was placed for Patient 2 due to a hospital admission on 2/12/26. Record review of the document titled, “Order Number: 1136588,” dated 2/19/26, revealed an order that read “Resume HH services upon discharge 2/16/26.” Further review of the document revealed a new frequency of skilled nursing, ordered once a week for 1 week, starting on 2/15/26. Record review of the document titled, “Order Number: 1151200,” dated 3/2/26, revealed an order that read “Resume HH services upon discharge 2/16/26.” Further review of the document revealed a new frequency of skilled nursing, ordered once a week for 1 week, starting on 03/01/26. Record review of the document titled, “Visit Note Report,” dated 3/3/26, revealed Patient 2 had a hospital discharge date of 2/19/26. Further review of this document revealed the following: “Visit Type: RN15 - Resumption of Care.” In an interview with the Administrator, and Supervising Nurse at 3:40 PM on 3/27/29, the Administrator confirmed that the ROC visit happened on 3/3/26 despite the patient discharging on 2/19/25. After reviewing the patient’s chart, she stated that what probably happened was that the Plan of Care had not been signed yet when the Hospital Hold was placed, and when the Plan of Care was signed by the physician on 2/19, it would have voided out the ROC order if that was places prior the signing of the Plan of Care. The Administrator explained there is a glitch in their EHR where if the POC is signed after orders come in, those orders are voided and have to be put in the system again. She said she “guessed” that is what happened in this case, and said if that was the case the order would have been cancelled out without notifying them, essentially making it so that the ROC visit never appeared on the nurses schedule. The Surveyor asked who was responsible for scheduling the ROC visits and the Administrator stated it was the Case Manager, who was in the office and joined the interview shortly after. In an interview with the Case Manager and Administrator at 3:45 PM on 3/27/29, the Case Manager confirmed that this is what happened. She stated that they did not realize that the ROC did not happen until 3/2/26, which is when they placed a new order for the ROC to occur the next day. The Surveyor asked the Administrator why it was important to patient care to ensure that ROC visits happen promptly after discharge. The Administrator stated it was important because the patients need continuity of care after coming home from the hospital, and they need to be re-assessed for any new needs, and they need to be seen to prevent further hospitalizations.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to integrate services to assure patient safety and treatment effectiveness in 1 out of 3 patients (Patient 2) whose records were reviewed in that: The agency failed to communicate with ALF 1 regarding the importance of the Patient 2 elevating his legs. This failure resulted in the patient not elevating his legs in the facility, which resulted in increased swelling and ultimately caused his bilateral leg wounds. Findings included: Review of the agency’s policies revealed a document titled, “Care/Service Coordination,” which read in part, “Care coordination will include, but not be limited to: I. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. J. Coordination of care delivery to meet the patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities. K. Ensuring that each patient, and their caregiver(s), where applicable, receive ongoing education and training provided by the organization regarding the care and services identified in the plan of care. The organization shall provide training, as necessary, to ensure a timely discharge. Further review of the document revealed the following: “Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note.” Review of the document titled, “Consumer Rights and Services Complaint Investigation Worksheet” for Intake #1078813 dated 3/25/26, revealed a complaint was filed to CII which read, in part, “Resident was hospitalized 2/12/2026 for worsening leg redness. EMS was called for weeping wounds (worsening redness, edema, and draining from his lower extremities p/FM 2) and worsening altered mental status. FM 2 told the attending physician that resident has [home health], but they have not done anything about his legs. Hospital records describe legs as erythema/edema/satellite lesions (redness, swelling, scabs) extended from his knees to his feet. Discharged 2/16/2026. Returned to community with orders for [home health]. Unable to determine when legs were wrapped. Notes on 3/10/2026 suggest that nurse was waiting on call back from PCP for orders to apply wraps. Agency has an unsigned order from Wound Care NP but it was not signed. Wound Care NP stated she absolutely did not give the order verbally and was only referred to [Patient 2] to treat the sacral wound (wound on bottom).” Further review of attachments to the intake revealed undated pictures of large, open wounds on both on backside of legs right under the knees. Review of the document titled, “Home Health Certification and Plan of Care,” dated for the period of 2/6/26 - 4/6/26, revealed Patient 2’s Plan of Care. Patient 2’s relevant diagnoses were listed as Type 2 Diabetes Mellitus (body not effectively regulating blood sugar), chronic kidney disease, anemia (low red blood cells), pressure ulcer of left buttock, stage 2 (a partial-thickness skin loss involving a shallow, open ulcer with a red-pink wound bed), primary hyperaldosteronism (hormonal imbalance), circulatory complications (blood flow/swelling issues), unspecified atrial fibrillation (heart rhythm disorder), chronic congestive heart failure (heart failure resulting in excess fluid in the body) . The Plan of Care had an ordered frequency of nursing visits as once every 2 weeks for 2 weeks, then twice a week for 7 weeks, then once a week for one week, although this was adjusted throughout the certification period. The following orders were included on the plan of care: “#1 left buttock (2.0 cm x 2.0 cm x 0.1 cm, no drainage, no odor, periwound (area around wound) normal for skin color) observing universal precautions and clean/aseptic technique (a set of specific practices and procedures—including hand hygiene, PPE use, and sterilization—designed to prevent the transfer of microorganisms and minimize infection risk during medical procedures), remove previous dressing and dispose of appropriately, cleanse wound with wound cleanser, pat dry with gauze, applied zinc oxide (versatile topical (on the skin) agent used to treat wounds by promoting faster healing, reducing inflammation, and offering antibacterial protection) to periwound (area around wound) and optifoam (type of dressing) dressing over wound. Wound care to be completed 2x week by skill nurse.” Review of the document titled, “Order Number: 1153789” dated 3/3/26, revealed a Resumption of Care order which read in part, “Skilled Nurse/Caregiver to perform/ teach wound care to pressure injury to #1 left buttock stage I pressure ulcer (0.5x0.2x0.1, no drainage, no odor) #2 right buttock stage II pressure ulcer (2x0.5x0.1, no drainage, no odor): cleanse with wound cleanser, Pat dry, apply moisture barrier to periwound, cover with silicone foam bordered dressing. Using aseptic/clean technique. Change dressing twice a week and prn. Discontinue wound care and supplies once healed. Skilled nurse to assess bilateral lower legs (venous insuffiency): cleanse with soap and water/wound cleanser, pat dry, apply lotion, may apply personal compression garments to bilateral lower legs for edema management. Using clean/aseptic technique. Skilled nurse to report increased redness or swelling to provider. Skilled nurse may provide the following wound care if legs are weeping, cleanse with wound cleanser, pat dry, apply Unna boot (compression wraps with antifungal cream), secure with rolled gauze and secure with coban (wrap). Unna boot to be changed twice a week if used. Discontinue wound care and supplies once healed.” Review of the document titled, “Order Number: 1178711,” dated 3/10/26, read in part, “Refer to [Wound Care Services] for edema management of bilateral lower legs.” Review of the document titled, “Order Number 1177276,” dated 3/10/26, revealed a verbal order entered by Supervising Nurse which read: “Verbal order received from [Wound Care NP]. Skilled nurse to assess bilateral lower legs (venous insufficiency): cleanse with soap and water/wound cleanser, pat dry, apply lotion, apply 4 layer compression wraps twice a week and PRN for soiled or dislodged dressing. Agency to complete once weekly, [Wound Care Services] to see once weekly. Discontinue wound care and supplies once healed.” This order was documented that it was received on 3/10/26 but it was not signed by the ordering nurse practitioner. Review of the document titled, “Complaint Report,” dated 2/13/26, revealed the following note: “2/12/26 - received a call from [Facility/ALF Nurse], with concerns related to lack of communication and& concerns on the care the patient was receiving/not receiving. She reports that [agency nurses] will come talk to her but does not fill out their form at the front. She reports when she went to the patient’s room after the nurse left, patient was extremely confused, legs were weeping and& stuck to the recliner. Due to concerns, patient was sent to ER & was admitted to the hospital and& is requiring IV abx (antibiotics through the bloodstream) at this time. She reports the daughter would like follow up as she also has concerns.” Review of the document titled, “Visit Note Report,” dated 3/7/26, revealed a nursing note by LVN A. The note read, in part, “Nurse arrived at home (ALF) patient is alert and oriented to self. He is confused most of the time. He does live in an assisted living facility and is supposed to be getting showers at least 3 times per week. [FM 2] is supposed to be talking with ALF 1 and making sure that they are actually bathing patient and applying creams to legs. Patient did have some 4 layer wraps in the closet. At one time patient was using them but had stopped once the skin was cleared up. Nurse noted scabbed areas to bilat(eral) (both sides) lower ext. Applied lotion and will call MD office Monday to discuss further wound care treatments. Patient buttocks (bottom) does have some redness encouraged to apply zinc cream (versatile topical (on the skin) agent used to treat wounds by promoting faster healing, reducing inflammation, and offering antibacterial protection) the buttocks daily and avoid prolonged sitting.” Review of the document titled, “Visit Note Report,” dated 3/10/26, revealed a nursing note by LVN A. The note read in part, “Nurse arrived at assisted living facility. Patient is sitting up in the recliner. Bilateral legs swollen and scabs noted to bilat(eral)(both) legs. Nurse cleansed legs with soap and water. Patted dry with towel. Applied lotion to bilat legs. Nurse instructed to keep them elevated, monitor for drainage or redness. Nurse has call into PCP regarding applying wraps. Awaiting call back. Also has redness to buttocks applied zinc cream(versatile topical (on the skin) agent used to treat wounds by promoting faster healing, reducing inflammation, and offering antibacterial protection) to the coccyx (bottom) area and instructed to off load.” Review of the document titled, “Patient Episode Coordination Notes Report,” revealed an entry on 3/19/26 by LVN A that read as follows: “Late documentation from 3/10: received at text from the nurse with [ALF 1] stating that [Patient 2]’s shower days are Sunday and Wednesday on the second shift from 2-10pm. This nurse sent response back; asked if we could coordinate with ALF 1 so that patient could shower. And agency nurse can come to provide wound care after. As of March 12th, still no response from [facility nurse]. This nurse sent another message asking her again if facility and nurse could coordinate so that patient could get his legs washed.” Review of the document titled, “Patient Episode Coordination Notes Report,” revealed an entry on 3/19/26 that read as followed: “[Patient 2] is complaining of both legs hurting and wraps feel too tight. This nurse responded to elevate the legs and if continues to call nursing back so visit can be moved up. Also spoke with [FM 2] about patient’s care at [ALF 1] them not bathing or coordinating with care team. She states that she will get back with agency nurse as her [family member] is in the ER.” The patient’s electronic health record was reviewed for any other documentation of care coordination with facility staff members. No other communications were recorded in the “Coordination Notes”. FM 2 was called 3 times: 12:21 PM, 12:25 PM, 2:09 PM on 3/27/26. Left voicemail for return call. In an interview with LVN A at 1:30 PM on 3/27/26, she stated that she had worked with Patient 2 off and on for years, and she stated that his legs were always very dry and rough and swollen at baseline. She confirmed she saw Patient 2 on 3/7/26 and his legs were getting “crusty”. She stated the nurses instruct the patient to elevate his legs when sitting, but that he was very forgetful and confused, and compliance was difficult. She stated that when she saw him on 3/10, his legs “looked worse” so she texted Wound Care NP, who she had worked with this patient in the past. Wound Care NP stated that they were not currently following Patient 2 but could start seeing him again. She stated she followed the current orders at this time, which allowed her to place compression wraps for swollen legs. She stated she tried to talk to the ALF 1 staff that day to attempt to coordinate showers on the day the nurses come so they could redo his compression wraps, but she was unable to find anyone and did not get a response from the text she sent to the ALF nurse. She confirmed that she got a text from FM 2 with concern that Patient 2’s legs were worsening and he was complaining that the wrap felt too tight. She stated that she received this text on 3/17/26 around 9:00 PM. She stated that she asked FM 2 if Patient 2 had been elevating his legs that day, and FM 2 said that he had not been. LVN A stated that if Patient 2 did not keep his legs elevated, they were likely more swollen and causing the compression wrap to feel tighter. LVN A stated that she instructed FM 2 to have Patient 2 elevate his legs, and if that did not help, to let her know and she could arrange a visit for the following day. She stated she did not hear from FM 2 again. LVN A stated that when they leave ALF 1, they are supposed to turn in a note of what was done with the patient that day and vital signs. She stated that she could not find the facility nurse to give the note to, so she gave it to the Medication Aide. She stated that she remembered telling the medication aide to tell the facility nurse that the patient needs to offload weight from his sacrum (bottom) because he had a red spot there. She did not know the name of the medication aide. She did not state if she told the Medication Aide or any other staff to make sure Patient 2 was elevating their legs. LVN A did state that she had texted FM 2 “before all this” and asked if she would consider moving Patient 2 to a facility where he could get more one on one care but FM 2 had said she could not afford to move him again. LVN A expressed concerns to the surveyor about the care the patient was receiving at ALF 1. She stated that the patient would say he was dry when the aides came around, but the patient would actually have a soiled and wet diaper, and that the aides would not check. She stated they did not help the patient elevate his legs. In a second phone interview with LVN A at 4:09 PM on 3/27/26, the Surveyor asked if LVN A ever spoke with anyone in ALF 1 about the importance of Patient 2 elevating his legs to prevent swelling and skin breakdown. LVN A stated, “I told the Medication med Aide that day (3/10/26) that he needed to elevate his legs. And then I had other communications with the facility RN about trying to coordinate his showers.” This was different from what LVN A had told the Surveyor in the previous interview. When the Surveyor asked why LVN A did not speak with ALF nurse about the importance of Patient 2 elevating his legs, she stated it was because she was not there that day. The Surveyor asked LVN A why it was important to ensure coordination of care between the facility and the home health agency. She stated it was important because this patient was non-compliant and needed help to keep his legs up. She stated she felt like all parties could have communicated better. LVN A said, “I think we should have communicated better with [FM 2] and told her we really thought he needed a higher level of care.” She stated FM 2 was overwhelmed, and that Patient 2 was getting more confused. She stated, “I think every person here including the patient could have done a better job communicating with each other, reporting, issues and following up. ALF 1 didn’t follow up, the home health agency didn’t follow up, the patient didn’t report anything.” LVN A stated that it was a good reminder to take those extra 5 minutes and ensure everyone taking care of the patient was on the same page about what needs to be done. In a phone interview with Wound Care NP at 11:55PM on 3/30/26, she confirmed she first saw the patient on 3/19/26 and called EMS due to his severe bilateral leg wounds. She stated that when she unwrapped his RLE there was a wound behind the knee just under the top of where the wrap was, and described it as red with broken skin and a mild odor. She stated she then unwrapped the LLE and that wound was deeper with more necrotic tissue and a stronger seem. She stated the LLE there was redness surrounding the wound and moving upwards towards the thigh. She stated it would be hard to say if anyone could have seen these wounds developing without removing the dressings. She stated that there was a little bit of redness, but the wounds were mainly under the bandages so it could have been difficult to see. Wound Care NP stated she could not see them at first with how he was sitting and the wraps covering them, but also stated that maybe if he was up and walking they could have been more visible, but it was hard to say. The Surveyor asked her in her professional opinion did she think wounds like this could develop in the course of 3 days? She stated she was unable to answer that because she had not received education on how quickly a wound could occur under compression wraps and she had not seen something like this before. Wound Care NP also stated that she did not give LVN A a verbal order on 3/10/26, and she stated she had no communication with the agency that day.”