Retreat Health Care Services Inc.

“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 observation, interview, and record review, the agency failed to ensure skilled nursing followed the written POC for 1 (Patient # 3) of 7 records reviewed for physicians’ orders, in that: The agency did not ensure Patient #3’s weight was taken and documented at every skilled nurse visit. This failure to follow the POC could place the agency’s patients at risk of hospitalizations and receiving inadequate care, services and negative outcomes. Findings included: Record review of Patient # 3’s POC dated 1/8/2024 – 3/7/2024 indicated he was 68 years old with diagnoses including heart failure, chronic kidney disease and long-term use of aspirin (blood thinner). The POC indicated the skilled nurse was to obtain a weight every skilled nurse visit. The POC indicated skilled nursing visits would occur twice a week for three weeks and once a week for six weeks. Record review of a skilled nursing visit note for Patient #3 dated 1/17/2024 did not have a documented weight. Record review of a skilled nursing visit note for Patient #3 dated 1/31/2024 did not have a documented weight. During an interview on 2/21/24 at 1:40 p.m., RN A said Patient #3 had congestive heart failure and had issues with high blood pressure, elevated heart rate, and shortness of breath. RN A said Patient #3 had recently been sent to the emergency room for shortness of breath, weakness, severe dizziness, and decreased level of consciousness. RN A said it was important to monitor Patient #3’s weight to see if there was a weight gain and to monitor for fluid buildup. RN A said she did not recall not getting a weight on Patient #3. RN A said normally if she could not get a weight, she would notify the physician and would measure his ankles to continue to monitor for fluid buildup. RN A said Patient #3 should be weighed at every skilled nurse visit because of his heart failure. During an interview on 2/21/24 at 1:40 p.m., RN B said weights were important for a patient with heart failure to monitor for fluid build-up. During an interview on 2/21/24 at 2:45 p.m., the DON said a patient with heart failure should have an order to monitor weights at each visit and notify the physician of weight gains outside of the parameters on the POC. The DON said the field nurses were responsible for assessing patients and QA was responsible for reviewing nurse notes and sending any corrections or questions to nurse. the DON said the plan of care was a physician’s order and should include interventions, goals, code status, medications, all diagnoses, frequency orders for each discipline providing care, vital sign parameters, safety precautions, diet and diagnosis. During an interview on 2/21/24 at 2:55 p.m., the administrator said the DON was responsible for the plans of care for patient safety and teaching of clients. Record review of an undated policy titled Physician participation in the Care-Planning Process, indicated its purpose was to ensure physician participation in the care planning process as appropriate to the care provided and according to law and regulation. Professional clinical staff will ensure that the patient’s physician participates in the care-planning process when: The care necessitates physicians orders in accordance with applicable law and regulation; and the patient’s condition or response to care changes, resulting in the organization contacting the physician. Information will be obtained from the patient’s physician at admission regarding the patient’s diagnosis, current medical findings, dietary restrictions, medication and treatment orders and will be documented on the plan of care and signed by the physician. Review of Managing Heart Failure dated June 13, 2023, and accessed on Managing Heart Failure Symptoms | American Heart Association indicated many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period and more than five pounds in a week. This weight gain may be due to retaining fluids since the heart is not functioning properly.”

“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 interview and record review, the agency failed to ensure the plan of care contained patient specific interventions and safety measures to protect against injury for 3 of 7 patients reviewed for plan of care. (Patient #4, Patient #6, and Patient #7) This failure could place patients at risk of not recognizing symptoms of bleeding, and not receiving proper care/instruction leading to complications and hospitalization. Findings included: Record review of Patient #4’s POC dated 1/29/2024- 3/28/2024 indicated she was 94 years old with diagnoses including hyponatremia (low sodium), chronic pain, high blood pressure, atrial fibrillation (an irregular and often very rapid heart rhythm that increases the risk of stroke, heart failure and other heart complications), and presence of cardiac pacemaker. The plan of care did not include pacemaker (battery powered device that prevents the heart from beating too slowly) safety precautions, location, or teaching. Record review of Patient # 6’s POC dated 1/1/2024- 2/29/2024 indicated he was 74 years old with diagnoses of stage 3 pressure ulcer (skin and soft tissue injury), chronic inflammatory demyelinating polyneuritis (progressive weakness and reduced senses in the arms and legs), hemiplegia (paralysis on one side), depression, high blood pressure, muscle weakness, long term use of aspirin (blood thinner) and wheelchair dependence. The POC did not include bleeding precautions or teaching. During an interview on 2/21/2024 at 11:20 a.m., Patient #7 said he had a pacemaker placed “several years ago” in the left side of his chest. Record review of a referral order dated 1/24/024 indicated Patient #7 had a surgical history of pacemaker placement on 10/1/2020. Record review of Patient #7’s POC dated 2/5/2024 – 4/4/2024 indicated he was 82 years old with diagnoses of prostate cancer, epilepsy (seizures), high blood pressure, and heart disease. The POC did not address Patient #7’s pacemaker location, safety precautions or teaching. During an interview on 2/21/2024 at 1:40 p.m., RN A said she built the plan of care based on the patients needs and it was reviewed in the office to ensure nothing was missing. RN A said if a patient was on blood thinners the POC should include an order to teach on bleeding precautions including symptoms of bleeding, who to call and teaching on the medication. RN A said there was a section on the POC for safety precautions where the bleeding precautions would be listed. RN A said when a patient has a pacemaker she would ask the patient about its functioning, document any teaching provided and incorporate into the POC so that other nurses caring for the patient would know where to examine the insertion point of the pacemaker. During an interview on 2/21/2024 at 1:51 p.m., RN B said she built/entered the data for the POC. RN B said patients on blood thinners should have bleeding precautions and teaching on bleeding on their POC. RN B said if the patient had a pacemaker, it should be documented in the assessment the type and placement of the pacemaker. RN B said it was important for the pacemaker to be included on the POC so there is proper coordination of care between nursing staff. During an interview on 2/21/2024 at 2:45 p.m., the DON said the plan of care was a physician’s order and should include interventions, goals, code status, medications, all diagnoses, frequency orders for each discipline providing care, vital sign parameters, safety precautions, diet and diagnosis. The DON said patient on blood thinners should have bleeding precautions and teaching on their POC. The DON said patients with a pacemaker should have a diagnosis coded on the POC. The DON said it was important to have an accurate and complete POC for care coordination and patient safety. During an interview on 2/21/2024 at 2:55 p.m., the administrator said the DON was responsible for the completeness and accuracy of the POC’s for the safety and teaching of patients. Record review of a policy dated 01-2018 titled Care-Planning indicated its purpose was to identify the agency’s processes for development, updating, revising the plan of care. The policy indicated it was the policy of the agency to develop an individualized care plan to meet the unique needs and circumstances of the patient. The individualized care plan will incorporate the needs, identified problems, specific care and services, patient wishes, goals, family and caregiver need, as appropriate, and the patient’s environment. The plan of care addresses the following: All pertinent diagnosis… any safety measures to protect against injury. Record review of an undated policy titled Physician participation in the Care-Planning Process, indicated its purpose was to ensure physician participation in the care planning process as appropriate to the care provided and according to law and regulation. Professional clinical staff will ensure that the patient’s physician participates in the care-planning process when: The care necessitates physicians orders in accordance with applicable law and regulation; and the patient’s condition or response to care changes, resulting in the organization contacting the physician. Information will be obtained from the patient’s physician at admission regarding the patient’s diagnosis, current medical findings, dietary restrictions, medication, and treatment orders and will be documented on the plan of care and signed by the physician. Review of Aspirin (oral route) precautions dated 02/22/2024 and accessed at Aspirin (Oral Route) Precautions - Mayo Clinic indicated “...this medicine may increase risk for bleeding problems, including stomach ulcers or bleeding. This usually occurs if you are taking aspirin with certain medicines. Check with your doctor right away if you have black, tarry stools, severe or continuing stomach pain, unusual bleeding, bruising, or weakness, or vomiting of blood or material that looks like coffee grounds…” Review of Living with a Pacemaker or implantable cardioverter defibrillator accessed at Living with a Pacemaker or Implantable Cardioverter Defibrillator ICD | Johns Hopkins Medicine indicated “…The following precautions should always be considered…Avoid magnetic resonance imaging (MRI) machines or other large magnetic fields, these may affect the programming or functioning of the pacemaker. Turn off large motors such as cars or boats, when working on them as they may temporarily “confuse” your pacemaker. If you have a surgical procedure done by a surgeon or a dentist, tell your surgeon or dentist that you have a pacemaker. Always carry an ID car that states you have a pacemaker. Although your device is built to last 5 to 7 years, you should have it checked regularly to ensure that it is working properly, your doctor may ask you to check your pulse rate periodically and report unusual symptoms of symptoms similar to those you had before the device to your healthcare provider right away.””