Elara Caring

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure that each patient received the home health services that were written in an individualized plan of care for 1 of 10 (Patient #1) patients reviewed in that the agency skilled nurses, LVN F, RN G, and LVN C, failed to obtain the abdominal measurement for Patient #1, when unable to obtain the patient’s weight, on 10/15/24, 10/18/24, 10/22/24, and 10/25/24, as ordered by the physician in the written plan of care. This failure could have resulted in the skilled nurse failing to identify signs of a worsening of the patient’s heart failure (a medical condition in which the heart is unable to pump effectively which can result in the buildup of fluid in the tissues of the body including the lungs and the abdomen, which can result in shortness of breath, difficulty breathing, increase in the abdominal measurement, and increase in weight) to allow the physician to order additional interventions if needed and could result in adverse outcomes to the patient including hospitalization. The findings included: Record review of the clinical record for Patient #1 included a plan of care, for the certification period of 08/31/24 – 10/29/24, signed by Physician #1, which indicated the patient had a diagnosis of heart failure and indicated the patient was to receive skilled nurse visits once a week for one week, twice a week for two weeks, then once a week for eight weeks. Record review of a physician’s order, dated 10/09/24, signed by Physician #1, indicated, “SN or trained patient/caregiver to obtain weight daily and weight gain of 2 LBS overnight or 5 LBS in a week to be reported to physician/provider. If unable to weigh patient, SN or trained patient/caregiver to obtain measurement of abdomen in CM daily and report an increase of 1 CM to physician/provider.” The order further indicated the patient was to receive skilled nurse visits once a week for one week, twice a week for two weeks, and then once a week for one week. Record review of hospital records, from Hospital #1, dated 10/11/24, indicated the patient was seen in the emergency room on this date for a complaint of shortness of breath and was diagnosed with acute respiratory failure (an inability of the respiratory system to take in enough oxygen or to remove enough carbon dioxide from the body which can be life threatening) with hypoxia (a medical condition in which there is not enough oxygen reaching the body’s tissues) and heart failure and was administered Lasix (a medication used to remove excess fluid from the body). Record review of a skilled nurse’s virtual visit (telephone visit) note, dated 10/12/24, signed by LVN D, indicated Patient #1 went to the emergency room at Hospital #1 on the evening of 10/11/24 for shortness of breath and was administered IV (medication is administered into the blood stream via a needle inserted into a blood vessel) Lasix and discharged home. Record review of a skilled nurse’s note, dated 10/15/24, signed by LVN F, did not indicate the skilled nurse, patient, or caregiver obtained the patient’s weight or abdominal measurement during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 10/18/24, signed by RN G, did not indicate the skilled nurse, patient, or caregiver obtained the patient’s weight or abdominal measurement during this visit as ordered by the physician in the written plan of care. Record review of a skilled nurse’s note, dated 10/22/24, signed by LVN C, did not indicate the skilled nurse, patient, or caregiver obtained the patient’s weight or abdominal measurement during this visit as ordered by the physician in the written plan of care. Record review of a recertification OASIS assessment, dated 10/25/24, signed by RN G, did not indicate the skilled nurse, patient, or caregiver obtained the patient’s weight or abdominal measurement during this visit as ordered by the physician in the written plan of care. Record review of the agency’s home folder for Patient #1, for the time-period of 10/09/24 – 10/25/24, did not include documentation to indicate the skilled nurse obtained the patient’s weight or abdominal measurement during the skilled nurse visits conducted on 10/15/24, 10/18/24, 10/22/24 and 10/25/24, as ordered by the physician in the written plan of care. During an interview conducted on 10/30/24 at 8:33 a.m., with LVN C and the alternate administrator/alternate supervising nurse, LVN C said she did not remember reading the part about obtaining the abdominal measurement on the physician’s order, dated 10/09/24. LVN C said she first obtained the abdominal measurement for Patient #1 on 10/29/24. LVN C said the patient could not weigh due to amputation (surgical removal) of both his legs below the knee. The alternate administrator/alternate supervising nurse said she had not audited the patient’s clinical record until 10/28/24 and that was when she realized there was no way to really get his weight and realized they needed to obtain the abdominal measurement. LVN C said she was not able to get the patient’s weight and she did not realize the abdominal measurement order was included in the physician’s orders until yesterday. When asked who was responsible for obtaining Patient #1’s weight or abdominal measurement if unable to weigh the patient, LVN C said it was the responsibility of the nurse. When asked how often the weight or abdominal measurement should be obtained, LVN C said they should be obtained at each skilled nurse visit. When asked if she had obtained the patient’s weight or abdominal measurement during the skilled nurse visit she conducted with Patient #1 on 10/22/24, LVN C said, “no.” When asked where the weight or abdominal measurement would be documented if they had been obtained, LVN C said they would be documented in the vital sign section of the skilled nurse’s note. When asked if there could have been any potential adverse outcomes related to the failure to obtain the weight or abdominal measurement if unable to obtain the weight for Patient #1, LVN C said, “yes,” and said the agency could potentially fail to identify a worsening of the patient’s heart failure as quickly. During an interview conducted on 10/30/24 at 11:00 a.m., with Patient #1’s Family Member #1 and Family Member #2, when asked if the nurses obtained the patient’s weight during each nurse visit, Family Member #1 said, “no,” because the patient was not able to easily weigh in the home as he had amputations of both lower legs. When asked if the nurses obtained the patient’s abdominal measurement, Family Member #1 said, “yes.” When asked when the nurses had begun doing this, Family Member #1 said she did not recall. During an interview conducted on 10/30/24 at 1:00 p.m., with RN G and the alternate administrator/alternate supervising nurse, RN G said she had reviewed the physician’s orders for Patient #1 but did not notice the order to obtain the patient’s abdominal measurement if unable to weigh the patient. When asked who was responsible for obtaining the patient’s weight or abdominal measurement if unable to obtain the weight, RN G said the nurse was responsible for completing this task during skilled nurse visits. When asked how frequently the abdominal measurement should be obtained if unable to weight the patient, RN G said, “I’m going to say every visit.” When asked if she had obtained Patient #1’s weight or abdominal measurement during the visits she conducted with the patient on 10/18/24 and 10/25/24, RN G said, “I did not.” RN G said she was unable to weigh the patient and was unaware of the order to obtain the abdominal measurement if unable to weigh the patient. RN G said if she had obtained the weight or abdominal measurement during the skilled nurse visit, she would have documented the finding in the skilled nurse’s note in the vital sign section and would also document the finding in the patient’s home folder. RN G said she knew the nurse was supposed to weigh the patient during visits but there was no way to get the patient on the scale and she did not know about the order to obtain the abdominal measurements. RN G said the patient/family did not refuse the abdominal measurement she (RN G) just did not know the nurse was supposed to obtain it. When asked if there could be any potential adverse outcome or harm to the patient related to the failure to obtain the abdominal measurement when unable to weigh the patient, RN G said she didn’t think so if the nurse did an appropriate assessment. When asked if she would agree that obtaining the weight or abdominal measurement was part of an appropriate nursing assessment for a patient with a diagnosis of heart failure, RN G said, “Yes.” During an interview conducted on 10/30/24 at 2:20 p.m., with LVN D and the alternate administrator/alternate supervising nurse, when asked regarding the virtual visit nurse’s note, dated 10/12/24, LVN D confirmed he conducted a virtual (telephone) visit with Patient #1 on this date and confirmed the patient had gone to the emergency room on 10/11/24. LVN D said he thought the hospital either increased the Lasix or gave the patient Lasix in the emergency room on 10/11/24. LVN D reviewed the virtual visit note, dated 10/12/24, and said what was documented in the note sounded correct for what he recalled. LVN D said Patient #1’s Family Member #1 said the patient had gone to the emergency room the previous night for increased shortness of breath and was given IV Lasix. During an interview conducted on 10/31/24 at 10:36 a.m., with LVN F and the alternate administrator/alternate supervising nurse, LVN F reviewed the physician’s orders for Patient #1 and said the orders said if the patient was unable to weigh the nurse was to obtain the abdominal measurement. LVN F said the patient could not stand to weigh, and so the nurses were to get his abdominal measurement. When asked who was responsible for obtaining the patient’s weight or the abdominal measurement if the patient was unable to weigh, LVN F said during skilled nurse visits the nurse should obtain the weight or abdominal measurement. When asked how often the weight or abdominal measurement should be obtained, LVN F said it should be obtained every day either by the nurse or the patient/caregiver if the nurse was not present. When asked if she had obtained the patient’s weight or abdominal measurement during the skilled nurse visit she conducted with the patient on 10/15/24, LVN F said she knew she had not obtained the patient’s abdominal measurement on 10/15/24. LVN F reviewed the skilled nurse’s note, dated 10/15/24, and said she did not document that she obtained the patient’s weight during that visit. When asked why the weight or abdominal measurement was not obtained, LVN F said, she did not remember why she did not get it. LVN F said if she did get the weight, she did not write it down. When asked where the weight or abdominal measurement would be documented if obtained during the visit, LVN F said she would document the abdominal measurement in the narrative section of the nurse’s note and in the patient’s home folder and if she had obtained the weight, she would document it in the vital signs section of the skilled nurse’s note and in the home folder. LVN F confirmed the patient had a recent below the knee amputation of his left leg and was difficult to weigh in the home. LVN F confirmed the patient and family did not refuse the weight or the abdominal measurement. When asked if there were any potential adverse outcomes related to the failure to obtain the weight or abdominal measurement for Patient #1, LVN F said, yes, potentially, especially for a patient with a diagnosis of heart failure and said it was possible the nurse would not catch a worsening of the heart failure early which could result in hospitalization. LVN F said she conducted a PRN (as needed) skilled nurse visit with Patient #1 on 10/11/24 because the patient’s Family Member #1 called and said the patient wasn’t feeling well. LVN said the patient’s heart rate was increased, his blood pressure was low, and he was complaining of shortness of breath. LVN F said the patient was so short of breath he was not able to get his words out to speak. LVN F said the patient’s Family Member #1 took the patient to the emergency room and after he returned home Patient #1’s Family Member #1 said the emergency room was able to take quite a bit of fluid off the patient and said the emergency room staff gave the patient IV Lasix during the visit. The surveyor reviewed the documentation from Patient #1’s home folder with LVN F and she confirmed there was no documentation of the patient’s weight or abdominal measurement for the date of 10/15/24. LVN F said there was nowhere else other than the skilled nurse’s note and the home folder where she would have documented the weight if obtained. During an interview conducted on 10/31/24 at 10:54 a.m., the administrator/supervising nurse said the physician’s orders for Patient #1 said to obtain the patient’s weight, and if unable to weigh the patient, to obtain the patient’s abdominal measurement daily. When asked who was responsible for obtaining the patient’s weight or abdominal measurement during skilled nurse visits, the administrator/supervising nurse said the nurse was responsible unless the family had already obtained it. The administrator/supervising nurse said if the family had already obtained the weight or abdominal measurement when the skilled nurse visit was made the nurse should review the family’s documentation and record what the finding was. The administrator/supervising nurse said this should be done every skilled nurse visit unless refused by the patient/family. When asked if the patient’s weight or abdominal measurement was obtained during the skilled nurse visits conducted on 10/15/24, 10/18/24, 10/22/24 and 10/25/24, the administrator/supervising nurse said, “No Ma’am.” The administrator/supervising nurse said if the weight or abdominal measurement had been obtained it should have been documented in the patient’s home folder and in the skilled nurse’s note. The administrator/supervising nurse said Patient #1 was unable to stand to weigh and his abdominal measurement was not obtained by the skilled nurse. The administrator/supervising nurse said the nurses did not realize there was an order to obtain the patient’s abdominal measurement if the patient was unable to weigh. The administrator/supervising nurse said the patient/family did not refuse the weight/abdominal measurement to her knowledge. When asked if there could be any adverse outcomes or potential harm to the patient related to the failure to obtain the weight or the abdominal measurement for Patient #1, the administrator/supervising nurse said she didn’t think so because the nurses were doing an assessment, which would include assessment of his abdomen, and she didn’t think failure to obtain the abdominal measurement could result in a failure to identify signs and symptoms of a worsening of the patient’s heart failure. When asked if obtaining the patient’s weight or abdominal measurement would be part of conducting a thorough nursing assessment for a patient with a diagnosis of heart failure, the administrator/supervising nurse said, “yes.” During an interview conducted on 10/31/24 at 1:12 p.m., with Physician #1’s Nurse #1, when asked if it would have been important to obtain the weight or abdominal measurements for Patient #1, Physician #1’s Nurse #1 said, “yes,” if the physician ordered it that would indicate the physician felt it needed to be done. When asked if there could be any adverse outcomes related to the failure of the agency to obtain the weight or abdominal measurements if the patient was unable to be weighed, Physician #1’s Nurse #1 said, “yes,” if the abdomen was distended (increased in size) and the -patient was retaining fluid the physician would need to know about that so interventions could be ordered if needed. Record review of an agency policy titled, “Admission Policy,” dated 09/09/2020, indicated, “Services for a client receiving Skilled Nursing … must follow a written Plan of Care established … by a physician …””