Enhabit 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 interview, the agency failed to ensure patient were free from abuse, neglect, and exploitation by agency employees for 1 of 7 active Patients (Patient #1) whose records were reviewed in that: LVN A neglected Patient #1 by not Completing the Skilled Nurse visit on 09/05/2023 and after she submitted a visit note for 09/05/2023. Patient 1’s Care Giver called on 09/06/2023 to report that the nurse never came to visit patient after she scraped her foot and needed the wound to be evaluated on 09/05/2023. This failure may lead the Patient to injury or affect the quality of care. Findings include: Review of Patient #1’s “Home Health certification and plan of care” revealed a 88-year-old female with diagnosis of Venous Insufficiency, Peripheral Vascular Disease (a Circulatory disease in which the blood vessels are narrowed which reduces blood flow to the limbs.) Essential Primary Hypertension (High Blood Pressure), Other diagnoses revealed Reduced Mobility, Repeated Falls, Pain In foot, also wounds to feet. The form also documented the start of care as 11/04/2021 and a “current episode or certification period of 08/26/2023-10/24/2025 with skilled nursing visits 1 week 1 visit, 2 visits for 1 week, 2 visits a week for 6 weeks. Review of the “nursing schedule” and “skilled nursing notes” for the visit conducted on 09/05/2023 revealed LVN A worked with Patient #1, Time Not specified. Per LVN A’s documentation, patient was sitting in the wheelchair in the dining room with No edema (swelling) noted, Assessment: Patient Continues to require Skilled Nursing for monitoring wounds for Infection and education on cardiovascular disease. Visit note was signed by Nurse on 09/05/2023 at 7:06 pm Review [of the agency’s form titled “provider investigation report” stated that an incident occurred on 09/06/2025 at 10:41am revealed that the Administrator had filed a complaint of an incident regarding Patient 1. Patient’s Caregiver had called the agency to report that a Skilled nursing visit was not completed for Patient 1 on 09/05/2023. Caregiver was advised by the Administrator that Patient 1 was seen by LVN A around noon on 09/05/2025. Caregiver stated that during that time Patient 1 was at a doctor’s appointment. The report further stated that LVN A was immediately reported to the agency’s Compliance department. The Agency reported the incident to HHSC on 09/06/23. The agency terminated LVN A on 9/06/23. Continued review of the agency’s form titled “Provider Investigation Report”, the report further stated that on 09/06/23 RN B conducted a home visit and notified Patient #1’s medical doctor at which orders were received for treatment of foot injury. The report also stated that the Administrator began an internal investigation by acquiring LVN A’s Global Positioning System [ A tracking method to alert the agency as to where the staff were located during the day,] report pulled from LVN A’ s tablet. The results showed that LVN A was not in or around Patient 1’s Home on 09/05/2023. According to the report, when LVN A was interviewed by the Administrator, LVN A responded with a different verbal version of her visit documented on 09/05/23. When the administrator brought this to her attention, LVN A stated, “I don’t know what you want me to say.” Lastly on the report, it stated LVN A was terminated on 09/06/2023 and was referred to the Texas Board of Nursing, Complaint 2023090180. On 02/06/25 at 8:30 PM, surveyor A conducted an interview with the Alternate Administrator stated that she was with the administrator when Patient 1’s caregiver called about the missed home visit with Patient #1 and that she was with the administrator through the whole process as she was being trained on the Complaint Process, The Alternate Administrator stated on 09/06/2025 the Administrator and herself interview LVN A and questioned whether she made the skilled nurse visit per the alternate administrators recollection LVN A just kept saying “ I’m Sorry.”. Surveyor A asked if there were other patients that had any missed visits from LVN A and the Alternate Administrator stated that the Administrator called the cooperate compliance team and they conducted an internal investigation and ran a Global Positioning system Check for 2 weeks prior to the incident and all previous visits were accounted for. Alternate Administrator was asked what happened after Care Giver called to report the Missed Visit, she stated that RN B went to the patient’s house to conduct a skilled nurse visit and completed wound care to the Client, RN B called the medical Doctor’s office to report the incident and left a message with the answering service. Surveyor asked if the Medical Doctor was notified of the missed visit, she stated “Yes” and notified the Doctors office and of the new injury to the foot. On 02/06/2025 at 1:00pm surveyor spoke with Patient 1’s Caregiver via telephone, regarding missed visit, He stated that Patient 1 had injured herself and called on 09/05/2023 and a visit would be made that day, on 09/06/2023 He called the agency to report that a visit was never made on 09/05/2025. He did state that another nurse visited on 09/06/2023 after he called to report the visit that was not made on the previous day. He stated that they discharged from the agency in the summer of 2024 due to hospitalization of Patient 1. On 02/11/2025 Surveyor A Called LVN A to conduct an interview. LVN A stated that she failed to complete the Skilled nurse visits as scheduled on 09/05/2023. She stated that she “had a lot of work and she honestly forgot to see her.” Surveyor asked if you failed to see the patient how come there was a Visit nurse submitted?, LVN A stated that she “ erroneously submitted a note”, she was also asked how did she have a patient signature on the note if it was submitted in error, she did not respond then , she stated that she “submitted a note on someone I had seen instead of a missed visit note.”. Surveyor - Asked what were her repercussions of missing the visit she stated that she was terminated from the agency and that she was reported to the Texas Board of nursing. During an interview with Administrator on 02/12/2025 at 10:36 am, she stated that she was the one who initiated the complaint to the state once the caregiver of Patient 1 reported that LVN A failed to complete the skilled Nursing visit. She stated that she called her compliance team for the agency further stated that their agency policy was that the client has the right to expect safe patient care from agency staff and had the right to be free from abuse, neglect, and exploitation. The Administrator stated that on 09/05/2023 the Patient 1’s caregiver called and stated Patient 1 had an injury the night before and needed a nurse to come and see Patient 1, the Administrator stated that she told the care giver that patient 1 had a scheduled nurse visit later that day. on 09/06/2023 the Caregiver called to report that the nurse failed to make the nursing visits on 09/05/2023, Surveyor asked the administrator what was the process to investigation g the missed visit after there was documentation stating that the visit was done? The administrator stated that she needed to notify compliance, review the GPS of the tablet and bring in and question the Nurse, that she also submitted the incident to the state she made a referral to the Texas Board of Nursing. She stated that on 09/06/2023 she had an interview with LVN A when question she had a different verbal version of her visit that what was documented on the note when this was brought to her attention, she only stated that “I don’t know what you want me to say.” There was no denial nor an admittance of guilt At that time the nurse was terminated. Surveyor asked the Administrator was Patient # 1’s medical doctor contacted on missed visit, she stated that Client 1’s Nurse Practioner was notified and that a message was given to the medical doctor. Review of policy entitled, S17 “Patient/client abuse, Neglect and exploitation” with a revised date of 11/07/2023, quoted in part… All Agency employees are mandated to report allegations and suspected abuse, Neglect and/ or exploitation and must Report…., Reportable conduct is defined as abuse or neglect that causes or may cause death or harm to an individual receiving agency services or consumer death following acts or omissions by a person…mental or emotional injury to a child that results in an observable and material impairment. The agency did not dispute the survey findings and did not provide this surveyor with any additional documents upon exit. [”