Encompass Home Health of Dfw

“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 patients were free from neglect for 1 of 11 patients (patient #4) whose record was reviewed, in that: the nurse (RN S) did not provide wound care for Patient #4. This failure placed Patient #4 at risk for wound deterioration by not receiving wound care as outlined in the patients plan of care which could lead to slower healing wound or, potentially, hospitalization if the wound deteriorated. Record review for Patient #4: Review of the plan of care (POC) for certification period 4/10/2024 to 6/8/2024 revealed in part: A start of care date of 8/14/2023. The plan of care was electronically signed and dated by the physician on 05/01/2024. The frequency of visits for skilled nurse was 1 time per week for 1 week and then 2 times per week for 8 weeks. Review of the section titled, “Orders of Discipline and Treatments:” read in part, “laceration and multiple toes on bilateral feetright [sic] great toeorder [sic]: HH nurse to change dressing 2X per week…” Review of the report titled, “Coordination Notes Report” revealed a note on page 3 of 4 dated 4/29/2024 that was entered by the Administrator read, “Physician notified of missed wound care visit on Saturday.” During an interview with the Administrator, she clarified the Saturday missed visit was for the date 4/27/2024. Review of the report titled, “Witness Affidavit” that was signed by the Administrator and dated 06/10/2024 read in part, “On 04/29/2024 I spoke with (RN S) regarding a patient visit being completed. (RN S) stated she had seen the patient on 04/27/2024… a few mins later (RN S) called back and stated, “I don’t want to lie to you I didn’t see him.” On 02/04/2025 at approximately 2:50 PM The surveyor conducted an interview with the Administrator. The surveyor asked the Administrator if RN S conducted a skilled nurses visit on 04/27/2024 for Patient #4. The Administrator stated, “at first she said she did see Patient #4 and did his wound care but when I told her the silent global positioning satellite (this is a system the agency uses to monitor the agency staff’s location at the time a nursing assessment is started) ping did not show her at the patients address she admitted that she didn’t visit the patient.” The surveyor asked what the outcome could be of missing a wound care visit. The Administrator stated, “the patient’s wound could deteriorate or maybe if there was signs of an infection it could be missed but we did a nurses visit on 04/29/2024 to evaluate the patient and there wasn’t any adverse effects or wound degression noted from the missed visit.” The surveyor asked what the agency investigation findings were. The Administrator stated, “we confirmed the findings of neglect and reported RN S to the Board of Nursing.” On 02/07/2025 at approximately 2:39 PM the surveyor conducted a phone interview with RN S. The surveyor asked if on 04/27/2024 RN S had a skilled nurses visit for patient #4. RN S stated, “yes.” The surveyor asked if the visit scheduled on 04/27/2024 was to provide wound care for patient 4. RN S stated, “yes.” The surveyor asked RN S if she conducted the nursing visit that was scheduled on 04/27/2024 for Patient #4. RN S stated, “no, I had a lot of stuff going on at that time plus the stuff going on at work. I was tired and I felt like I couldn’t get a hold of it and I made a very stupid mistake. I mean I it was a really stupid mistake.” The surveyor asked what the outcome of not completing a nursing visit that is scheduled for a client. RN S stated, “I mean… I mean he didn’t get the care that he needed. It could cause him to not get his dressing change done and the wound could get worse.” The surveyor asked RN S if she felt that by not conducting the nursing visit it could be considered neglect. RN S stated, “I don’t know I have never done anything like this it was a stupid mistake. I knew it was stupid.” Review of the agency’s policy titled, “Patient abuse, neglect & exploitation Texas S17” original issue date: 01-01-2000 reviewed date: 09-25-2024 read in part, “…2.0 Definitions… 2.3 Neglect is the failure of a caregiver to supply… health care when reasonably able to do so…””