Dfw Home Health Mckinney

“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 a patient’s right to be free from neglect by an agency employee (RN A) for one of one patient (Patient 1) with diabetes (high blood sugar) who developed a foot wound in that the agency nurse failed to notify the physician of the wound and obtain wound care orders. This failure resulted in Patient 1 being harmed and hospitalized with a diabetic foot ulcer and skin infection that required surgical debridement (removal of dead skin and foreign material from a wound) and IV antibiotics (medicine used to fight infections). The failure placed all clients at potential risk of poor care and a deteriorating health status. Findings included: The active employee roster provided to the surveyor by the Adm/DON on 04/03/2025 at 12:45 PM included RN A’s hire date was 08/27/2023. Record review of the Texas Unified Licensing Information Portal (a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) included a self-reported incident (Intake #546866) in which the Adm/DON reported to the HHSC Complaint and Incident Intake on 11/22/2024. The report included an allegation of Neglect of Patient 1 by RN A. The report read in part, “… Patient [Patient 1] called… 11/15/24… stated [RN A] wrapped his right foot with Coban (bandage wrap) during visit on Wednesday 11/13/24 and his foot is now purple and there is another wound on right foot… advised patients [Family Member] who ws (sic) present and concerned to remove wrap. He did and… is going to take him to the hospital. Patient was admitted. [RN A] had documentation of new wound in his narrative but did not add the wound to the wound record report nor did he document the care he provided and no order for care provided… Met with [RN A] Monday 11/18/24… to discuss mistakes. He did confirm he wrapped with Coban and did not have an order to do so. Discussed the severity of these mistakes…” Record review of Patient 1’s electronic health record included a plan of care dated 10/24/2024 - 12/22/2024 with a start of care date of 10/24/2024 that was electronically signed by RN B on 10/24/2024. The plan of care included a diagnosis of diabetes with nerve damage and peripheral vascular disease (slow and progressive disorder of the blood vessels that can cause narrowing, blockage, or spasms)and orders for the nurse to visit the patient once a week for nine weeks. The plan of care included orders for the nurse to assess the lower extremities for the presence of lesions every visit. The plan of care included goals for the patient/caregiver to verbalize/demonstrate knowledge in preserving skin integrity and to verbalize an understanding of diabetic foot care. The plan of care did not include evidence of any wounds or wound care orders. The record included a start of care nurse visit note (nurse visit #1) conducted by RN B on 10/24/2024. The visit note did not include evidence of any wounds or wound care orders. The record included a nurse visit note (nurse visit #2) conducted by RN A on 11/01/2024. The visit note read in part, “… integumentary (skin) findings… wound(s)… care coordination document communication with other disciplines/individuals (… patient, caregivers… supervisor) involved with this case. Include attended/scheduled physician/authorized practitioner appointments along with any changes made to the plan of care since the last visit… NA… pt has a wound to second toe on right foot. wound assessed and bandaid replaced…” The visit note did not include evidence the physician was notified and wound care orders obtained. The record included a nurse visit note (nurse visit #3) conducted by RN A on 11/03/2024. The visit note read in part, “… integumentary… Indicate integumentary findings… No problems identified…” The visit note did not include evidence of any wounds or wound care orders. The record included a nurse visit note (nurse visit #4) conducted by RN A on 11/13/2024. The visit note read in part, “… integumentary (skin) findings… wound(s)… document communication with other disciplines/individuals (… patient, caregivers… supervisor) involved with this case. Include attended/scheduled physician/authorized practitioner appointments along with any changes made to the plan of care since the last visit… NA… assessment complete. pt has a wound to top of right foot…” The visit note did not include evidence the physician was notified and wound care orders obtained. The visit note did not include any wound care provided. The record included a client coordination note report completed by RN C on 11/15/2024 that read in part, “… [Family Member] called and reported foot is hurting/discolored and has new wounds on it stated he called the nurse and was instructed to take the wrap off…” The record included a physician order #35869315 completed by RN C on 11/15/2024 that read in part, “… patient called reporting new wounds to foot after wrapping the foot. SN to perform prn for eval and contact MD for further orders…” The record included a nurse visit note completed by the Adm/DON on 11/15/2024 that read in part, “… date collection only – no visit made… this assessment is currently being completed for the following reason… transferred to an inpatient facility… which inpatient facility has the patient been admitted… hospital… for what reason(s) did the patient require hospitalization… wound infection or deterioration… date… 11/15/2024…” The record included an agency complaint report processed by the Adm/DON and dated 11/15/2024 that read in part, “… [Family Member] states that nurse wrapped the leg on Wed and it began to hurt. He called the nurse who put the wrap on Wed and was instructed to take it off. [Family Member] stated that the foot was discolored and there was a “awful” wound on the extremety (sic) that needs to be looked at. Advised that wills (sic) end (sic) nurse out to evaluate and contact the Dr… ED notified. Clinician involved on PTO and not able to reach today. Filed incident report, had managers discussion with [RN A] upon return. Patient unfortunately was hospitalized…” The record included a client coordination note report completed by LVN on 11/18/2024 that read in part, “… hospital hold… date of admission: 11/15 Admitting diagnosis: Diabetic foot infection Hospital Name: [Hospital]…” The record included hospital records from [Hospital] that included an admission date of 11/15/2024 with a diagnosis of diabetic right foot infection and cellulitis (bacterial infection of the skin and tissues beneath the skin). The record read in part, “… Patient…presented to [Hospital] ED with complaining of worsening of diabetic foot .. infection… 2 days ago, patient noticed, he had 2 small open wounds on… the right foot… Patient’s wounds were addressed by the home health nurse today and noticed significant progress with swelling/erythema (redness) to majority of his right foot and recommended the patient to come to the ED for further evaluation… Patient was treated with IV vancomycin (antibiotic used to treat serious infections that is administered through a vein) in the ED… debridement today…” The record included medical records from [Skilled Nursing Facility] that included Patient 1 was admitted to the facility on 12/02/2024 and included a diagnosis of diabetes with a foot ulcer and skin infection. The record contained a clinical notes report dated 12/02/2024 that included Patient 1 arrived at [Skilled Nursing Facility] in a wheelchair with EMT assistance. The patient had a right foot wound and an IV in the left arm for the administration of IV antibiotics every 8 hours for 7 days. Record review of RN A’s personnel record included that on 10/08/2024, RN A completed a skills lab check-off /competency assessment where RN A demonstrated competency in wound cleansing and dressing application utilizing proper hand hygiene; compression wraps (a wrap dressing used to alleviate swelling); and verbalized how to assess for diabetic ulcers and indications, contraindications and basic treatment options. The record included RN A was oriented to the agency’s policies and procedures, including abuse, neglect, exploitation, and client rights. The surveyor called Patient 1 on 04/04/2025 at 12:06 PM; the call was not returned. During an interview with Patient 1’s Family Member, the Family Member reported: Patient 1 had a history of toe amputations, skin grafts (a surgical procedure that involves removing healthy skin from one area of the body to another), and foot complications due to diabetes and sensitive feet. Patient 1 was hospitalized in November 2024 due to a foot infection. What started as one small wound turned into three wounds, and the doctors were afraid the foot infection would reach the bone. The wound wrap used by [RN A] may have worsened the wound. The foot with the wound developed a blockage that prevented the wound from healing. While hospitalized, Patient 1 developed a bowel obstruction that required additional testing. Patient 1 was hospitalized for approximately two weeks, discharged and re-hospitalized several days later for an additional week due to confusion and weakness. Following the second hospital discharge, Patient 1 was placed in a skilled nursing facility and stayed for three weeks before returning home. The foot wound eventually healed. During an interview with the Adm/DON on 04/04/2025 at 1:44 PM, the surveyor asked what agency processes failed with Patient 1. The Adm/DON stated she did not know why RN A did wound care without notifying the physician and obtain an order. The failure was poor judgment and caused harm to Patient 1 who required hospitalization. RN A was placed on a 2-day work leave after the incident and wound care competency was re-verified before RN A returned to work. During an interview with RN A on 04/04/2025 at 11:15 AM, RN A reported: Patient 1 had one scabbed foot wound on the 11/13/2024 nurse visit. There were no wound care supplies in the home. RN A did not want to leave the scabbed wound open so he covered the wound with supplies RN A had on hand and applied a 4 X 4 (medical gauze) and wrapped the wound with Coban. Patient 1 ended up having circulatory problems that worsened the wound. RN A did not notify the doctor and did not obtain doctor orders for the wound care provided. RN A could not recall why he did not document the wound care provided and a wound assessment on the 11/13/2024 visit note. The surveyor asked what the outcome was for Patient 1. RN A stated Patient 1 was hospitalized for reasons unrelated to the wound but RN A could not remember the reasons for the hospitalization. The surveyor stated the hospital records included Patient 1 was hospitalized due to a wound infection on his foot. RN A stated he vaguely remembered Patient 1 had a wound infection. Patient 1 had no harm and was not neglected by RN A because RN A would not put Patient 1 in harm’s way. RN A thought he was doing the right thing by addressing the wound but the [home health agency] disagreed with him. RN A was placed on a 2-day leave of absence because of the incident and received additional agency training. During an interview with RN B on 04/04/2025 at 12:55 PM, RN B reported: RN B was not aware Patient 1 had a wound before 11/15/2024. On her 10/24/2024 admission visit (Visit #1), Patient 1 did not have a wound. On 11/15/2024, RN B was notified by RN A that Patient 1 had a wound that had worsened. RN B notified Patient 1’s mobile nurse practitioner to obtain orders but the patient went to the hospital before RN B had time to make a home visit to assess the wound. The surveyor called RN C on 04/04/2025 at 12:54 PM; the call was not returned. RN C was no longer employed by the agency. Agency policy titled, “Patient Rights, Responsibilities And Conduct Requirements (Texas Only) 1.001T” with a revised date of 12/01/21 read in part, “… Patient Rights… 10. The patient has the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect, misappropriation of property, and exploitation by an agency employee, volunteer, or contractor…” Agency policy titled, “Patient Abuse, Exploitation, and Neglect: Assessment, Identification and Reporting (Texas only) 2.1.005 T” with a revised date of 11/1/24 read in part, “… PURPOSE: To identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect… Definitions as defined in Texas Human Resource Code Chapter 48, section 48.002… B. Neglect Failure to provide one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services… Definitions of Employee Reportable Conduct as defined in the Texas Human Resource Code Chapter 48 section 48.401… Reportable Conduct: Includes: abuse or neglect that causes or may cause death or harm to an individual receiving agency Services…””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review, observation, and interview, RN A failed to ensure accurate comprehensive assessments were provided to 1 (Patient #5) of 5 patient records reviewed with home visits. RN A conducted 4 comprehensive assessments on 5/23/2023, 7/20/2023, 9/19/2023 and 11/16/2023, and failed to provide and document an accurate assessment that included pertinent diagnoses consistent with the patient’s current health status, at the time of the assessment. RN A’s failure to conduct an accurate comprehensive assessment could cause a decline in the patient’s health status due to the patient not being provided a thorough and complete physical assessment by the clinician to determine the care and needs of the patient. Findings include: Review of Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 11/21/2023 – 1/19/2024. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a disease that affects the way the body processes blood sugar and can affect blood vessels in kidneys that can cause kidney damage). Other diagnoses included, ESRD (a condition in which a person’s kidneys cease functioning on a permanent basis that’s leads to dialysis) and Dependence on renal dialysis (a condition in which a person must have frequent treatments that help the body remove extra fluid and waste products from the blood when the kidneys are not able to). The POC included orders for a skilled nurse visit one time a week for 8 weeks. Review of Patient #5’s clinical record included skilled nursing notes ordered by the patient’s physician for one time a week for 8 weeks that included the following dates, 11/21, 11/28, 12/6, 12/12, 12/21, 12/26/2023, 1/3/2024, 1/10, 1/17/2024. Review of the skilled nursing notes, included in Patient #5’s clinical record, did not include any documentation regarding the patient’s diagnoses of ESRD and/or dialysis. A home visit was conducted on 1/18/24 at 11:30 AM with Patient #5. Patient #5 reported he never had a kidney problem or dialysis. In an interview with the Administrator/DON on 1/19/24 at approximately 3:15 PM, the surveyor went over the findings regarding Patient #5’ diagnoses of ESRD and Dependence on Renal dialysis. The Administrator/DON asked if she could check on the finding. At approximately 3:30 PM the Administrator/DON returned and stated Patient #5 did not have ESRD and was not dependent on dialysis. The Administrator/DON stated she was not sure why the diagnoses were included on the patient’s comprehensive assessments and the patient’s POCs. She stated she looked back at previous POCs and found the diagnoses were included on the POCs beginning May 25, 2023, through January 17, 2024. The surveyor continued to review Patient #5’s clinical record that included the following. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 5/25/2023 – 7/23/2023 signed and dated by RN A on 5/23/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. Physician orders included SN effective 5/28/23, 1 time a week for 8 weeks and PT effective 6/4/23 for 1 time a week for 1 week. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 7/24/2023 – 9/21/2023 signed and dated by RN A on 7/20/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. The POC included orders for a skilled nurse visit one time a week for 8 weeks. Patient #5’s clinical record included a POC with a SOC date of 3/31/22 and a certification period of 9/22/23 to 11/20/23 signed and dated by RN A on 9/19/2023. The POC listed a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Other diagnoses included, ESRD and Dependence on renal dialysis. The POC included orders for a skilled nurse 3 times a week for 1 week and 1 time a week for 8 weeks. The surveyor conducted a phone interview on 2/1/2024 at 10:30 AM with RN A and reviewed the findings regarding the comprehensive OASIS assessments that RN A provided to Patient #5. RN A stated she knew Patient #5 very well and had done the past several comprehensive OASIS assessments. RN A stated Patient #5 has a diagnosis of DMII and has an order from the physician for a urinary catheter change once every month by agency nurses. RN A stated she knew Patient #5 did not have ESRD and was not dependent on dialysis. She stated she may have inadvertently added the diagnoses, but that Patient #5 did not have either of the diagnoses. The agency’s policy read as follows, “Patient Assessment, Initial and Reassessment, policy # 2.1.002” with the last review date of 01/01/2024. The policy included, “The comprehensive assessment is the responsibility of one clinician…. All patients receive ongoing and periodic reassessments. Comprehensive OASIS assessments are made prior to patient recertification for all adult patients receiving skilled care…. Procedure: 1. Upon admission and reassessments, the qualified clinician performs the following assessment activities and collects the following data: A. Current health status, psychological, functional, and cognitive status… H. pertinent physical findings L. pertinent medical history….””