Advanced Home Health of New Mexico

“Upon patient record review, 6 of 14 (Patient #2,3,6,7,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: The medication profile contains Dorzolamide opthalmic drops with no directive of which eye to place the eye drops. Corrected on site. Patient 3: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 6: The medication profile 12/13/24 contains an order for Nitro 0.4mg SL 1 tab every 5 minutes prn for chest pain. There is no max dose or what to do if chest pain is not controlled. Corrected on site. Patient 7: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 9: The medication profile contains Miralax ordered with no diluent. Corrected on site. Patient 10: The assisted living MAR has Brain Food powder that is not on the medication profile and Insulin Glargine ordered daily since 2/7/24,the hospice medication profile has the Insulin glargine ordered “1X as needed”.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: During home visit the daughter and son in law of patient inquired about her buttocks pain being so severe and not being able to get her comfortable. They asked if there was anything they could put on her buttocks to make it heal or more comfortable. The SN asked if it was just red or was it open? The Daughter stated it is open. The SN stated the last time she was there (SN visit 2/3/25) it was only red. There is no documentation on 2/3/25 of the buttocks or coccyx being red or presence of a pressure ulcer documented. The daughter states she has pictures that they took on 1/28/25 if we wanted to see. The picture taken on 1/28/25 was of an orange sized open area to patients buttocks. The patient has been seen twice weekly by the SN since admission 1/24/25. There is no documentation of the nurse assessing the patient’s buttocks. There are care plans for risk for skin breakdown though the buttocks wound was not noted by the nurse until today’s visit 2/5/25 once family informed the SN of it. There is no documentation of any preventative measures other than positioning of patient.”

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 4: Pt is ordered O2 continuously. The SN documented 1/24/25 “Pt found sitting at kitchen table not wearing O2, lethargic, O2 sat 83....RN found O2 tubing and put it on patient...family cannot convince patient to wear O2 at all times, patient is still smoking which is a fire hazard”. There is no evidence she educated the patient and family of this fire hazard or O2 safety this visit. There was evidence of the visit prior of education regarding fire related injuries. She then documented the caregiver “built a fire in the pellet stove and RN took patient to sit by the fire”. This is an unsafe action by the nurse. A patient wearing Oxygen cannot sit next to a fire place as a spark could catch patient on fire.”

“Upon patient record review, 2 of 14 (Patient #3,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: During home visit the daughter and son in law of patient inquired about her buttocks pain being so severe and not being able to get her comfortable. They asked if there was anything they could put on her buttocks to make it heal or more comfortable. The SN asked if it was just red or was it open? The Daughter stated it is open. The SN stated the last time she was there (SN visit 2/3/25) it was only red. There is no documentation on 2/3/25 of the buttocks or coccyx being red or presence of a pressure ulcer documented. The daughter states she has pictures that they took on 1/28/25 if we wanted to see. The picture taken on 1/28/25 was of an orange sized open area to patients buttocks. The patient has been seen twice weekly by the SN since admission 1/24/25. There is no documentation of the nurse assessing the patient’s buttocks. There are care plans for risk for skin breakdown though the buttocks wound was not noted by the nurse until today’s visit 2/5/25 once family informed the SN of it. There is no documentation of any preventative measures other than positioning of patient. There is no evidence of problem and goals. Patient 9: The POC 1/19/25 contains orders for Eliquis twice daily for DVT. There is no evidence of a risk for bleeding care plan with goals and interventions.”

“Upon patient record review, 7 of 14 (Patient #2,3,5,6,7,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The POC 8/16/24 contains Dorzolamide opthalmic drops with no directive of which eye to place the eye drops. Corrected on site. In addition, the SN educated the patient on 1/15/25 to use incentive spirometer for lung health. There is no order for an incentive spirometer to be used. Patient 3: The POC 1/24/25 contains an order for Miralax with no diluent. Corrected on site medication discontinued. Patient 5: The POC 1/9/25 contains wound care orders though does not state who is to perform the wound care. Patient 6: The POC 12/13/24 contains an order for Nitro 0.4mg SL 1 tab every 5 minutes prn for chest pain. There is not max dose or what to do if chest pain is not controlled. The wound care order on 1/7/25 does not state who is to perform the wound care. Patient 7: The POC 1/8/25 contains an order for Miralax with no diluent. Corrected on site. Patient 9: The POC 1/19/25 Contains Miralax ordered with no diluent. Corrected on site. A foley order written “SN to insert foley catheter 16french 10ml with no frequency. Patient 10: The POC 1/24/25 contains an order Lantus 100 units/ml SQ inject 27 units as needed. There is no directive of what the blood sugar needs to be in order to require the PRN insulin. The assisted living facility order is for the 27 units to be given daily since 2/7/24.”

“Upon patient record review, 3 of 14 (Patient #1,3,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: Upon home visit finding patient is wearing heel protector cuffs to bilateral feet. There was no order on the POC for them. Corrected on site. Patient 3: Upon home visit finding, patient has a specialty air flow mattress that was not included in the POC. Patient 10: Upon home visit finding, patient has a specialty air flow mattress that was not included in the POC.”

“Upon patient record review, 4 of 14 (Patient #1,3,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The POC 1/27/25 contains an order for SN 2 times per week for 12 weeks. The week of 1/26/25-2/1/25 the SN saw the patient once on 1/28/25. There is no missed visit documentation or evidence patient refused the visit. Patient 3:The POC 1/24/25 contains an order to remove sutures and apply steri strips to wound. The SN documented removing the sutures though did not document applying steri strips as ordered. Patient 7: The POC 1/8/25 has orders for SN twice weekly. The SN completed 3 visits the week of 1/12/25-1/18/25 on 1/14,1/15,1/17 with no evidence of any of the visits being prn or an order for increased visits. The SN identified a new pressure ulcer to the coccyx on 1/28/25 and documented “performed wound care to site” and on 1/30/25 and 2/3/25 wound care/dressing changed performed. There is no evidence of an order for wound care to the coccyx. Patient 8: The POC 1/11/25 contains an order for SN twice weekly, the week of 1/25/25-2/1/25 there was no second visit made and no missed visit documentation or evidence of refusal of visit.”

“Upon patient client record review, 5 of 14 (Patient #3,5,6,7,9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The SN documented on the comprehensive assessment “recommend daily cbg”. CBG is not an approved abbreviation the correct approved abbreviation in CBG capitalized according to agency policy Abbreviations and symbols 4-100.1. Patient 5: The SN documented on recertification 1/8/25, 1/2/25 and 1/5/25 “wound care per care plan”, there is no evidence the POC was followed. The aide documented their visits on 12/24/24 and 12/27/24 on a “post mortem” visit note. This pt is still living. Patient 6: The SN documented on 1/17/25 and 1/24/25 “wound dressing changed as ordered”. On 1/31/25 the SN documented “wound care performed”. There is no evidence the SN followed the POC. Patient 7: The SN documented on 1/8/25,1/15/25 “wound care per plan of care”. There is no evidence the POC was followed. The SN documented on 1/17/25 “sacral duodenum applied as ordered”. This note is not clear. Patient 9: The SN documented on 1/29/25 “RN attempted foley catheter insertion per order”. There is no evidence the SN followed the POC.”