Every finding on record at A Lovng Touch LLC

A complaint survey, prompted by #CO102254 was completed on 10/31/23. One deficiency was cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure services and treatments were provided in accordance with physician's orders for 3 of 10 patients reviewed receiving wound care (Patients #6, #8 and #9). Findings include: 1. The clinical record for Patient #9 was reviewed on 10/31/23. The plan of care (POC) for the certification periods dated 8/26/23 to 10/24/23 and 10/25/23 to 12/23/23, revealed a start of care date of 6/27/23; diagnoses included bronchopulmonary dysplasia originating in the perinatal period, chronic respiratory failure with hypoxia, other specified congenital malformations of respiratory system and other specific congenital malformations of brain. POC orders included skilled nursing (SN) visits 24 hours per day 7 days per week for ventilator management, medication administration, gastrointestinal tube (g-tube) feedings, vital signs, assessment and monitoring. POC orders included physical therapy (PT) visits twice a week, occupational therapy (OT) visits twice a week and speech therapy (ST) visits three times a week. a) The agency failed to ensure SN provided care and treatment as ordered by the physician due to missing visit notes for Patient #9. Review of the visit schedule for the dates of 8/26/23 to 10/29/23 revealed the following 12 days and shifts did not have any SN visit notes; 10/3/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/4/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/6/23 evening shift from 9:00 p.m. to 8:00 a.m. 10/8/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/9/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/10/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/11/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/15/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/17/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/23/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/26/23 evening shift from 4:00 p.m. to 8:00 a.m. 10/29/23 evening shift from 4:00 p.m. to 8:00 a.m. Due to the lack of SN visit notes during these shifts it was unknown if the SN provided care and treatment as ordered by the physician. 2. Similar findings were found for Patients #6 and #8. 3. During an interview on 10/31/23 at 1:00 p.m., the administrator and alternate administrator stated SN visit notes should be put into the Electronic Medical Record (EMR) system within 48 to 72 hours. When asked, the administrator who was also the evening shift nurse for Patient #9, stated she had the notes written at home but had not yet time to enter them into the system. The alternate administrator stated that nurses who did not enter the SN visit notes into the EMR system in a timely manner would receive a text message reminding them to do so. The administrator and alternate administrator both confirmed the administrator had received those texts regarding the missing SN visit notes and had not been able to enter them into the EMR system.