Every finding on record at Aaa Home Health Agency,Inc

Complaint Survey #LA62905

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the nurse did not remove the adaptic dressing which was ordered to remain in place during wound care for 1 (Patient #1) of 5 sampled patients reviewed for wound care per physician orders. Findings: Review of Patient #1’s Record revealed Patient #1 was admitted to the agency on 02/11/2021. Further review revealed Patient #1 was admitted with, in part, a posterior left heel stage IV pressure ulcer. Review of Patient #1’s Discharge Summary for General Surgery dated 11/16/2021 revealed diagnosis of stage IV pressure ulcer of the left heel and subacute osteomyelitis of the left foot. Review of Patient #1’ Discharge Orders revealed discharge procedure orders included, in part, the skilled nurse was to remove the dressing in 72 hours, and leave the adaptic dressing (oil based dressing) dressing in the wound, and pack the wound with saline moistened gauze. Review of Patient #1’s Physician Orders dated 11/19/2021 revealed, in part, clean left heel wound with normal saline or Vashe (wound cleanser), apply gentian violet (substance used to protect intact skin from breakdown) to periwound (intact skin around the wound), reapply gentian violet as fading, leave the adaptic dressing in the wound, pack the wound with saline moistened gauze, cover the wound with an ABD (thick absorbent dressing) pad, wrap with cast padding, and secure with coban (long dressing used to secure other dressings) without compression. Review of Patient #1’s Nursing Visit Note Report dated 11/19/2021 revealed Patient #1’s wound had no change in status, wound with 75-100% granulation tissue, and faint odor was assessed by S2LPN (Licensed Practical Nurse). Review of Patient #1’s Nursing Visit Note Report dated 11/22/2021 revealed, in part, Patient #1 stated he had nurse visit on Friday and the adaptic dressing was supposed to be left in place from bone removal last week. Patient #1 stated it came out of the wound during the dressing change. Review of Patient #1’s Complaint Form dated 11/22/2021 revealed, in part, Patient #1 called the agency to ask S2LPN, nurse which provided services on 11/19/2021, not be sent back to his home to perform visits. Patient #1 stated S2LPN had removed and threw away his recently placed skin graft. Further review of findings after investigation revealed the adaptic dressing was removed/dislodged with the old dressing, and S2LPN did not call and notify the wound care physician of the dislodgement. Review of Wound Care Progress Note dated 03/16/2022 revealed amniotic band was previously tried but inadvertently removed soon after placement. Review of Patient #1’s Hospital Record revealed Patient #1 was discharged post procedure on 03/31/2022. Review revealed Patient #1 had a debridement with skin graft application to left heel ulcer. Further review revealed orders included the skilled nurse was to change the wound vacuum dressing three times per week as follows: leave adaptic dressing under sponge intact with changes, remove old dressing, cleanse/irrigate the wound with normal saline or wound cleanser, protect the periwound tissue with the wound vacuum drape, fill the wound bed with black granufoam, and wound vacuum setting at 75mmHg continuous. Review of Patient #1’s Physician Order dated 04/01/2022 revealed ordered included the skilled nurse to cleanse wound to the left heel with normal saline, prepare periwound area with vacuum drape, leave adaptic dressing under sponge intact with changes, fill entire cavity with black foam, cover with transparent drape and apply tubing, apply negative pressure device at 75mmHg continuous. Review of Patient #1’s Nursing Visit Note Report dated 04/01/2022, performed by S3RN (Registered Nurse), revealed a left heel suspected deep tissue injury with 50-75% epithelization assessed, with a small amount of purulent drainage and faint odor. Further review revealed no documented evidence of the physician having been notified of the drainage and/or the faint odor. Review of Patient #1’s Nursing Visit Note Report dated 04/04/2022, performed by S3RN (Registered Nurse), revealed a left heel suspected deep tissue injury with less than 25% epithelization assessed with a small amount of purulent drainage and faint odor. Further review revealed no documented evidence of the physician having been notified of the drainage and/or the faint odor. Review of Patient #1’s Nursing Visit Note Report dated 04/05/2022, performed by S3RN (Registered Nurse), revealed a left heel suspected deep tissue injury with 75-100% granulation, moderate amount of purulent drainage and faint odor. Further review revealed no documented evidence of the physician having been notified of the drainage and/or the faint odor. Review of Patient #1’s Complaint Report revealed S1Administrator/DON (Director of Nursing) received a call from Patient #1 on 04/06/2022. Patient #1 stated he went to the wound care clinic and was informed by the physician his skin graft was no longer in place. Review of Patient #1’s Wound Care Progress Note dated 04/13/2022 revealed stage IV pressure ulcer of left heel with good granulation in base of wound with no skin substitute appreciated in the wound. Review revealed Patient #1 reported home health removed "smelly tissue" at first wound vaccum change. Further review revealed photos provided by Patient #1 revealed skin substitute adherent to adaptic dressing that was removed from the wound. Review revealed sutures were completely displaced and not in medial wound as previously replaced. In an interview on 05/11/2022 at 12:39pm, S3RN stated she saw Patient #1 the next day after he was released from the hospital and the adaptic dressing had come off with the sponge. S3RN stated the adaptic dressing was never thrown away, and it was applied back to the wound. S3RN stated she did not notify the physician of the adaptic dressing having been removed. S3RN stated on 04/04/2022 the adaptic dressing came off with the sponge again and she replaced it again, and confirmed she did not notify the physician. S3RN further stated on the 04/05/2022 visit the wound had a little smell and Patient #1 wanted it cleaned out so she cleaned the adaptic dressing, and the wound, and dressed the wound back. S3RN stated the graft was still present in the wound on 04/05/2022, and when questioned why the documentation had 75-100% granulation tissue, she was unable to explain the inconsistency if the graft was still in place how granulation tissue would be visible. S3RN stated she had taken pictures on Patient #1’s phone of the wound. S3RN stated on 04/05/2022 Patient #1 did have some slough to the wound which she removed due to the odor while doing the treatment. S3RN stated it was possible part of the slough may have been the skin graft. S3RN stated she did not remember if she sent a notification of adaptic dressing coming off the physician. In an interview on 05/11/2022 at 11:51am, Patient #1’s wound care physician, stated in November 2021 Patient #1 had a procedure which removed part of the necrotic calcaneal bone which left a large open area which was filled by a product called a amnioband, a product which contained crushed amniotic tissues, she stated they used the product to form a “ball” which was used to fill the void left after the surgery. Patient #1’s physician stated the second procedure at the end of March 2022 was an actual skin graft which was sutured in place all around the wound and some in the center of the graft. Patient #1’s physician stated after both procedures the agency and the patient was given strict orders to not remove the adaptic dressing. Patient #1’s physician stated if the adaptic dressing had been left in place in both incidents it would have preserved the amnioband and skin graft. Patient #1’s physician stated Patient #1 was not without fault, because Patient #1 was not offloading the left heel as he had been walking on the left foot. Patient #1’s physician stated she was never notified of Patient #1’s skin graft being removed, odor, or anything else with the wound until he was seen for routine care at his next wound care clinic visit. Patient #1’s physician stated one of her nurses were shown a picture the field nurse had taken on Patient #1’s phone, of the adaptic dressing and the wound, and the graft prior to cleaning was still viable, and if the adaptic dressing had been left in place the skin graft may have taken. Patient #1’s physician stated for both procedures the nurses not leaving the adaptic dressing on the wound delayed wound healing.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to: 1. Notify Patient #4’s Physician of the assessment of a new wound for 1 of 4 sampled patients (Patient #4); and 2. Ensure Patient #4’s Physician had received notification of increased pain and ensure follow-up was received for 1 of 4 sampled patients (Patient #4) reviewed for wounds in a total sample of 9. Findings: Review of Patient #4’s Home Health Certification and Plan of Care for certification period of 02/25/2022 to 04/25/2022 revealed Patient #4 was admitted on 02/25/2022 with left foot diabetic foot ulcer. Review of Patient #4’s Hospital Discharge paperwork dated 02/24/2022 revealed Patient #4 had dry eschar (dry nonviable tissue) to the medial (inside) aspect of the 2nd toes and distal (tip) aspect of the 3rd toe of the left foot. Review of Patient #4’s Physician Order dated 03/17/2022 revealed an order for an extra skilled nurse visit on 03/18/2022 due to a new wound. Review of Patient #4’s Nursing Visit Note Report dated 03/18/2022 revealed Patient #4 had a small wound that had developed on the left foot 3rd toe lateral side, caregiver stated she had noticed this new wound recently. Further review revealed no documented evidence and the agency presented no documented evidence of the nurse having notified the physician of the new wound or the assessment of the new wound. Review of Patient #4’s Nursing Visit Note Report dated 04/11/2022 revealed Patient #4 reported a pain level of 6/10 (scale of 0 being no pain and 10 being the worst pain imaginable) and requesting pain medication to be ordered. Further review revealed a SBAR (Situation, Background, Assessment, and Recommendation) fax was sent to Patient #4’s Physician on 04/11/2022. Review of Patient #4’s record revealed no documented evidence and the agency presented no documented evidence of the agency ensuring the physician received the above mentioned fax notification of increased pain level of 6/10 from 04/11/2022 to 04/13/2022. In an interview on 04/22/2022 at 9:07am, S4LPN (Licensed Practical Nurse) stated she sent the SBAR on 04/11/2022 and she did not follow-up on the SBAR and was notified of the physician responding back on 04/13/2022. In an interview on 04/22/2022 at 9:30am, S3RN (Registered Nurse) stated she did not think follow-up for the new wound on 03/18/2022 was completed. S3RN stated with any new condition if she did not feel like it was crucial she would send a SBAR instead of phone call. S3RN stated she did not remember any communication back from the physician on the SBAR on 04/11/2022. In an interview on 04/22/2022 at 9:45am, S2LPN/Scheduler stated the agency prints out SBARs and places in folder and as responses come in will attach together. S2LPN/Scheduler stated the agency will check at end of week if response not received, but agency was not checking daily. In an interview on 04/22/2022 at 2:31pm, S1Administrator/DON (Director of Nursing) stated the agency had no documentation to present of Patient #4’s physician having been notified of the assessment of the new wound on 03/18/2022, nor the follow-up of the SBAR sent on 04/11/2022 until 04/13/2022 when the physician notified the agency Patient #4 had been admitted to the hospital. S1Administrator/DON further stated the agency should have followed up on both situations in a timely manner.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to clarify Patient #4’s wound care orders, which contained a solution the patient was allergic to, prior to the caregiver administering the treatment for 1 of 4 sampled patients (Patient #4) reviewed for wound care in a total sample of 9. Findings: Review of Patient #4’s Hospital Discharge and Referral to Home Health dated 02/24/2022 revealed, in part, Patient #4 was documented as having an allergy to Iodine and Iodine containing products. Review of Patient #4’s Physician Order dated 03/08/2022 revealed an order for a skilled nurse to perform/instruct/reinforce the following wound care to the caregiver: wash every 1-2 days, apply betadine (iodine containing solution, used to dry eschar) paint to eschars (dry nonviable tissue) to left 2nd and 3rd toes, weaving gauze between the toes and cover with dry, sterile dressing. Review of Patient #4’s Client Coordination Note Report dated 03/13/2022 revealed the skilled nurse received a message from Patient #4’s caregiver today regarding changes in the appearance of Patient #4’s wound related to white blotches and pain. Further review revealed Patient #4’s caregiver stated the patient was having a stinging pain which started after iodine started. Review revealed Patient #4 was to be seen the following day, and to go to the emergency room if the pain worsened or became unbearable. Review of Patient #4’s Record revealed no documented evidence of the agency having clarified the physician order for betadine, due to Patient #4’s iodine allergy, prior to Patient #4’s caregiver having performed the above mentioned treatment. Further review revealed no documented evidence of Patient #4’s physician having been notified of Patient #4’s pain and white blotches until the skilled nurse visit on 03/14/2022. In an interview on 04/22/2022 at 9:07am, S4LPN (Licensed Practical Nurse) stated Patient #4’s caregiver called her on 03/13/2022 about having pain and burning after the use of betadine, and he was allergic to betadine. S4LPN stated she spoke with S3RN (Registered Nurse) and was instructed to inform the patient if the pain worsened to go to the emergency room if not he would be seen the next day. In an interview on 04/22/2022 at 9:30am, S3RN stated she received the phone call from S4LPN about Patient #4 having a burning after the use of iodine. S3RN stated Patient #4’s caregiver was comfortable with waiting to see the nurse on 03/14/2022. In an interview on 04/22/2022 at 2:31pm, S1Administrator/DON (Director of Nursing) stated the agency did not identify the 03/08/2022 wound care treatment order included betadine, and that Patient #4 was allergic to iodine containing substances. S1Administrator/DON stated the agency should have caught this discrepancy and notified Patient #4’s physician and notified Patient #4’s caregiver not to administer the treatment until the order was clarified. S1Administrator/DON further stated the nurse should have also notified Patient #4’s physician of the new signs of white blotches and pain, and nurse should have made a home visit and assessed the patient.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, observation, and interview the agency failed to: 1) Ensure the nurse changed her gloves during wound care per agency’s Policy and Procedures for 1 of 1 patients observed for wound care (Patient #1); 2) Ensure the nurse changed her gloves between patient contact and touching other surfaces for 1 of 1 patients observed for wound care (Patient #1); 3) Ensure the nurse did not contaminate her clean wound care field which included her clean dressings, with her hair for 1 of 1 patients observed for wound care (Patient #1); 4) Ensure the nurse performed appropriate hand washing prior to starting wound care for 1 of 1 patients observed for wound care (Patient #1); and 5) Ensure the nurse maintained sterile technique during a sterile procedure for 1 of 1 patients observed for port flushing (Patient #3) in a total sample of 9 patients. Findings: Patient #1 Review of the agency’s Policy and Procedure for Hand Hygiene revealed, in part: -Staff to perform hand hygiene, in part: before direct contact with patients, before performing an aseptic task; if moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects; and at the conclusion of the visit after contact with a patient’s intact skin. -Change gloves during patient care if moving from a contaminated body site to a clean body site. Review of Patient #1’s Home Health Certification and Plan of Care for certification period 03/29/2022 to 05/27/2022 revealed, in part, the following wound care order: cleanse wound with normal saline, pat dry with gauze, apply calmoseptine to irritated areas around wound, lightly pack wound with saline moistened gauze, cover with abdominal pad and secure with tape daily, using clean technique, until healed. Observation on 04/20/2022 at 1:25pm, revealed S4LPN (Licensed Practical Nurse) did not wash her hands with soap and water prior to starting the wound care procedure on Patient #1’s right ischium stage 4 pressure ulcer. S4LPN used an alcohol based hand rub to clean her hands prior to starting wound care. Observation revealed S4LPN completed urinary perineal care for Patient #1 and did not change gloves and did not perform hand hygiene prior to removing dirty wound dressing. Further observation revealed S4LPN put on new gloves to clean the ischial wound and did not change gloves before packing the ischial wound. S4LPN then changed gloves and dressed the wound. S4LPN then, without changing gloves and without performing hand hygiene, touched the can of saline spray with dirty gloves and picked up wound care supplies. S4LPN was then observed reaching into Patient 1’s person back pack for wipes using the same gloved hands. Further observation revealed S4LPN’s hair touched the clean barrier and the clean wound care supplies during the entire wound care process. In an interview on 04/20/2022 at 3:10pm S1Administator/DON (Director of Nursing), which was present during the observation, stated she was aware of the breaks in infection control during Patient #1’s wound care performed by S4LPN. S1Administrator/DON further stated those breaks in infection control during Patient #1’s ischium stage 4 wound care should have never happened. In an interview on 04/22/2022 at 9:03am, S4LPN stated she should have been changing her gloves more often and performing hand hygiene more often throughout her wound care on Patient #1. Patient #3 Review of the agency’s Implanted Venous Access Port Procedure Guide revealed, in part: -Open the sterile dressing kit keeping the inside of the wrapper sterile so it can be used as a sterile filed. -Open the additional supply packages and allow the items to fall onto the sterile field, maintaining the sterility of the supplies. -Apply sterile gloves, and maintain sterility during procedure. Review of Patient #3’s Home Health Certification and Plan of Care for certification period 04/04/2022 to 06/02/2022 revealed, in part, the following order: nurse to access mediport every three months with 20-22 gauge Huber needle to maintain patency, using sterile technique cleanse mediport site with chlorapep, flush with normal saline10ml, followed by Heparin (used to prevent blood clots) 3-5ml. Observation on 04/20/2022 at 12:50pm, S3RN (Registered Nurse) prepped her area for her sterile field to complete the Mediport flush for Patient #3. Further observation revealed S3RN placed the Huber needle in unsterile packaging into the sterile field. Further observation revealed S3RN grabbed the shirt of Patient #3 with her right sterile gloved hand and then grab the Huber needle on the sterile field with the same sterile glove. In an interview on 04/20/2022 at 3:04pm, S1Administrartor/DON stated S3RN placed the Huber needle in the sterile field and broke infection control prior to performing the Mediport flush for Patient #3. In an interview on 04/22/2022 at 9:23am, S3RN stated she was aware of the breaks she made in infection control while performing Patient #3’s mediport flush. S3RN further stated she knew she should have dropped the Huber needle into the sterile field without the packaging and she should not have touched the shirt on Patient #3 because it broke sterile technique.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to: Ensure patients with physician’s orders for Home Health Aide (HHA) received HHA services as ordered for 2 of 2 sampled patients (Patient #7 and Patient #8); andEnsure a patient with orders for the Medical Social Worker (MSW) received MSW services as ordered for 1 of 4 sampled patients (Patient #8) reviewed for care and services per physician orders in a total sample of 9 patients. Findings: Patient #7 Review of Patient #7’s Referral dated 02/27/2022 revealed Patient #7’s physician ordered, in part, Home Health Aide (HHA) services. Review of Patient #7’s record revealed no documented evidence of the HHA having ever provided services. Further review revealed no documented evidence of the physician having been notified of the agency not providing HHA services or approval of Patient #7 not being provided HHA services. In an interview on 04/22/2022 at 2:15pm, S1Administrator/DON (Director of Nursing) stated the agency had no documented evidence of Patient #7’s physician having been notified of the agency not providing HHA services. Patient #8 Review of Patient #8’s Referral dated 10/06/2021 revealed Patient #8’s physician ordered, in part, Medical Social Worker (MSW) and HHA services. Review of Patient #8’s record revealed no documented evidence of the HHA and/or MSW having ever provided services. Further review revealed no documented evidence of the physician having been notified of the agency not providing MSW and/or HHA services or approval of Patient #7 not being provided HHA and MSW services. In an interview on 04/22/2022 at 2:20pm, S1Administrator/DON stated the agency had no documented evidence of Patient #8’s physician having been notified of the agency not providing HHA services. S1Adminsitrator/DON further stated the MSW was not captured on the clinical intake and was an oversight; therefore the MSW was not sent to see the patient.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a registered nurse (RN) assessed a wound after a change in wound status prior to delegating wound care to the licensed practical nurse (LPN) for 1 of 4 sampled patients (Patient #4) reviewed for wound care in a total sample of 9. Findings: Review of the State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses Wound Care Management revealed in accord with the Law Governing the Practice of Nursing (RS 37:913(14) the registered nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the Board's rules on delegation (LAC 46:XLVII.3703.). The registered nurse retains the accountability for the total nursing care of the individual. The registered nurse may delegate to a licensed practical nurse wound care interventions in any situation when the registered nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Furthermore, the patient's medical and nursing orders are not subject to continuous change or complex modification, appropriate RN supervision is available. Review of Patient #4’s Home Health Certification and Plan of Care for certification period of 02/25/2022 to 04/25/2022 revealed Patient #4 was admitted with Diabetic Foot Ulcer and Cellulitis of the left lower extremity. Review of Patient #4’s Client Coordination Note Report dated 03/13/2022 revealed the skilled nurse received a message from Patient #4’s caregiver today regarding Patient #4’s wound with white blotches and pain. Review of Patient #4’s Nurse Visit Note Report dated 03/14/2022 revealed S4LPN assessed Patient #4’s new wound symptoms on 03/24/2022. Further review revealed no documented evidence and the agency presented no documented evidence of the registered nurse having assessed Patient #4’s new wound symptoms prior to delegating wound care to the LPN. In an interview on 04/22/2022 at 9:07am, S4LPN (Licensed Practical Nurse) stated Patient #4’s caregiver called her on 03/13/2022 about having pain and burning after the use of betadine, and he was allergic to betadine. S4LPN stated she spoke with S3RN (Registered Nurse) and was instructed to inform the patient if the pain worsened to go to the emergency room if not he would be seen the next day. In an interview on 04/22/2022 at 2:31pm, S1Administrator/DON (Director of Nursing) stated the nurse should have went out and assessed the patient, and because there was a change in the status of the wound a RN should have reassessed the wound prior to the LPN providing care again to the wound.