Every finding on record at Acaria Inc

A recertification survey was completed on 8/30/23. Three deficiencies were 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 were provided in accordance with physician's orders for 1 of 5 active patients reviewed who received wound care (Patient #3). Findings include: AGENCY POLICY According to an agency policy revised March 2019 and titled, Plan of Care - CMS [Centers for Medicare] #485 and Physician Orders, (read in pertinent parts): "Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care." "Care and services provided will be provided according to physician orders. Orders are current and updated." 1. The clinical record for Patient #3 was reviewed on 8/28/23. The plan of care (POC) for the certification period dated 7/3/23 to 8/31/23 revealed a start of care date of 7/3/23; diagnosis included left ankle wound, hypertension, glaucoma, legal blindness, pyoderma gangrenosum, ulcerative colitis, atrial fibrillation and coronary artery stent placement. Plan of care orders included skilled nursing (SN) three times a week for eight weeks and two as needed (PRN) visits for assessment, pain management, medication management, and oxygen saturation monitoring PRN and wound care to the left ankle three times a week. a) The agency failed to ensure wound care was completed as ordered. Further review of Patient #3's POC revealed the wound care order for Patient #3's left ankle was as follows: clean the wound with normal saline (NS), apply medihoney gel (a wound care product with antibacterial and antiinflammatory properties) to the wound bed, and cover with a border foam dressing. Review of Patient #3's supplemental orders revealed a wound care order from a wound care clinic from 7/10/23 which ordered wound care to Patient #3's left ankle wound be completed three days a week as followed: apply medihoney gel and calcium alginate (a type of wound care dressing used to promote wound repair typically used with moderate to heavily draining wounds) to the wound, cover the wound with Mepilex (a type of border foam dressing), and apply tubi-grip (provides consistent and even compression) over the wound care dressing. Review of Patient #3's SN notes revealed on 7/12/23, 7/14/23, 7/20/23, 7/23/23, 7/26/23, and 8/2/23 RN #4 documented she completed the following wound care to Patient #3's left ankle: cleansed the wound with NS, applied medihoney gel to the wound bed, and covered the wound with a border foam dressing. The intervention for Patient #3's left ankle on these six SN notes was as follows: clean wound with NS, apply medihoney gel to the wound bed and cover with a border foam dressing effective 7/3/23. RN #4 failed six times to apply calcium alginate to the wound after the medihoney and failed to apply tubigrip over Patient #3's left ankle wound as ordered on 7/10/23. Review of Patient #3's SN notes revealed on 7/18/23 and 7/31/23 the director of nursing (DON) documented she completed the following wound care to Patient #3's left ankle: cleansed the wound with NS, applied medihoney gel to the wound bed and covered with border foam dressing. The intervention for Patient #3's left ankle on these two SN notes was as follows: clean wound with NS, apply medihoney gel to the wound bed and cover with a border foam dressing effective 7/3/23. The DON failed two times to apply calcium alginate to the wound after the medihoney and failed to apply tubigrip over Patient #3's left ankle wound as ordered on 7/10/23. During an interview on 8/30/23 at 12:28 p.m., RN #4 stated she and the DON both managed Patient #3's care. RN #4 stated when a patient received a new order for wound care, the RN case manager was responsible for updating the interventions in the agency's electronic medical record (EMR) to alert all SNs who worked with the patient about the new order. RN #4 stated she was responsible for updating Patient #3's wound care interventions in the agency's EMR. RN #4 stated she forgot to update Patient #3's wound care intervention in the EMR after the agency received the 7/10/23 supplemental order from Patient #3's wound care clinic. RN #4 stated she did not apply the calcium alginate to Patient #3's left ankle wound during the six visits from 7/12/23 through 8/2/23 she provided Patient #3 wound care to his left ankle as the intervention failed to remind her of this addition to Patient #3's left ankle wound care. RN #4 stated she did apply the tubigrip over Patient #3's left ankle wound but forgot to document applying the tubigrip. During an interview on 8/30/23 at 1:55 p.m., the DON stated prior to each wound care visit she would reference a patient's wound care interventions in the EMR and used those interventions to guide what treatment she provided the patient. The DON acknowledged she did not apply calcium alginate to Patient #3's left ankle wound and she did not apply tubigrip over Patient #3's left ankle as ordered on 7/18/23 or 7/31/23. The DON stated the failure of not updating Patient #3's wound care interventions in the agency's EMR when the agency received new wound care orders on 7/10/23 led to her noncompliance with Patient #3's ordered wound care.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure communication occurred with all physicians involved in the patient's care for clarification of conflicting wound care orders for 1 of 5 active patient records reviewed who received wound care (Patient #3). Findings include: AGENCY POLICY According to an agency policy revised March 2019 and titled, Plan of Care - CMS [Centers for Medicare] #485 and Physician Orders, (read in pertinent parts): "Orders are verified when: -There are questions or discrepancies with orders." "The plan of care may include orders for treatment or services received from physicians other than the responsible physician. Such orders must be approved by the responsible physician and incorporated into an updated plan of care. In the event of a change in patient condition or needs that suggest outcomes are not being achieved and/or that the patient's plan of care should be altered, the Agency will notify both the responsible physician and the physician(s) associated with the relevant aspect of care." 1.The clinical record for Patient #3 was reviewed on 8/28/23. The plan of care (POC) for the certification period dated 7/3/23 to 8/31/23 revealed a start of care date of 7/3/23; diagnosis included left ankle wound, hypertension, glaucoma, legal blindness, pyoderma gangrenosum, ulcerative colitis, atrial fibrillation and coronary artery stent placement. Plan of care orders included skilled nursing (SN) three times a week for eight weeks and two as needed (PRN) visits for assessment, pain management, medication management, and oxygen saturation monitoring PRN and wound care to the left ankle three times a week. a) The agency failed to ensure care coordination occurred among Patient #3's physician's when the agency received conflicting wound care orders for Patient #3's left ankle wound. Review of Patient #3's clinical record revealed an unsigned verbal order documented by RN #4 on 8/10/23 effective 8/9/23 from Patient #3's dermatologist who ordered the following wound care three times a week for two weeks to Patient #3's left ankle wound: clean with normal saline (NS), apply Clobetasol Propionate (a corticosteroid used to treat skin conditions) to the wound bed and cover with a border foam dressing. Review of Patient #3's clinical record revealed a supplemental order from the wound care clinic Patient #3's received care from dated 8/11/23 and faxed to the agency on 8/11/12 at 11:23 a.m. which ordered the following wound care be completed three times a week for Patient #3's left ankle wound: apply calcium alginate (a type of wound care dressing used to promote wound repair typically used with moderate to heavily draining wounds) to the wound and then cover the wound with Mepilex (a type of border foam dressing), and apply tubi-grip (provides consistent and even compression) over the wound care dressing. Review of SN notes revealed on 8/9/23, RN #4 documented Patient #3 saw his dermatologist on 8/7/23 and the dermatologist ordered a Clobetasol cream be applied to Patient #3's left ankle wound. RN #4 documented she provided the following wound care to Patient #3's left ankle wound: removed the old dressing, cleaned the wound with NS, applied Clobetasol cream to the wound bed, and covered the wound with border foam dressing. RN #4 documented Patient #3 had an appointment at the wound care clinic on 8/4/23 and received a steroid injection to his left ankle and had a follow up visit with the wound care clinic on 8/11/23. RN #4 documented she updated the director of nursing (DON) on Patient #3's new left ankle wound care orders. RN #4 also documented she left a voicemail with Patient #3's PCP regarding Patient #3's skipped Metoprolol (medicine used to treat high blood pressure, chest pain, and heart failure) and heart palpitations. Review of a SN note on 8/11/23 revealed RN #4 documented Patient #3 had a missed visit due to Patient #3 having an appointment at the wound care clinic where wound care was provided. Review of a SN note on 8/14/23 revealed the DON documented she asked Patient #3 if he wanted the wound care as ordered by his dermatologist on 8/9/23 or the wound care as ordered by the wound care clinic on 8/11/23. Patient #3 stated he wanted the DON to apply the Clobetasol cream as ordered by the dermatologist on 8/9/23. The DON documented she cleaned Patient #3's left ankle wound with NS, applied the Clobetasol Propionate to the wound bed and covered the wound with a border foam dressing. The DON documented she called Patient #3's wound care clinic to receive clarification on the wound care order the agency received on 8/11/23 for Patient #3. There was no documented evidence the DON attempted to contact Patient #3's dermatologist or PCP to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of a SN note on 8/16/23 revealed RN #4 documented the she provided the following wound care to Patient #3's left ankle wound per Patient #3's request: removed the old dressing, cleaned the wound with NS, applied Clobetasol cream to the wound bed, and covered the wound with border foam dressing. RN #4 documented the agency had not received a return call back from Patient #3's wound care clinic regarding clarification on the two conflicting orders for Patient #3's left ankle wound. There was no documented evidence RN #4 attempted to contact Patient #3's dermatologist or PCP or reattempted to contact Patient #3's wound care clinic to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of a SN note on 8/18/23 revealed RN #4 documented she provided the following wound care to Patient #3's left ankle wound: cleaned the wound with NS, applied Clobetasol cream to the wound bed, covered with border foam dressing. RN #4 documented Patient #3 had a dermatology appointment on 8/21/23 and RN #4 informed the DON of this appointment. There was no documented evidence RN #4 attempted to contact Patient #3's dermatologist or PCP or reattempted to contact Patient #3's wound care clinic to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of a SN note on 8/21/23 revealed the DON documented she provided the following wound care to Patient #3's left ankle wound: cleaned the wound with NS, applied Clobetasol to the wound bed, and covered the wound with border foam dressing. The DON documented she conferenced with RN #4 regarding the wound care provided to Patient #3's left ankle. There was no documented evidence the DON attempted to contact Patient #3's dermatologist or PCP or reattempted to contact Patient #3's wound care clinic to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of a SN note on 8/23/23 revealed RN #4 documented Patient #3 had a missed visit due to Patient #3 having a dermatology appointment and wound care provided at the appointment. There was no documented evidence RN #4 attempted to contact Patient #3's dermatologist or PCP or reattempted to contact Patient #3's wound care clinic to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of a SN note on 8/25/23 revealed RN #4 documented Patient #3 had a missed visit due to Patient #3 having a wound care clinic appointment and wound care provided at the appointment. There was no documented evidence RN #4 attempted to contact Patient #3's dermatologist or PCP or reattempted to contact Patient #3's wound care clinic to receive clarification regarding the two conflicting wound care orders received for Patient #3's left ankle wound. Review of Patient #3's inter-office communication notes failed to show either the DON or RN #4 attempted to contact Patient #3's wound care clinic a second time for clarification regarding Patient #3's conflicting wound care orders from his dermatologist on 8/9/23 and from the wound care clinic on 8/11/23. The inter-office communication notes also failed to show either the DON or RN #4 attempted to contact Patient #3's dermatologist or PCP for clarification regarding the conflicting wound care orders. During an interview on 8/30/23 at 12:33 p.m., RN #4 stated she was aware of the two conflicting wound care orders for Patient #3. RN #4 stated the DON informed RN #4 the DON had called the wound care clinic for clarification. When RN #4 treated Patient #3 on 8/16/23 she stated neither RN #4 or the DON had heard back from Patient #3's wound care clinic so she asked Patient #3 which order he wanted her to follow and she completed Patient #3's wound care per the order Patient #3 requested be followed. RN #4 stated she thought the wound care clinic had been called twice for clarification of the conflicting orders and did not think it appropriate to call a third time, but acknowledged upon reviewing Patient #3's SN notes from 08/9/23 to 8/25/23 and inter-office communication notes only one phone call to the wound care clinic was documented. RN #4 stated she did not call Patient #3's dermatologist for clarification of orders as she thought the DON had called the dermatologist. RN #4 stated she did not call Patient #3's PCP for clarification on the two conflicting left ankle wound care orders as the PCP was not the doctor who prescribed either order. During an interview on 8/30/23 at 1:59 p.m., the DON stated when she provided Patient #3 wound care to his left ankle on 8/14/23 she was aware of both the 8/9/23 order from Patient #3's dermatologist and the 8/11/23 order from the wound care clinic. The DON stated she asked the patient which order he wanted the DON to follow and she completed the wound care per the order Patient #3 chose. The DON stated she left a voice message for the RN from the wound care clinic who sent the 8/11/23 order for Patient #3's left ankle wound care. In the voice message the DON informed the wound care clinic RN of the order from Patient #3's dermatologist on 8/9/23 and asked for clarification as on 8/11/23 the wound care clinic provided the agency different orders for Patient #3's left ankle wound care. The DON stated the wound care clinic never returned the DON's call to clarify Patient #3's wound care orders. The DON stated she did not attempt to call Patient #3's dermatologist as she was not aware of who Patient #3's dermatologist was and stated she informed RN #4 she did not have the number for Patient #3's dermatologist. The DON acknowledged the 8/9/23 verbal order written by RN #4 had a dermatologist's physician assistant (PA) name listed on the order, but she did not think to use this information to assist her to contact Patient #3's dermatologist. The DON stated she did not attempt to contact Patient #3's PCP to receive clarification on which wound care order the agency should follow for wound care as she had contacted the wound care clinic. The DON acknowledged the agency failed to care coordinate with all physicians involved in Patient #3's care. During an interview on 8/30/23 at 3:08 p.m., the administrator stated some patients have many doctors involved in their care and it can lead to confusing situations. The administrator stated if a patient received two conflicting orders, the expectation was any SN who provided care to the patient would explain to the patient the SN was to follow the last order received for the patient while attempting to contact the physicians who provided the conflicting orders and/or the patient's PCP to receive clarification on what order the SN was to follow. Additionally, the administrator stated if the patient refused to have the SN follow the last order, the SN should document the refusal and contact the PCP and/or the ordering physician regarding the refusal. The administrator acknowledged the agency failed to have care coordination among all physicians caring for Patient #3 to receive clarification on which wound care order the SN should have followed for Patient #3's left ankle wound.

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 interview and record review, the agency failed to coordinate care delivery between internal care providers in the coordination of care activities in order to meet the needs of the patient for 1 of 5 active patients reviewed receiving wound care (Patient #11). Findings include: AGENCY POLICY According to the agency's policy titled, "Coordination of Patient Care" dated March 2019 (read in pertinent parts): "Coordination of Agency's internal resources includes: Assuring all involved staff members are aware of the patient's plan of care; Limiting the number of staff per discipline who provide care to a patient, when possible." 1. The clinical record for Patient #11 was reviewed on 8/29/23. The plan of care (POC) for the certification period dated 7/18/23 to 9/15/23 revealed a start of care date of 5/19/23; diagnoses included venous insufficiency (chronic), unspecified wound left lower leg, postthrombotic syndrome localized swelling unspecified lower limb, essential hypertension and long term use of anticoagulants. POC orders included skilled nursing (SN) three times a week for 9 weeks, and two as needed (PRN) visits for wound care to lower left extremity three times a week, obtain international normalized ratio (INR) every 4 weeks, assessment, pain management, medication management, oxygen saturation monitoring. a) The agency failed to coordinate patient care between internal care providers (RN #4 and DON), to ensure collaboration of care and services to meet the patient's needs. Further review of Patient #11's POC revealed the wound care order for Patient #11's left leg wound was as follows: cleanse wound with normal saline (NS), apply adaptic (a primary dressing made of knitted cellulose fabric designed to protect the wound while preventing the dressing from adhering to the wound) to wound bed, calcium alginate (a type of wound care dressing used to promote wound repair typically used with moderate to heavily draining wounds), cover with 4x4 gauze, secure with 2-layer compression wrap from base of toes to below knee. Review of Patient #11's supplemental orders revealed a wound care order from the primary care physician from 7/21/23 which ordered the following wound care to Patient #11's left medial lower leg wound to be completed three days a week: cleanse wound with NS, apply adaptic to wound bed, calcium alginate, cover with 4x4 gauze, secure with 2-layer compression wrap from base of toes to below knee. Review of Patient #11's SN notes revealed on 7/23/23 and 7/26/23 RN #4 documented she completed the following wound care to Patient #11's lower left leg (LLE) wounds and left medial leg wound: cleaned wound with NS, apply adaptic to wound bed, calcium alginate, cover with 4x4 gauze, secure with 2-layer compression wrap from base of toes to below knee. Furthermore on 7/23/23, RN #4 noted the wound measurements for the wounds were as follows: left lower leg upper wound was length (L) 1.9 centimeters (cm), width (W) 3.0 cm, and depth (D) 0.2 cm; left lower leg lower wound was L 1.4 cm, W 2.5 cm, and D 0.2 cm; left medial leg wound was L 0.3 cm, W 0.3 cm, and D was 0.2 cm. Review of Patient #11's SN notes revealed on 7/28/23 the DON documented she completed the following wound care on Patient #11's wounds: cleaned wound with NS, adaptic and calcium alginate applied to wound bed, covered with 4x4 gauze, wrapped leg with two layer compression. The DON did not mention which left leg wound she performed wound care for. There was no documentation regarding left lower upper wound, left lower leg lower wound or left medial leg wound. There was no documentation of coordination between the DON and RN #4 regarding which of the two wounds documented by RN #4 wound care was provided. Review of Patient #11's SN notes revealed on 7/31/23 the DON documented she completed the following wound care to Patient #11's wounds; SN cleaned 2 wounds on lower left extremity, applied adaptic and calcium alginate to wound bed, cover with 4x4 gauze, secured with 2-layer compression wrap from base to toes to below knee. Furthermore the DON documented the wound measurements for two wounds as L 1x1 cm, W 1x1 cm, and D as 0.1 cm for both wounds. The DON did not mention which wounds were measured, nor if wound care was performed for the left medial wound. There was no documentation of coordination between the DON and RN #4 regarding which of the two wounds documented by RN #4 wound care was provided. Review of Patient #11's SN notes revealed on 8/4/23 RN #4 documented the following wound care for Patient #11's LLE wounds and left medial leg wound: cleaned wound with NS applied calcium alginate to wound bed, covered with 4x4 gauze and secured with 2 layer compression from base of toes to below knee. Furthermore RN #4 documented the wound measurements as follows: lower left leg upper wound L 1.3 cm, W 1.4 cm, D 0.2 cm; lower left leg lower wound, L 1.0 cm, W 2.0 cm, D 0.3 cm; left medial leg wound L 1.1 cm, W 1.5 cm, D 0.2 cm. Review of Patient #11's SN notes revealed on 8/7/23 the DON documented the following wound care for Patient #11 to all open wounds: cleaned wound with NS, covered with adaptic, calcium alginate, applied over it, covered with 4x4 gauze, secured with 2 layer compression/kerlix and coban. Furthermore the DON documented that all four wounds measured L 1.0 cm, W 1.0 cm, D 0.1 cm. There was no documentation of coordination between the DON and RN #4 to the appearance of a fourth wound, which was previously not mentioned. Review of Patient #11's SN notes revealed on 8/9/23, 8/11/23, 8/15/23 and 8/18/23 RN #4 documented the following wound care for Patient #11's LLE wounds and left medial leg wound:cleaned wound with NS, applied calcium alginate to wound bed, covered with 4x4 gauze and secured with 2 layer compression from base of toes to below knee. There was no documentation of coordination between RN #4 and the DON regarding the fourth wound which was mentioned on 8/7/23, but was not mentioned during subsequent visits. During an interview on 8/30/23 at 11:58 a.m. RN #4 stated Patient #11 had two wounds on his left leg and another wound developed on the inner part of his left leg on 7/21/23. RN #4 went on to state Patient #11 had three wounds during the time period of 7/21/23 to 8/22/23, when two of the wounds healed. RN #4 stated she coordinated care with the DON in the record of Patient #11 and via text messages. RN #4 could not find documentation regarding the care coordination between herself and the DON regarding the different number of wounds tracked during the time period between 7/21/23 and 8/9/23. During an interview on 8/30/23 at 12:49 p.m., the DON stated Patient #11 had three wounds on 7/21/23. The DON went on to state that on 7/28 and 7/31 when she documented two wounds on Patient #11, she did not differentiate wounds between lateral medial or distal. The DON stated she provided care to all of Patient #11's visible wounds. The DON stated Patient #11 developed blisters on and off on his left leg that would appear as a wound one visit and be gone the next visit. The DON stated on 8/7/23 when she reported a fourth wound, she referenced the areas of weeping she noted at the visit for Patient #11 and she provided wound care to those four areas. The DON agreed she and RN #4 did not do a good job of communicating as to how to label the wounds on Patient #11 which made it unclear as to what was being treated. Record review failed to reveal any care coordination between RN #4 and the DON regarding the correct number of wounds on Patient #11's leg. Record review failed to show coordination regarding the fourth wound that the DON documented on 8/7/23 During an interview on 8/30/23 at 3:13 p.m., the administrator acknowledged the agency failed to have a consistent labeling system used to identify when a patient had multiple wounds on a single limb to ensure all SNs who provided care to the patient were aware of the number of wounds on the patient's limb which required treatment. The administrator stated the agency would come up with a system all SNs could use and ensure SNs improved their documentation to reduce this issue in the future.