Every finding on record at Adaptive Nursing and Healthcare Services, LLC

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Registered Nurse (RN) failed to ensure the comprehensive assessment included an accurate and complete medication list for 1 of 1 home visit observations (#2) and 1 of 3 records reviewed (#5), in a total sample of 5 records. Findings include: 1. An agency job description titled "Adaptive Nursing and Healthcare Services. Job Description. Position: ... Case Manager ...," revised 4/8/21, stated " ... Responsibilities / Essential Functions: ... 2. Performs and initial and ongoing client assessments based on Agency policy and standards of practice to ensure effective and appropriate home care services ...." 2. A home visit observation was conducted on 6/10/21 at 3:58 PM with Patient #2 (start of care 5/14/21) and RN #1. During the home visit, a bottle of Triad Hydrophilic Wound cream was observed in the patient's bathroom. RN #1 was observed performing a medication reconciliation with the patient's current medications. The nurse failed to add the Triad Hydrophilic Wound cream to the patient's medication list. A second home visit observation was conducted on 6/10/21 at 6:47 PM with Patient #2 and HHA #1. During the visit, HHA #1 was observed assisting Patient #2 with a shower. After the patient completed their shower and dried with a towel, Patient #2 handed the home health aide a bottle of Triad Hydrophilic Wound Dressing cream, and HHA #1 applied a small amount to the patient's inner buttocks using gloved hands. HHA #1 reported the patient had been using the medication for the past week. The clinical record of Patient #2 was reviewed on 6/10/21 and indicated patient diagnoses including but not limited to chronic kidney disease, urinary retention, anxiety disorder, major depressive disorder, Bipolar disorder, and Essential hypertension (elevated blood pressure with no known cause), and mixed incontinence (inability to control bowel and bladder function). The record included a medication list, reviewed and signed by RN #1 on 5/16/21, which failed to evidence Triad Hydrophilic Wound dressing as an active medication. 3. The clinical record of Patient #5 was reviewed on 6/11/21, and indicated a start of care of 8/30/2020, with patient diagnoses including but not limited to vascular dementia, essential hypertension, chronic atrial fibrillation (irregular heart rhythm), bed confinement status, and mixed incontinence. The clinical record included a comprehensive assessment conducted on 5/26/21 by RN #2. The comprehensive assessment contained a medication list, signed and reviewed by RN #2 on 5/27/21, which included the medications " ... Nystatin [given to treat fungal infections of the skin] 100,000 units/g [gram] topical cream, take 1 application once a day ... as needed (prn) for Rash/anti-fungal ... hydrocortisone [topical steroid given to decrease itch and inflammation caused from a variety of skin conditions] 2.5% topical cream, take 1 application once a day ... as needed (prn) for Itch ...." The medication list failed to evidence clear and concise directions on where to apply the topical (applied to the skin) medications. 4. An interview was conducted on 6/14/21 at 10:11 AM with the administrator and alternate administrator. During the interview, the Administrator indicated the medication list should include all medications the patient was currently using, including topical medications. 17-14-1(a)(1)(B)