Every finding on record at B.C.P., Inc.

A complaint validation survey was conducted at 1255 Kilauea Avenue, Hilo Hawaii 96720 on August 4, 2021 to investigate complaint # 8887 in the Aspen Complaint Tracking System (ACTS). The agency was found not to be in compliance with the Conditions for Coverage Part 484.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to develop an individualized plan of care for one patient (P)1 that included nutritional requirements and all necessary interventions to address the underlying risk factors to prevent hospital admission. The comprehensive admission assessed P1 as a very high risk nutritional risk and high risk for pressure ulcers. As a result of this deficiency, there was the potential the skilled nurses did not on each home visit assess and monitor P1 for additional medical conditions or complications which may have contributed to P1's hospitalization. Findings include: 1) P1 is a 92 year old male with pertinent medical history of Peripheral Vascular Disease (circulation disorder), a non pressure chronic ulcer of right heel, peripheral vascular disease, chronic kidney disease, and chronic anemia. P1 is alert, with limited mobility. He is bed and wheelchair-bound with fecal and urinary incontinence. P1 had an active wound to the right heel and currently lives in a care home who has 24/7 caregivers who provide him with all medication management, meal preparation, total activities of daily living, and transportation to medical appointments. P1's start of care with the Home Health Agency (HHA) was 03/24/21 for the primary reason of wound care. 2) On 08/04/21 reviewed the "RN Visit Note" completed by RN1 on her initial visit on the start of care (SOC) date 03/24/21. The "Visit Note Report" revealed the Oasis comprehensive assessment was completed at that time. The visit note included: P1 was at risk for hospitalization because of unintentional weight loss, decline in mental, emotional, or behavioral status in the past 3 months, difficulty complying with medical instructions and was immunocompromised. The Norton Pressure Sore Risk Assessment rated P1's physical condition as "very bad". His Norton Risk Score was 10 which is high risk for pressure ulcers. P1's integumentary (skin) assessment revealed he has a nonpressure chronic ulcer of the right heel, but did not have any other wounds or pressure ulcers at that time. In addition he was assessed to be a very high nutritional risk. 3) On 08/04/21 reviewed the "Home Health Certification and Plan of Care (POC)" which RN1 developed on the initial visit 03/24/21 after she received verbal orders from MD1. The frequency of skilled nursing visits was once a week for eight weeks. The "Orders of Discipline and Treatments" included the following: "Skilled nursing (SN) to perform wound care and instruct caregiver (CG) in wound care. Perform wound care to right heel non pressure ulceration...." "SN to evaluate and develop plan of care in consultation with the physician that includes infection prevention/control ...health promotion, nutritional needs, skilled nurse to assess/evaluate co-morbid conditions including non-pres (pressure) chr (chronic) ulcer of right heel....Brkdown (breakdown) skin [sic] other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications...." Goals/Rehabilitation plans included: "Non-PRs chr ulcer of right heel... will improve as evidenced by a decrease in size, drainage.... Client/Caregiver will verbalize/demonstrate increased confidence and ability to self manage pressure ulcer prevention as evidenced by teach back elevating feet on 7/7 days of week to prevent edema and blister formation within 4 weeks." "An individualized plan of care will be established that meets the client's assessed needs, goals and risks related to non-pres chr ulcer of right heel... " P1's POC was not comprehensive and did not include specific goals or interventions for P1's nutritional risk. In addition, it did not include the goal to have zero new wounds or pressure ulcers with interventions to prevent them. 4) On 08/04/21 review of P1's visit notes revealed the following: On 04/27/21 RN2 assumed care of P1. The visit note documented "no problems identified" for integumentary assessment findings. Interventions provided included "instruct client/caregiver regarding routine inspection of the skin, positioning, offloading and skin care management" and "instruct client/caregiver on nutritional recommendations that promote control of disease process." The goals met were documented CG demonstrated correct process for routine skin inspection, appropriate support surfaces and positioning, and verbalizes understanding of dietary requirements that promote control of disease process. There is no documentation of the what dietary requirements were discussed, and nothing in the POC. In addition there is no documentation of what education was provided for pressure ulcer prevention and no interventions in the POC. On the home visit 05/04/21 RN2 documented "Client (P)1 has acquired skin breakdown to sacral area and that the "Caregiver educated on wound care to the sacral area." At that time the sacral wound was measured and documented to be 1.5 x 2 x 0.2 (length x width x depth cenimeters) and described as "necrotic tissue type white." The wound was cleansed with mild soap and water and pat dry with gauze dressing to be done every three days and as needed. On the home visit 05/12/21 RN2 documented the sacral pressure ulcer worsened, and measured at 2.5 x 2 x 0. The necrotic (dead) tissue type was documented as yellow. MD1 was notified and provided additional orders. On the home visit 05/17/21 P1 at approximately 11:30 AM, RN2 noted a change in condition. P1 had a temporal temperature of 101.6, cough and chills. RN2 did not assess the wounds at that time, but contacted MD1 who wanted P1 to go to the Emergency Room. 5) On 5/17/21 at 03:59 P1 went to the Emergency Room by ambulance and was admitted for sepsis (a life threatening medical emergency where the body has an extreme response to an infection). MD2 documented in the admission history and physical the diagnosis sepsis due to UTI (urinary tract infection), cellulitis..." On 05/18/21 P1 had a surgical procedure. The preoperative diagnosis was "Necrotic sacral ulcer was purulence (pus)." The postoperative diagnosis was "Necrotizing infection of skin, subcutaneous tissue, and fascia of sacral area." The wound was debrided. 6) 08/4/21 at approximately 11:15 AM during an interview with RN2, she said she took over P1's care from another RN (RN1) and that her first visit with him was 04/27/21. RN2 said at that time she went by the POC developed by RN1, and only focused on the right heel wound. RN2 said P1 was in a wheel chair the whole visit and she did not assess any other areas of his skin and did not undress him. There was no documentation that there was a discussion with P1's caregiver about daily skin inspections or if there had been any issues. RN2 went on to say when she went for the home visit on 05/04/21 the CG took P1 to the bed and asked her (RN2) to check his butt. RN2 identified a new stage 2 pressure ulcer (PU) on the coccyx and called MD1 to report the PU and obtained orders for treatment. 7) On 08/04/21 reviewed the one of the documents provided for wound assessments the agency used as policy titled: "Skin and Wound Care - Assessment : Pressure Ulcer Risk/Prevention Section : 25.01" copyright 2014, " The Visiting Nurses Association of America..." The document included the following: "Key Points ...2. Use a validated pressure ulcer risk assessment tool to identify patient's risk and risk factors... b. Reassess at regular intervals (every visit is recommended) with validated tool. c. Assess bed and chair-bound patients for additional risk factors such as, incontinence..." "6. Recommendations for an effective prevention program include four goals: ...c. Protect against the adverse effects of pressure, friction, and shear. d. Reduce the the incidence of pressure ulcers through educational programs. "7. The purpose of identifying patients at risk for pressure ulcers is to prevent ulcers from occurring through early intervention." "Procedure...5. Inspect patient's skin. a. Instruct patient/caregiver to inspect skin on a daily basis. b. Show patient/caregiver location of bony prominences. " 8) On 08/4/21 at approximately 10:20 AM during an interview with the Clinical Manager, she said it was the expectation the RN's assess P1's skin on each home visit.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interviews and record review (RR) the agency failed to update one patients (P)1 plan of care to include new verbal orders. On 05/04/21 Registered Nurse (RN)2 identified P1 had a new Pressure Ulcer on his coccyx. P1's physician was notified for new orders, but RN2 did not add the orders or wound to the plan of care (COP). Findings include: 1) P1 is a 92 year old male with pertinent medical history of Peripheral Vascular Disease, a non pressure chronic ulcer of right heel, anemia and chronic bronchitis. He had been living in a care home the past two years. P1 has an active wound to the right heel and currently lives in a care home who has 24/7 caregivers who provide him with all medication management, meal preparation, total activities of daily living, and transportation to medical appointments. P1's start of care with the Home Health Agency (HHA) was 03/24/21 for the primary reason of wound care. 2)On 07/04/21 RR of P1's medical records revealed the following: The "Home Health Certification and Plan of Care" dated 03/24/21 included; "Skilled Nursing to perform wound care and instruct ... (Care Giver [CG] in wound care to right heel nonpressure ulceration. Cleanse areas with NS (normal saline) apply silvadeen daily using clean technique, may leave open to air. "Skilled Nurse to evaluate and develop plan of care in consultation with the physician that includes infection prevention/control.....Skilled Nurse to to assess/evaluate co-morbid conditions including non-prs (pressure) chr (chronic) ulcer of right heel and midft (midfoot) lmt (limited) to beakdown skin other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications..." P1 was determined to be a high risk for pressure ulcers based on his comprehensive assessment completed on 03/24/21. At that time P1 had only the wound on his right heel. On 05/04/21 RN2's visit note documented "no problems" identified for the integumentary (skin) assessment. The visit note also included a P1 had a new stage 2 pressure ulcer to mid posterior sacral area. It was measured to be "1.5 x 2 x. 02 (Length x width x depth centimeters)" Depth description of the wound was "necrotic," with total necrotic slough 26-100% and 0-25% total necrotic tissue eschar. Documented wound care provided was; "Cleanse sacral wound with mild soap and water and pat dry, cover with gauze with border, change dressing every 3 days and as needed for spoilage and dislodgement. Clients caregiver to be taught wound care and teach back to skilled nurse..." 3) The patient goals on the 05/04/21 were not updated to reflect the new coccyx wound, and only read; "to heal wound to Right heel." On 05/12/21 RN2's visit note documented an increase size of the coccyx wound. P1's goals and interventions were still not updated to include the coccyx wound or treatment for this wound.