Every finding on record at Blessing Hospital

An investigation was conducted on 07/13/2021 through 07/14/2021 for Complaint #IL00135557/211647. The Home Health Agency was not in compliance with the Standards for Skilled Professional Services, 42 CFR 484.75, Authorized for this survey, as evidenced by: Abbreviations: DOS- Date of Service E- Employee NS- Normal Saline OT- Occupational Therapy Pt- Patient SN- Skilled Nurse

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: A. Based on document review and interview, it was determined in 2 of 10 (Pt #1, Pt #8) patients records reviewed, the Agency failed to ensure services were provided per physician's order. This has the potential to affect all patients serviced by the Agency with a current average monthly census of 375 patients. Findings include: 1. The policy titled "Wound Care and Documentation" (last approved on 06/2021) was reviewed on 07/13/21 at approximately 2:00 PM. The policy noted, "Procedure: 1. Physician orders are required for all wound care/dressings..." 2. Pt #1 Start of Care (SOC): 02/12/2021 Diagnoses: Osteomyelitits of Vertebra Region and Coccyx Pressure Ulcer Stage 4. The record was reviewed on 07/13/2021 at approximately 12:30 PM. The Skilled Nurse (SN) visit note dated 03/22/2021 noted the wound was cleansed with NS (Normal Saline). The record lacked a physician's order for the wound care. 3. Pt #8 SOC: 12/4/2020 Diagnosis: Bilateral Hydronephrosis. The record was reviewed on 07/14/2021 at approximately 10:00 AM. The SN notes dated 03/2/2021 through 03/22/2021 noted the stage 2 coccyx pressure ulcer was cleansed with soap and water and covered with Mepilex dressing. The record lacked a physician's order for the wound care. 4. During an interview on 7/14/2021 at approximately 11:30 AM, the Clinical Manager/Registered Nurse (E#5) reviewed Pt #1 and Pt #8's records and verbally agreed the records lacked a physician orders for the wound care and there should have been an order. B. Based on document review and interview, it was determined 1 of 10 (Pt #5) patients records reviewed, the hospital failed to ensure dressing changes were conducted as ordered by the physician. This has the potential to affect all patients who receive services by the Agency with an average monthly census of 375 patients. Findings include: 1. The policy titled "Wound Care and Documentation" (last approved 06/2021) was reviewed on 07/13/2021. The policy noted "6. Staff will assess the home environment... standards of care must be followed by caregivers when home care staff is not present. a. Caregivers should be taught the specific care of the wound... b. The caregiver should demonstrate the ability to perform the wound care procedure in a competent manner..." 2. Pt #5 SOC: 06/18/2021 Diagnosis: Unspecified displaced fracture of 2nd cervical vertebrae. The record was reviewed on 07/13/2021 at approximately 12:30 PM. The Physician's order dated 06/24/2021 at 8:00 AM noted, "Cleanse left neck with normal saline, apply Xeroform and cover with Mepilex. Change daily." The Physician's order dated 06/24/2021 at 10:45 AM noted, "SN frequency increased due to: Pt having increase in wounds and pt (patient)/spouse unable to care for self. Needing frequent observation... pt and spouse not able to understand how to apply and change dressing... Change melgisorb AG daily and mepilex every 3 days..." The Physician's order dated 06/28/2021 at 4:00 PM noted, "Cleanse wound with normal saline or soap and water if drainage. Apply Melgisorb AG to left clavicle, left chin daily... Cleanse left neck with normal saline, apply Xeroform and cover with Mepilex. Change daily..." The record noted wound care was provided twice weekly during the Skilled Nurse visits until transferred to an Assisted Living Center on 07/01/2021 where the dressing could be changed daily. The record lacked documentation the Skilled Nurse notified the physician that daily wound care was unable to be conducted as ordered. 3. During an interview on 07/14/2021 at approximately 11:30 AM, E#5 reviewed Pt #5's record and stated "We (E#5 and E#6 (Pt #1's Skilled Nurse) discussed this. I told E#6 to call the physician and increase the visit frequency so the dressing could be conducted as ordered." E#5 verbally agreed the dressings were not conducted as ordered and should have been.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on the document review and interview, it was determined in 3 of 10 (Pt #5, Pt #7, Pt# 8) patients records reviewed, the Agency failed to ensure clinical notes were prepared in accordance with the Agency's policy. This has the potential to affect all patients serviced by the Agency with a current average monthly census of 375 patients. Findings include: 1. The policy titled "Patient Records Documentation-Retention-Protection-Review" (last approved 03/2021) was reviewed on 07/14/2021 at approximately 2:20 PM. The policy noted, "... Each patient... will have an accurate medical record... j.... ii. Patient signature required at time of visit unless documented acceptable exception.... iii. Clinical notes are entered electronically or written the day service is provided. Staff will use electronic signatures for clinical notes and verbal orders." 2. The policy titled "Wound Care and Documentation" (last approved 06/2021) was reviewed on 07/13/2021 at approximately 2:00 PM. The policy noted, "... a. wound documentation for every visit should include... wound measurements..." 3. Pt #5 Start of Care (SOC): 06/18/2021 Diagnosis: Unspecified displaced fracture of 2nd cervical vertebrae. The record was reviewed on 07/13/2021 at approximately 12:30 PM. The following notes were not completed per policy: a) Occupational Therapy (OT) note dated 06/23/2021 was completed on 07/09/2021; b) OT note dated 06/25/2021 was completed on 07/09/20211 and lacked the patient's signature; c) OT note dated 06/28/2021 was completed on 07/13/2021 and lacked the patient's signature; d) OT note dated 06/30/2021 was completed on 07/13/2021; e) Skilled Nurse (SN) notes dated 06/24/2021, 07/02/2021, 07/06/2021 and 07/08/2021 lacked a patient's signature; f) SN note dated 06/25/2021 was not completed as of 07/13/2021. 4. Pt #7 SOC: 03/04/2021 Diagnoses: Pressure Ulcer Left Buttocks Stage 3 and Diabetes. The record was reviewed on 07/14/2021 at approximately 10:45 AM. SN visit note dated 03/25/2021 noted a wound on the buttock. The record lacked documentation of the wound measurement. 5. Pt#8 SOC: 12/04/2020 Diagnosis: Bilateral Hydronephrosis. The record was reviewed on 07/14/2021 at approximately 10:00 AM. The SN visit note dated 02/12/2021 noted a Foley catheter was placed although Pt #8 was voiding without difficulty. 6. During an interview on 07/14/2021 approximately 11:30 AM, the Clinical Manager/Registered Nurse (E#5) reviewed Pt #5, Pt #7 and Pt #8's records and verbally agreed the documentation was inaccurate, not completed day of service and/or not signed by the patient and should not have been.