Every finding on record at Bridge Home Health East Bay, LLC

The following represents the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00722802 Representing the Department: HFEN, 31403 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint number CA00722802.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency did not provide services as outlined in the plan of care for one of three sampled patients (Patient 1). Patient 1 did not receive home health aide services and missed one day of antibiotics. These failures resulted in missed medication to fight infection and patient dissatisfaction with the care provided. Findings: Record review on 9/8/2021 of the policy and procedure, "Verification of Physician Orders," dated April 2018, showed " the orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients." Review of the document, "Health Certification and Plan of Care" showed Patient 1's start of care was 1/13/2021 with the current certification period 1/13/2021 to 3/13/2021. The diagnoses included bacteremia (bacteria in the blood). Furthermore, Patient 1 was to receive "Ceftriaxone sodium injection (antibiotic) 1 gm (gram) each administer 50 ml (milliliter) by PICC line (percutaneous indwelling central catheter is a tube inserted into a vein in the arm and is passed through to the larger veins near the heart) to deliver medications), every 24 hours for 9 days for bacteremia." Additional orders included a home health aide (provides assistance with activities of daily living, such as bathing, dressing...) twice per week for 8 weeks "Effective 1/15/2021." In an interview on 8/26/2021 at 3:26 p.m., Patient 1 stated the agency, "Did not have my medication," and was, "Not happy with the care." Review of the document, "Patient Communication" dated 1/13/2021 showed, "Pt (patient) didn't receive today ATB (antibiotic) dose because pt. didn't have IV (intravenous) lines" to administer the medication. In an interview and concurrent record review on 8/27/2021 at 11:30 a.m., the agency's Clinical Manager (CM) confirmed there had been a delay in administering Patient 1's antibiotic. The CM stated staff were instructed to call the patient the day before to ensure the supplies were in the home prior to the visit for continuity of care. CM stated there was no documentation in the clinical record which showed staff communicated with Patient 1 prior to the visit. In a second interview on 8/27/21 at 12:15 p.m., CM stated he instructed staff during the agency's orientation to make a "Courtesy" call the day before the visit to let the patient know of the visit and to ensure the supplies were in the home. Furthermore, CM stated for Patient 1, if they (staff) had discovered part of the medication administration set missing, it would have given staff time to call the supply company. In an interview on 8/30/2021 at 2:51 p.m., the Registered Nurse 1 (RN 1) confirmed she had not called Patient 1 prior to her visit on 1/13/2021 to confirm whether all of the supplies were in the home. RN 1 stated she did not administer the antibiotic that day because the tubing for the medication was missing. Review of the home health aide document, "Aide Care Plan," showed the plan was dated 1/13/2021. In a concurrent interview on 8/27/2021, at 11:30 a.m., CM confirmed the home health aide never visited Patient 1.