Every finding on record at Bridgeway Health Services LLC

Purpose of Visit: Complaint Investigation Entrance Date: 7/18/22 Agency Census: Licensed and Certified Home Health: 318 Licensed Home Health: 0 Personal Assistance Services: 0 Intake # 364248 Abbreviations: HHA- Home Health Agency SN- Skilled Nurse Cm – Centimeters w – width rt – right NS – normal saline w/- with vac – vacuum MMHg – millimeters of mercury

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care for 1 of 3 patients (Patient #1) reviewed. This failure resulted in the patient missing four consecutive days of skilled nurse visits for wound care. This failure increased the risk that the patient’s wound would become infected and increased the risk of re-hospitalization. The findings included: Review of the plan of care for Patient #1 indicated that the patient was admitted on 4/21/22 with a primary diagnosis of dislocation of right hip prosthesis. Review of a nursing visit note dated 7/05/22 for Patient #1 revealed that the patient had a large hip wound measuring 15cm long, 10cm wide, and 6cm deep as a result of surgery to remove a large blood clot around the hip joint. Patient #1 had a wound vac in place to keep the wound closed and promote healing. Review of a physician’s order dated 6/30/22 indicated, “SN frequency: 1w1, 3w6, 2w1,” meaning the skilled nurse to visit once a week for 1 week, three times a week for 6 weeks, and twice a week for one week. The physician’s order also included orders for wound care: “Clean rt hip surgical wound wound w/NS, pat dry w/Gauze, apply skin prep to peri-wound, apply vac drape to peri-wound, cut to fit black foam apply to wound bed, cover w/vac drape, apply track pad, apply vac drape over track pad to secure if necessary and start vac @ 120 MMHg with continuous/intermittent pressure.” On 07/07/22, Patient #1 was transferred to the hospital for complications related to the large hip wound. Review of agency discharge summary revealed that Patient #1 was discharged on 7/09/22 with the reason for discharge listed as “hospitalized.” In an interview with Patient #1 on 7/18/22 at 11:23 AM, the patient indicated that she had been discharged from the hospital on 7/11/22, and patient had expected the agency to make a home visit on 7/12/22. The agency made no visit on 7/12/22, 7/13/22, 7/14/22. On 7/15/22, the agency informed the patient that she had been discharged by the agency. In an interview on 7/18/22 at 4:00 PM with Administrator, when asked if agency had notified the patient that she had been discharged from the agency, Administrator said, “We did not specifically talk to the patient while she was in the hospital.” When asked when the hospital had been notified of the discharge, and who had notified the hospital staff, Administrator said, “I can’t find anything that specifically addresses who they talked to or when.” In an interview on 7/18/22 at 4:39 PM with Alternate Administrator, when presented with the findings that Patient #1 had been without nursing care for 4 days and asked what the risk to the patient would be if the patient did not receive wound care, Alternate Administrator said, “Infection… I mean… but we knew before she went to the hospital that she was needing a higher level of care than we could provide for her… There’s a drop of communication there, we can admit that.” Review of agency policy (dated 08/01/2020) titled Patient/Client Transfer, Discharge, and Agency Dissolution read in part, “Discharge notice will be provided as required by Federal and State law… The Agency must send all necessary medical information pertaining to the patients’ current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner, to ensure a safe and effective transition of 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 assure communication with all physicians involved in the plan of care when a patient was discharged from the HHA during a hospitalization (Patient #1). This failure resulted in the patient’s physician being unaware that the patient was not receiving any home health services until 4 days after the patient was discharged from the hospital. This failure increased the risk that the patient would develop complications from lack of wound care for a large hip wound and increased the risk for re-hospitalization. The findings included: Review of plan of care for Patient #1 indicated that the patient was admitted on 4/21/22 with a primary diagnosis of dislocation of right hip prosthesis. Review of a nursing visit note dated 7/05/22 for Patient #1 revealed that the patient had a large hip wound measuring 15cm long, 10cm wide, and 6cm deep as a result of surgery to remove a large blood clot around the hip joint. Patient #1 had a wound vac in place to keep the wound closed and promote healing. Review of a physician’s order dated 6/30/22 indicated, “SN frequency: 1w1, 3w6, 2w1,” meaning the skilled nurse to visit once a week for 1 week, three times a week for 6 weeks, and twice a week for one week. The physician’s order also included orders for wound care: “Clean rt hip surgical wound wound w/NS, pat dry w/Gauze, apply skin prep to peri-wound, apply vac drape to peri-wound, cut to fit black foam apply to wound bed, cover w/vac drape, apply track pad, apply vac drape over track pad to secure if necessary and start vac @ 120 MMHg with continuous/intermittent pressure.” On 07/07/22, Patient #1 was transferred to the hospital for complications related to the large hip wound. Review of agency discharge summary revealed that Patient #1 was discharged on 7/09/22 with the reason for discharge listed as “hospitalized.” The clinical record failed to reveal that the patient’s physician was notified of the patient’s hospitalization and the agency’s intention to discharge the patient. In an interview with Patient #1 on 7/18/22 at 11:23 AM, the patient indicated that she had been discharged from the hospital on 7/11/22, and patient had expected the agency to make a home visit on 7/12/22. The agency made no visit on 7/12/22, 7/13/22, 7/14/22. On 7/15/22, the agency told the patient that she had been discharged by the agency. In an interview on 7/18/22 at 4:00 PM with Administrator, when asked if agency had notified the patient that she had been discharged from the agency, Administrator said, “We did not specifically talk to the patient while she was in the hospital.” When asked when the hospital had been notified of the discharge, and who had notified the hospital staff, Administrator said, “I can’t find anything that specifically addresses who they talked to or when.” In an interview on 7/18/22 at 4:39 PM with Alternate Administrator, when presented with the findings that Patient #1 had been without nursing care for 4 days and asked what the risk to the patient would be if the patient did not receive wound care, Alternate Administrator said, “Infection… I mean… but we knew before she went to the hospital that she was needing a higher level of care than we could provide for her… There’s a drop of communication there, we can admit that.” Review of agency policy (dated 08/01/2020) titled Patient/Client Transfer, Discharge, and Agency Dissolution read in part, “Discharge notice will be provided as required by Federal and State law… The Agency must send all necessary medical information pertaining to the patients’ current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner, to ensure a safe and effective transition of care.”

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on interview and record, the clinical manager failed to provide oversight including patient care, in that: A. The agency failed to assure communication with all physicians involved in the plan of care when a patient was discharged during a hospitalization (Patient #1), and B. The agency failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care for 1 of 3 patients (Patient #1) reviewed. These failures resulted in the patient and the patient’s physician being unable to plan for continuity of care. This failure increased the risk of developing an infection and increased the risk of re-hospitalization. These failures resulted in the patient and the patient’s physician being unable to plan for continuity of care. This failure increased the risk of developing an infection and increased the risk of re-hospitalization. The findings included: A. Review of plan of care for Patient #1 indicated that the patient was admitted on 4/21/22 with a primary diagnosis of dislocation of right hip prosthesis. Review of a nursing visit note dated 7/05/22 for Patient #1 revealed that the patient had a large hip wound measuring 15cm long, 10cm wide, and 6cm deep as a result of surgery to remove a large blood clot around the hip joint. Patient #1 had a wound vac in place to keep the wound closed and promote healing. Review of a physician’s order dated 6/30/22 indicated, “SN frequency: 1w1, 3w6, 2w1,” meaning the skilled nurse to visit once a week for 1 week, three times a week for 6 weeks, and twice a week for one week. The physician’s order also included orders for wound care: “Clean rt hip surgical wound wound w/NS, pat dry w/Gauze, apply skin prep to peri-wound, apply vac drape to peri-wound, cut to fit black foam apply to wound bed, cover w/vac drape, apply track pad, apply vac drape over track pad to secure if necessary and start vac @ 120 MMHg with continuous/intermittent pressure.” On 07/07/22, Patient #1 was transferred to the hospital for complications related to the large hip wound. Review of agency discharge summary revealed that Patient #1 was discharged on 7/09/22 with the reason for discharge listed as “hospitalized.” In an interview with Patient #1 on 7/18/22 at 11:23 AM, the patient indicated that she had been discharged from the hospital on 7/11/22, and patient had expected the agency to make a home visit on 7/12/22. The agency made no visit on 7/12/22, 7/13/22, 7/14/22. On 7/15/22, the patient was told that she had been discharged by the agency. In an interview on 7/18/22 at 4:00 PM with Administrator, when asked if agency had notified the patient that she had been discharged from the agency, Administrator said, “We did not specifically talk to the patient while she was in the hospital.” When asked when the hospital had been notified of the discharge, and who had notified the hospital staff, Administrator said, “I can’t find anything that specifically addresses who they talked to or when.” In an interview on 7/18/22 at 4:39 PM with Alternate Administrator, when presented with the findings that Patient #1 had been without nursing care for 4 days and asked what the risk to the patient would be if the patient did not receive wound care, Alternate Administrator said, “Infection… I mean… but we knew before she went to the hospital that she was needing a higher level of care than we could provide for her… There’s a drop of communication there, we can admit that.” Review of agency policy (dated 08/01/2020) titled Patient/Client Transfer, Discharge, and Agency Dissolution read in part, “Discharge notice will be provided as required by Federal and State law… The Agency must send all necessary medical information pertaining to the patients’ current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner, to ensure a safe and effective transition of care.” B. Review of communication note dated 7/18/22 at 3:11 PM indicated that on 7/15/22 at 10:00 AM the agency notified Patient #1’s physician that Patient #1 had been discharged from the agency. In an interview on 7/18/22 at 4:39 PM with Alternate Administrator, when presented with the findings that Patient #1 had been without nursing care for 4 days and asked what the risk to the patient would be if the patient did not receive wound care, Alternate Administrator said, “Infection… I mean… but we knew before she went to the hospital that she was needing a higher level of care than we could provide for her… There’s a drop of communication there, we can admit that.” Review of agency policy (dated 08/01/2020) titled Patient/Client Transfer, Discharge, and Agency Dissolution read in part, “Discharge… The Agency will assess each patient’s/client’s discharge planning and/or continuing care needs on admission and on an ongoing basis and will involve the interdisciplinary care team where appropriate, the physician… the patient/client and the representative (if any) or caregiver(s) in the planning process…” Review of agency policy (dated 01/13/18) titled Responsibilities of the Administrator read in part, “The Agency defines the responsibilities of the Administrator to include, but not be limited to… Administratively supervising the provision of quality care to Agency patients/clients.”