Every finding on record at Centerwell Certified Healthcare Corp

A complaint investigation survey was conducted on February 23, 2022. The complaint was substantiated and standard level deficiencies to the Medicare Conditions of Participation were identified.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on policy review, complaint log review, clinical record review and staff interview the agency failed to document the complaint and the resolution of the complaint for 1 of 1 patient with a documented complaint (#1). The findings include: Agency policies were received on 02/23/2022 at 4:00 p.m. from the Executive director. According to the agency policy, “Complaint Management” (annual policy review 06/2011), it stated “All complaints made by patient, family, or the patient’s responsible party either verbally or in writing will be reviewed, evaluated and forwarded to the appropriate manager for resolution. Actions and resolution will be documented on the Complaint log… All complaints will be logged with ongoing documentation until resolved… Complaint investigation/ Documentation/ Resolution … The agency must investigate complaints made by a patient, patient representative (if any), patient caregivers and family, including but not limited to the following topics: Treatment or care that is or fails to be furnished, is furnished inconsistently, or is furnished inappropriately.” The Complaint Log was provided by Executive director on 02/23/2022 at 11:00 a.m. Patient #1 did not have a complaint on the log. Patient #1 was admitted on 01/20/2022 with a diagnosis of Pressure ulcer of Left heel, unstageable, Cellulitis of Left lower limb and Diabetes Mellitus with Diabetic Neuropathy. The Plan of care dates 01/20/2022 through 03/20/2022 revealed skilled nursing services were ordered for wound care. The visit frequency included 1 time per week for 1 week; 2 times per week for 1 week; 3 times per week for 1 week; 2 times per week for 2 weeks; 1 time per week for 3 weeks with 2 as needed (PRN) visits for disease, wound, medication and pain management. The wound care order for 01/20/2022 was as follows: “Skilled nurse to perform/teach pressure ulcer care to left medial heel. Cleanse with NSS (Normal Saline solution), apply hydrogel, cover with wet to dry NSS 4x4. Secure with rolled gauze tape using clean/aseptic technique. Change dressing every MON/WED/FRI and PRN (as needed) soiling/ dislodgement. May utilize equivalent products. Once taught, patient/caregiver to perform on days skilled nurse is not in home. {sic}. Nurse #1 visited patient on 01/24/2022. The narrative from the visit stated, “RN visited patient for routine visit with wound care. PNT (patient) was very ill upon arrival because she states we have bad communication and provide half a_ _ care. I reiterated to the patient that we would do our best to address all of {sic} her concerns and make her satisfied with our services. Patient stated okay but said she did not have much faith in us…she likes to have her visit scheduled out and wants to know exactly what time we are coming days before the visit. I educated the patient that most clinicians do not set a time that far out due to volatility of scheduling that we scheduled the night before. Patient states understanding.” In an interview with nurse #1 on 02/23/2022 at 4:25 p.m. was asked how complaints are handled. Her response was “typically I report that (complaints/concerns) to the manager. I did speak to the scheduler and Clinical manager (CM) #2.” Per CM #2 on 02/23/2022 at 4:40 p.m., stated “the process would be for the nurse to have called me regarding the complaint or caregivers concerns.” The CM #2 stated she would “hear the patient out and try to come to a resolution at this point. I would document that in patients complaint log, talk with clinician. If unable to resolve, I would notify the Branch Director. {sic}” CM #2 also reported she only talked to the caregiver when she called to discontinue services.” She stated she was not aware of the complaint. In an interview with the Executive director on 02/23/2022 @ 4:45 p.m., she reported the complaint should have been logged and documented.

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: Based on clinical record review and staff interview, the nurse failed to provide wound care according to the Plan of Care for 1 of 1 patient with a wound (#1). The findings include: Patient #1 was admitted on 01/20/2022 with a diagnosis of Pressure ulcer of Left heel, unstageable, Cellulitis of Left lower limb and Diabetes Mellitus with Diabetic Neuropathy. The Plan of care dates 01/20/2022 through 03/20/2022 revealed skilled nursing services were ordered for wound care. The visit frequency included 1 time per week for 1 week; 2 times per week for 1 week; 3 times per week for 1 week; 2 times per week for 2 weeks; 1 time per week for 3 weeks with 2 as needed (PRN) visits for disease, wound, medication and pain management. The wound care order for 01/20/2022 was as follows: “Skilled nurse to perform/teach pressure ulcer care to left medial heel. Cleanse with NSS (Normal Saline solution), apply hydrogel, cover with wet to dry NSS 4x4. Secure with rolled gauze, tape using clean/aseptic technique. Change dressing every MON/WED/FRI and PRN soiling/ dislodgement. May utilize equivalent products. Once taught, patient/caregiver to perform on days skilled nurse is not in home. {sic}.” In an interview with nurse #1 on 02/23/2022 at 4:25 p.m. she stated patient’s nurse visits were changed to 2 times per week Monday and Friday. Nurse #1 also stated she had taken a call from the patient on 02/07/2022 and the patient was upset and “wanted to know where she was at? Expected someone 02/07” {sic}. Nurse reports she “explained to the patient her days had been changed… and she was planning to go on 02/08.” In an interview on 02/23/2022 at 5:00 p.m. with the executive director, CM 2 and 3 all agreed the Plan of Care order was for Monday, Wednesday and Friday. No order was found to change the specific days of the nursing visits for wound care.

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: Based on clinical record review and staff interviews the nursing staff failed to make visits to perform wound care in accordance with the plan of care [POC] for 1 of 3 patients [#1]; and failed to perform dressing changes in accordance with the Plan of Care for 1 of 3 patients with wounds [#3]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 2/4/21 and diagnosis of Encounter for Change or Removal of Surgical Wound Dressings and Encounter for Surgical Aftercare Following Surgery on the Circulatory System. A review of the Plan of Care [POC] for the certification period 2/4/21-4/4/21 revealed orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 2 weeks and 1 time every 2 weeks for 4 weeks and "SN to perform/teach incision/suture site care right lower leg. Cleanse with one [sic] cleanser and gauze or soap and water, cover with xeroform and dry gauze, secure with light two-layer compression wrap using clean/aseptic technique. Change dressing twice a week and prn [as needed] soiling/dislodgement ...Once taught, patient/caregiver to perform on days skilled nurse is not in the home." A review of the clinical record revealed only 1 SN visit was made the week of 2/4/21. On 3/11/21 an interview was conducted with RN # 2 [RN who did the initial visit and developed the plan of care]. RN # 2 confirmed only 1 visit was made the week of 2/4/21. "I do the admissions and I am not sure why the 2nd visit was not made that week." 2. Patient # 3 had a Start of Care date of 1/26/21 and a diagnosis of Pressure Ulcer of Sacral Region, Stage 3. A review of the Plan of Care for the certification period 1/26/21 to 3/26/21 revealed orders for, SN [skilled nursing] 2 times a week for 3 weeks; 1 time a week for 4 weeks; 3 times a week for 1 week; 1 time a week for 1 week and "Skilled nurse to perform /teach pressure ulcer care to coccyx. Cleanse with wound cleanser, pack with Aquacel rope, cover with Optilock and foam dressing. Secure with tape using clean/aseptic technique. Change dressing every week by HHSN [home health skilled nurse] and PRN [as needed] soiling or dislodgement. Once taught patient/caregiver to perform on days skilled nurse is not in the home." A review of the wound record report revealed the dressing to the sacral/coccyx area was changed 2 times the week of 1/26/21-1/29/21. LPN # 3 made the visit on 1/29/21 and documented the dressing to the sacral area was changed. LPN # 3 made both visits the week of 2/1/21-2/4/21 and documented she changed the dressing during both visits. An interview was conducted with LPN # 3 on 3/11/21 at approximately 11 am. During the interview the LPN confirmed the dressing to the sacral area was changed 2 times per week. "I didn ' t know the dressing change was only 1 time per week." On 3/11/21 at approximately 12 pm an interview was conducted with the executive director. The executive director confirmed the frequency of dressing changes the patient received was not in accordance with the POC.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on clinical record review and patient and staff interviews the nursing staff failed to educate caregivers on dressing changes for 1 of 3 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 2/4/21 and diagnosis of Encounter for Change or Removal of Surgical Wound Dressings and Encounter for Surgical Aftercare Following Surgery on the Circulatory System. A review of the Plan of Care [POC] for the certification period 2/4/21-4/4/21 revealed orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 2 weeks and 1 time every 2 weeks for 4 weeks and "SN to perform/teach incision/suture site care right lower leg. Cleanse with one [sic] cleanser and gauze or soap and water, cover with xeroform and dry gauze, secure with light two-layer compression wrap using clean/aseptic technique. Change dressing twice a week and prn [as needed] soiling/dislodgement ...Once taught, patient/caregiver to perform on days skilled nurse is not in the home." On 2/23/21 a supplemental order was written that stated, "apply Dakins soaked gauze to right groin three times per week." A review of the clinical record revealed no documentation related to the patient or the caregiver being educated on the dressing changes/wound care. An interview was conducted with Patient # 1 on 3/10/21 at approximately 3 pm. During the interview Patient # 1 stated, " ...The nurse has never shown my sister how to do the dressing change. When my sister was doing the dressing changes, she just did the best she could." An interview was conducted with the executive director on 3/11/21 at approximately 10 am. During the interview the executive director confirmed the nursing staff failed to do the appropriate teaching.