Every finding on record at Cgh Home Nursing

Recertification survey was conducted. Standard level deficiencies cited. Abbreviations: # = number POC/PsOC = Plan of care/Plans of care SN = Skilled Nurse Pt./ Pts. = Patient/Patients OT = Occupational Therapy/Therapist

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on the clinical records review and Staff interview, it was determined that the Agency failed to ensure the Staff followed the Physician orders in the plan of care. This was found in 3 of 10 (Pts. #1, 5 and 8) Plans of Care reviewed. Findings include: 1. Patient #1 was admitted to the Home Health Services on 06/16/23 with the Diagnosis of Encounter for Attention to Colostomy. The clinical record was reviewed on 08/01/23. The Physician orders dated 06/16/23 required the Skilled Nurse to measure the wound, weekly. The SN did not measure the patient’s wound the week of 06/23/23 (week #7). 2. Patient #5 was admitted to the Home Health Services on 01/23/23 with the Diagnosis of Multiple Sclerosis. The clinical record was reviewed on 08/01/23. The Physician orders dated 05/03/23 required the Occupational Therapy (OT) 1 time a week for 9 weeks to assess the patient. The OT did not visit/assess the patient the week of 06/04/23 (week #6). 3. Patient #8 was admitted to the Home Health Services on 08/20/22 with the Diagnosis of Aftercare following Surgery for Neoplasm. The clinical record was reviewed on 08/01/23. The Physician orders dated 10/19/22 required the Skilled Nurse to measure the wound, weekly. The SN did not measure the patient’s wound the weeks of 10/30/22 and 11/27/22 (weeks #2 and 7). 4. During the interview with the Administrator and Agency Supervisor, on 08/02/23 at 2:30 PM, it was confirmed that the Staff did not follow the plan of care orders.