Every finding on record at Gonzales Healthcare Systems

Purpose of Visit: Recertification Survey Entrance Conference: 03/15/22 at 10:11 a.m., with the Administrator and the Alternate Administrator/Supervising Nurse. Census: Licensed and Certified Home Health – 11 Licensed Home Health - 52 An exit conference was conducted on 03/18/22 1:45 p.m., with the Administrator and telephonically with the Alternate Administrator /Supervising Nurse. The preliminary findings were discussed, The agency is in compliance with no deficiencies/violations cited. Acronyms/Abbreviations: ECR – Electronic Clinical Record LPN – Licensed Practical Nurse LVN – Licensed Vocational Nurse POC - Plan of Care PRN/prn - As needed RN - Registered Nurse SN - Skilled Nurse SNV – Skilled Nurse Visit RLE – Right Lower Extremity & - Symbol for And X – Symbol for Times / - Symbol for per

Purpose of Visit: Recertification Survey Entrance Conference: 03/15/22 at 10:11 a.m., with the Administrator and the Alternate Administrator/Supervising Nurse. Census: Licensed and Certified Home Health – 11 Licensed Home Health - 52 An exit conference was conducted on 03/18/22 1:45 p.m., with the Administrator and telephonically with the Alternate Administrator /Supervising Nurse. The preliminary findings were discussed, and the agency was afforded the opportunity to provide additional information. Written instructions for submitting an acceptable plan of correction within 10 calendar days of receipt of the Statement of Licensure Violations were provided. Acronyms/Abbreviations: ECR – Electronic Clinical Record LPN – Licensed Practical Nurse LVN – Licensed Vocational Nurse POC - Plan of Care PRN/prn - As needed RN - Registered Nurse SN - Skilled Nurse SNV – Skilled Nurse Visit RLE – Right Lower Extremity & - Symbol for And X – Symbol for Times / - Symbol for per

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) included all orders for care for one of 11 patients (Patient #11) whose records were reviewed in that: There was no physician’s order for the SN to remove the Mepilex dressing from Patient #11’s wound. This deficient practice placed Patient # 11 at risk for inadequate care, and services, which could also affect the agency’s other active patients when staff do not obtain or comply with physician’s orders. The findings included: Review of Patient #11’s electronic clinical record (ECR) revealed a plan of care (POC) for certification period from 01/31/22 through 03/31/22 with a diagnosis of Unspecified open wound of the right lower leg. Continued review of the POC in the section titled “Patient Specific Interventions/Educations” read in part, Admit Order 1/31/22 to 03/31/22: SN frequency; two times a week for nine weeks, four PRN, falls, medication management…Wound care changes/orders.” Review of SN Visit Note dated 2/28/22 revealed “that the SN removed Mepilex as ordered and cleansed wound to RLE with Sterile Normal Saline (SNS) and gauze, and patted dry with gauze. SN covered with SNS wet to dry dressing using Kerlix, gauze and ABD (Abdominal dressing) and secured with tape.” Continued review of Client #11's ECR included the following physician's orders: 02/11/22 - "Home Health to perform wound care twice weekly to RLE: Clean with SNS, cover wound with SNS wet to dry dressing and secure with tape. Patient may perform wound care between SNV." 02/25/22 - "...no changes to current wound care. Continue wound care as ordered." 03/16/22 - "Wound care to RLE twice weekly per Home Health: Cleans with SNS/gauze, apply moistened Kerlix with SNS to wound bed, cover with dry sterile 4X4 gauze/ABD & wrap with Kerlix & secure with ace/tape. Patient to perform wound care between SNV." Continued review of the ECR did not reveal documented evidence of physician’s orders for the SN to remove the Mepilex dressing. In an interview and concurrent record review on 03/18/22 at 11:37 a.m., the Administrator stated, “that on 02/25/22, the RN spoke with the wound care doctor and documented the verbal instructions to remove the Mepilex dressing in the communications note but the RN did not write an order, and further stated that it [verbal instruction to remove the Mepilex dressing] should have written in an order.” Review of the agency’s policy (Number 4.004.1) titled, “Physician Order/Plan of Care” (undated) read in part, “3. Verbal orders may be received by the registered nurse, licensed practical nurse, physical therapist…Verbal orders are put into writing, signed, time of order and dated by the person receiving the order.”