Every finding on record at Guneratne LLC

A recertification survey was completed on 10/6/22. Four deficiencies were cited.

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 interview and record review, the agency failed to record all patient care orders in the plans of care for 2 of 4 patients reviewed receiving wound care (Patient's # 5 and #6) Findings include: AGENCY POLICY According to the agency's policy, titled Care Planning, Coordination of Services and Quality of Care, dated 2/6/2019, (in pertinent parts): "Each patient will receive an individualized written plan of care, including any revisions or additions. The individualized plan of care will specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment. The individualized plan of care will include the following: Types of Services, supplies and equipment required All medications and treatments" 1. The clinical record for Patient #5 was reviewed on 10/4/22. The plan of care for the certification periods dated 8/5/22 to 10/3/22 and 10/4/22 to 12/2/22, revealed a start of care date of 5/5/22; diagnoses included; varicose veins of right lower extremity with inflammation, varicose veins of left lower extremity with inflammation, heart failure unspecified and lymphedema not elsewhere classified. The plan of care orders included skilled nurse (SN) services three times weekly for eight weeks to provide skilled assessment, wound care, and patient education. a) Clinical record review revealed the agency failed to document wound care orders on Patient #5's plan of care. Review of the clinical record on 10/5/22 revealed orders from Parker Adventist Hospital Wound Care and Hyperbaric Medicine dated 7/29/22, 8/4/22, and 8/16/22, indicating the need for bilateral lower extremity multilayer wraps to be done twice a week by the home care agency. Each lower extremity was to be cleansed with soap and water, patted dry, then wrapped with the multilayered dressings, consisting of a moist gauze layer, kerlix wrap then coban (a stretching compression type wrap). The right ankle had optilock applied on the outside of the right ankle on top of the coban layer. Review of the initial plan of care dated 8/5/22, as well as the recertification plan of care on 10/4/22 failed to reveal specific wound care orders for patient #5, under the orders and treatment section. 2. The clinical record for Patient #6 was reviewed on 10/5/22. The plan of care for the certification periods dated 5/12/22 to 7/10/22 and 7/11/22 to 9/8/22, revealed a start of care date of 5/12/22; diagnoses included bullous pemphigoid, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of right foot with specified severity, non-pressure chronic ulcer of other part of left foot with specified severity, lymphedema, encounter for fitting of urinary device and type 2 diabetes mellitus with diabetic chronic kidney disease. The Plan of Care orders included SN services three times weekly for nine weeks to provide skilled assessment, wound care, and patient education. a) Clinical record review revealed the agency failed to document wound care orders on Patient #6's plan of care. Review of the clinical record revealed wound care orders from Kaiser Permanente, signed and dated by a nurse practitioner (NP) on 6/22/22. The orders were as follows; to bilateral legs: remove old dressing, wash wounds with mild soap and water, gently exfoliate dry skin/legs with debride soft or washcloth to remove dry skin on legs and feet, rinse and pat dry. Use non scented, mild soaps such as cetaphil cleanser, dove liquid soap or Johnson and Johnson baby shampoo. Moisture legs with lotion after showering. Apply Xeroform to heels and bottom of feet. Do not apply Xeroform to macerated areas between toes. Weave aquacel AG ribbon (silver rope) between toes, secure legs, feet, toes with gauze wrap. Apply Tubigrips double layer D to each leg (a type of compress covering). Change dressing three times a week. To sacral round: remove old dressing and shower as usual. Wash wounds with mild so:ap and water, rinse and pat dry. Do not rub or scrub the area. Use non scented, mild soaps such as cetaphil cleanser, dove liquid soap or Johnson and Johnson baby shampoo. Apply zinc based cream to the sacrum three times a week and as needed. Cover with Mepilex border foam dressing. Review of the recertification plan of care dated 7/12/22 failed to reveal any specific instructions for wound care, the orders stated: "Standing Wound Care Orders: Skilled Nurse may cleanse wounds w/NS or Sterile H2O, pat dry w/ 4x4gauze @ each visit & then continue wound care orders as directed". During an interview on 10/5/22 at 11:29 a.m., RN #6 stated she had no idea all orders needed to be on the plan of care. 3. During an interview on 10/4/22 at 4:30 p.m. the alternate administrator stated she thought that because the primary MD for Patient #5 was from the wound clinic following the orders that were sent over were sufficient. For Patient #5 and #6, she further stated she was not clinical and did not know orders needed to be on the plan of care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition that suggested a need to alter the plan of care for 2 of 4 patients whose record was reviewed and who received skilled nursing (SN) for wound care (Patients #5 and B). 2. The clinical record for Patient #5 was reviewed on 10/4/22. The plan of care for the certification periods dated 8/5/22 to 10/3/22 and 10/4/22 to 12/2/22, revealed a start of care date of 5/5/22; diagnoses included; varicose veins of right lower extremity with inflammation, varicose veins of left lower extremity with inflammation, heart failure unspecified and lymphedema not elsewhere classified. The plan of care order included skilled nurse (SN) services three times weekly for eight weeks to provide skilled assessment, wound care, and patient education. a) Clinical record review revealed the agency nursing staff (RN#6) failed to notify Patient 5's primary care provider, when new open areas occurred. Review of the clinical record 10/5/22, revealed a note from Parker Adventist Hospital Wound Care and Hyperbaric Medicine, that stated "we are considering your wounds to be healed", it further stated for the home care agency to continue the multilayer wraps to bilateral lower extremities. Review of the SN clinical note dated 8/31/22, completed by RN #6, stated "Patient has new open areas that are bleeding around the creases in the ankle and the top part of the foot." The clinical note failed to reveal if the MD had been updated or not. Further review of the clinical record failed to reveal any documentation that the MD or wound care clinic had been updated. During an interview on 10/5/22 at 11:29 a.m. RN #6, stated she did not update the MD because Patient #5 had an upcoming wound care clinic appointment. She further stated that Patient #5, never made it to the wound clinic appointment and she still had not updated the MD at the wound care clinic. Findings include: AGENCY POLICY According to an agency policy dated 3/1/19, titled "Care Planning, Coordination of Services, and Quality of Care, (read in pertinent parts): "The agency will promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered." "COORDINATION OF CARE The agency will: -Assure communication with all physicians involved in the plan of care." According to the agency policy dated 11/21/12, titled, "Medical Policies and Physician's Orders," (read in pertinent parts): "The professional documents all communication with the physician and/or the laboratory." 1. The clinical record for Patient B was reviewed on 10/5/22. The plan of care for the certification period dated 8/24/22 to 10/22/22 revealed a start of care date of 8/24/22; diagnosis included: stage 2 pressure ulcer; hypertension, chronic diastolic heart failure, chronic obstructive pulmonary disease\, atrial fibrillation, osteoarthritis, chronic pain, contracture of left foot and right ankle, anemia, occlusion and stenosis of bilateral carotid arteries, bipolar disorder and hyperlipidemia. The plan of care orders included SN two times a week for four weeks for skilled observation and assessment, vital signs, education and wound care. a) Clinical record review revealed the agency nursing staff failed to notify Patient B's primary care provider, nurse practitioner (NP) #8 when she developed a new wound. Review of a skilled nursing (SN) notes for Patient B written on 8/24/22, 8/26/22, 8/29/22, 9/1/22, 9/6/22, 9/8/22, 9/12/22, and 9/15/22 and 9/19/22 and 9/22/22 revealed that registered nurse (RN) #6 identified and documented that Patient B has a stage 2 pressure ulcer on her right dorsum of her foot. There was no further documentation that Patient B had any other wounds. Review of a picture sent to the agency management staff via a secured text messaging system from RN #6 on 9/19/22 showed Patient B's right foot had a wound located on her right fifth toe. The picture also showed a wound tape measure labeled with Patient B's name, dated 9/19/22 and had documented measurements of 0.5 cm in length and 0.5 cm in width. Continued review of SN notes for Patient B written on 9/19/22 and 9/22/22 by RN #6 showed there was no documentation evidence that RN #6 had contacted NP #8, Patient B's primary care provider, that Patient B had developed a new right fifth toe wound on 9/19/22. Review of a SN note for Patient B written on 9/26/22 revealed that RN #6 documented Patient B had a wound on her right fourth toe and she documented that Patient B has a wound to her right fifth toe. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated when Patient B started care on 8/24/22 she had one wound, the wound on her right fourth toe. RN #6 stated on 9/19/22 that she observed Patient B had developed a second wound, located on her right fifth toe. RN #6 acknowledged the picture she sent to agency management staff on 9/19/22 showed Patient B's new right fifth toe wound with the wound's size documented on the wound tape measure seen in the photograph. RN #6 stated she failed to inform Patient B's primary care provider, NP #8, that Patient B had developed a new wound on her right fifth toe on 9/19/22 as she was unsure if she should classify the change in Patient B's skin integrity on her fifth toe as a wound. RN #6 stated, the wound on Patient B's right fifth toe developed due to Patient B soaking her right foot in ice water and a scab fell off her right fifth toe. RN #6 stated on 9/22/22 she noted that Patient B continued to have broken skin on her right fifth toe, but was still trying to decide if she should classify Patient B's broken skin on her right fifth toe as a wound. On 9/26/22, RN #6 documented Patient B's broken skin on her right fifth toe as a wound. RN #6 stated she felt since the broken skin on Patient B 's right fifth toe was still present after a week, that she should classify it as a wound. RN #6 stated she did not contact NP #8 to inform her of Patient B's new right fifth toe wound until 9/29/22. RN #6 stated she left a voice message with NP #8's medical assistant on 9/29/22 and never received a call back. RN #6 stated she did not document her attempt to reach NP #8 on 9/29/22 nor did she attempt to call NP #8 again when she did not get a return call from NP #8. RN #6 stated she should have informed NP #8 of Patient B's right fifth toe wound on 9/19/22, the day she first noticed the wound, and she should have documented her attempted contact with NP #8 on 9/29/22. b) Clinical record review revealed the agency nursing staff failed to notify Patient B's NP when Patient B developed a change in skin integrity on her right first toe. Review of a SN note for Patient B completed on 9/26/22 showed RN #6 documented Patient B had a wound on her right fourth toe, her right fifth toe and "a second toe is open with drainage minimal and a large blister with purple discoloration." There was no documentation evidence in this note that RN #6 attempted to contact NP #8 to inform her that Patient B had developed a large blister with purple discoloration on a toe with minimal drainage. Review of a photograph sent to agency management by RN #6 on 9/26/22 showed Patient B's right foot with a blister on the top of her right first toe with purple discoloration on the skin surrounding the blister. The picture also showed the backside of a wound tape measure with Patient B's name, dated 9/26/22 and that the picture was of Patient B's "big toe." Review of a SN note for Patient B dated 9/29/22 showed RN #6 documented Patient B had a wound on her right fourth toe, her right fifth toe and "second toe is open with drainage minimal and a large blister [popped] blood with purple discoloration." There was no documentation evidence in this note that RN #6 attempted to contact NP #8 to inform her that Patient B had developed a blister on her right first toe, that the blister had popped, and the skin surrounding the blister was purple. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated when she first notice Patient B had developed a blister and bruise on her right big toe on 9/26/22, but she did not attempt to let NP #8 until 9/29/22 when the blister had popped and was draining blood. RN #6 stated she called NP #8's medical assistants voicemail on 9/29/22 and left a message about Patient B's new right big toe bruising and popped blister. RN #6 acknowledged she failed to document her attempt to contact NP #8 and she failed to follow up with another phone call to NP #8.

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 interview and record review, the nurse failed to ensure the patient received care in conformance with physician's orders and as indicated in the plan of care for 1 of 4 patient records reviewed who received skilled nursing (SN) for wound care (Patient B). Findings include: AGENCY POLICY According to the agency policy dated 11/21/12, titled, "Medical Policies and Physician's Orders," (read in pertinent parts): "All patients who receive skilled home care services will have orders for all services from a physician." "The professional documents all communication with the physician and/or the laboratory." "A nurse receives verbal orders from the physician, the physician's nursing staff or discharge planners of community institutions. Verbal orders must be sent for confirmation and countersignature by the physician within 10 days and received back no less than 30 days." "Treatment ordered by the physician shall be the only medical treatments carried out." 1.The clinical record for Patient B was reviewed on 10/5/22. The plan of care for the certification period dated 8/24/22 to 10/22/22 revealed a start of care date of 8/24/22; diagnosis included: stage 2 pressure ulcer; hypertension, chronic diastolic heart failure, chronic obstructive pulmonary disease\, atrial fibrillation, osteoarthritis, chronic pain, contracture of left foot and right ankle, anemia, occlusion and stenosis of bilateral carotid arteries, bipolar disorder and hyperlipidemia. The plan of care orders included SN two times a week for four weeks for skilled observation and assessment, vital signs, education and wound care. a) Registered nurse (RN) #6 failed to follow physician orders when she provided wound care to Patient B. A review of scanned documents in the agency's electronic medical record (EMR) for Patient B revealed a physician order written by Patient B's podiatrist on 8/18/22 and received by the agency on 8/23/22 for Patient B which stated agency nurses were to perform the following wound care for Patient B's right fourth toe wound: calcium alginate (a type of wound care dressing used on moderate to heavily draining wounds) with a dry sterile dressing to be changed every other day. Further review of Patient B's plan of care dated 8/24/22 through 10/22/22 signed by RN #6 on 8/24/22, the administrator on 8/26/22 and Patient B's primary care practitioner (PCP) on 10/5/22 showed Patient B had the following wound care order for her right fourth toe wound: cleanse affected area gently with normal saline; apply skin protection ointment barrier, if possible, cover with plastic wrap; re-apply two times a day as needed. Review of SN notes from 8/24/22 through 10/3/22 for Patient B showed RN #6 documented 13 times that she performed the following wound care on Patient B's right fourth toe wound: cleansed with normal saline and applied petroleum jelly to the surrounding tissue of the wound. The wound care, RN #6 provided to Patient B from 8/24/22 to 10/3/22 failed to follow the wound care orders written by Patient B's podiatrist on 8/18/22. A review of Patient B's medical record in the agency's EMR revealed there were no other verbal or supplemental orders for Patient B's wound care. Additionally, there were no call log notes which showed RN #6 had communicated with either Patient B's PCP or podiatrist to change Patient B's wound care orders from Patient B's podiatrist original orders written on 8/18/22. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated she was unaware the agency had received wound care orders for Patient B on 8/23/22 from Patient B's podiatrist Dr. #9. RN #6 stated she did not have access to that scanned document with her EMR access. RN #6 stated when she completed the initial visit for Patient B, she entered Patient B's right fourth toe wound into the EMR and the EMR provided her with the standing physician orders she wrote on Patient's B plan of care and followed from 8/24/22 through 10/3/22 for treatment of Patient B's right fourth toe wound. RN #6 stated she spoke with Patient B's PCP on 8/24/22 to confirm with Patient B's PCP that RN #6 was approved to follow the standing wound care order provided by the EMR to cleanse Patient B's right fourth toe wound with normal saline, apply a protective ointment, cover with plastic wrap if able and change up to two times daily as needed. RN #6 acknowledged she failed to document this conversation with Patient B's PCP and she failed to write a verbal order for this wound care treatment. During an interview on 10/5/22 at 4:53 p.m., the alternate administrator stated RN #6 had the same access to the EMR as the agency management staff and stated RN #6 would have had access to the wound care order written by Patient B's podiatrist on 8/18/22 and entered into the agency EMR on 8/23/22 for Patient B's wound care to her right fourth toe wound. The alternate administrator stated the agency nurses have been educated that they were not to provide wound care without having orders from a physician. The alternate administrator stated if RN #6 did not see the order written by Patient B's podiatrist, then RN #6 should have called Patient B's PCP or podiatrist for Patient B's wound care orders. The alternate administrator further stated RN #6 should have documented that conversation and written a verbal order for that wound care to cover the nurse and agency on care they were providing until the plan of care was signed by the practitioner following Patient B's care. The alternate administrator stated she did not have a clinical background so she was unaware if the agency EMR provided nurses with standing orders for wound care. The administrator, who was the agency director of clinical services and a registered nurse, was unavailable for an interview. During an interview on 10/6/22 at 11:08 a.m., the chief clinical officer (CCO) for the agency's corporate office stated the EMR the agency used did not have standing physician orders for wound care loaded into the EMR. The CCO stated when a SN entered a wound into a patient's record in the EMR, the EMR would prompt the SN to fill in sections for wound care such as what the SN was to cleanse the wound with and what dressing the wound would be covered with. The CCO stated the EMR provided commonly used wound care cleansers and dressings, but these options provided in the EMR were not standing physician orders. The CCO stated she reviewed Patient B's medical record and acknowledged RN #6 failed to follow the physician order written by Patient B's podiatrist for wound care. The CCO stated RN #6 failed to document that she had a conversation with Patient B's PCP or a verbal order for the wound care she did provide to Patient B from 8/24/22 through 10/3/22. The CCO stated it appeared RN #6 required further education that the drop down boxes in the EMR were not standing physician orders and reeducation that she should document all her conversations with practitioners regarding patient orders/care. b) RN #6 failed to follow physician orders for treatment visit frequency for Patient B. Review of secured text message between RN #6, the administrator and alternate administrator regarding Patient B, showed on 8/24/22 at 9:56 a.m. the alternate administrator informed RN #6 and the administrator that the medical assistant for Patient B's PCP provided a verbal order for Patient B to provide wound care three times a week and the alternate administrator asked the administrator to write the verbal order. The same text message indicated acknowledgement of this text message by both the administrator and RN #6. Review of verbal orders for Patient B revealed: -On 8/23/22 at 3:15 p.m., the administrator wrote a verbal order from Patient B's PCP which stated, "SN for wound care three times a week." This order was sent to Patient B's PCP for signature on 8/26/22 and returned signed by Patient B's PCP on 10/5/22. -On 9/19/22 at 10:51 a.m. the administrator wrote a verbal order for Patient B, from Patient B's PCP for SN two times a week for five weeks (9/19/22 to 10/22/22). This order was sent to Patient B's PCP on 9/23/22 and signed by Patient B's PCP on 9/25/22. Review of SN notes for Patient B completed by RN #6 showed RN #6 provided treatment to Patient B two times a week for four weeks from 8/24/22 to 9/18/22, which failed to follow the verbal order treatment frequency written on 8/23/22 for three times a week until the next verbal order for two times a week was written on 9/19/22. Review of Patient B's medical record in the EMR failed to show missed visits documented for the four missed visits that Patient B had. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated she did not see nor was she aware of the verbal order written by the administrator for Patient B stating Patient B's SN frequency was to be three times a week, although the 8/23/22 text message showed RN #6 was aware of the verbal order written for three times a week. RN #6 stated after she completed Patient B's start of care visit, she called Patient B's PCP and discussed the treatment plan/frequency and RN #6 stated Patient B's PCP agreed to RN #6's treatment plan and frequency. RN #6 stated she failed to document this conversation or write any verbal orders regarding care and treatment that Patient B's PCP provided RN #6 for Patient B. During an interview on 10/5/22 at 4:53 p.m., the alternate administrator stated agency policy was the SN should read through the referral prior to starting care with the patient to ensure they were aware of all orders/communication received prior to the SN starting and providing care. The alternate administrator stated RN #6 received the secure text message which stated the agency received a verbal order from Patient B's PCP for Patient B for wound care three times a week, thus the alternate agency manager was not sure why RN #6 wrote on the plan of care for Patient B for two times a week and only provided two times a week wound care for Patient B. During an interview on 10/6/22 at 11:08 a.m., the CCO stated RN #6 should have documented her conversation with Patient B's PCP regarding changing Patient B's frequency from three times a week to two times a week and failing to document this conversation meant RN #6 failed to follow physician orders for the visit frequency of Patient B.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled professionals assumed responsibility for preparing and maintaining accurate and complete clinical notes for 2 of 4 patients who received skilled nursing (SN) services specifically for wound care (Patients #5, and B). 2. The clinical record for Patient B was reviewed on 10/5/22. The plan of care for the certification period dated 8/24/22 to 10/22/22 revealed a start of care date of 8/24/22; diagnosis included: stage 2 pressure ulcer; hypertension, chronic diastolic heart failure, chronic obstructive pulmonary disease, atrial fibrillation, osteoarthritis, chronic pain, contracture of left foot and right ankle, anemia, occlusion and stenosis of bilateral carotid arteries, bipolar disorder and hyperlipidemia. The plan of care orders included SN two times a week for four weeks for skilled observation/assessment, vital signs, education and wound care. a) Clinical record review revealed the agency failed to ensure the RN documented an accurate and complete clinical note regarding the number of wounds Patient B had. Review of a SN note for Patient B on 9/19/22 showed RN #6 documented Patient B had a right fourth toe wound that measured 0.5 cm by 0.5 cm. RN #6 failed to document any other wounds on Patient B's body. Review of a picture sent to the agency management staff via a secured text messaging system from RN #6 on 9/19/22 showed, Patient B's right foot had a wound located on her right fifth toe. The picture also showed a wound tape measure labeled with Patient B's name, dated 9/19/22 and had documented measurements of 0.5 cm in length and 0.5 cm in width. Review of SN for Patient B on 9/22/22 showed RN #6 documented Patient B had a right fourth toe wound and failed to document any other wounds on Patient B's body. Review of a SN for Patient B on 9/26/22 showed RN #6 documented Patient B had a wound on her right fourth and right fifth toe. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated when Patient B started care on 8/24/22 she had one wound, the wound on her right fourth toe. RN #6 stated on 9/19/22 that she observed Patient B had developed a second wound, located on her right fifth toe. RN #6 acknowledged the picture she sent to agency management staff on 9/19/22 showed Patient B's new right fifth toe wound with the wound's size documented on the wound tape measure seen in the photograph. RN #6 stated she failed to document that Patient B had developed a wound on her right fifth toe until 9/26/22 as she was unsure if she should classify the change in Patient B's skin integrity on her fifth toe as a wound until 9/26/22. RN #6 stated, the wound on Patient B's right fifth toe developed due to Patient B soaking her right foot in ice water and a scab fell off her right fifth toe. RN #6 stated on 9/22/22 she noted that Patient B continued to have broken skin on her right fifth toe, but was still trying to decide if she should classify Patient B's broken skin on her right fifth toe as a wound. On 9/26/22, RN #6 documented Patient B's broken skin on her right fifth toe as a wound. RN #6 stated she felt since the broken skin on Patient B 's right fifth toe was still present after a week, that she should classify it as a wound. RN #6 stated she should have documented that Patient B had developed a change in condition in her skin on 9/19/22 even if she was unsure if she should classify the change as a wound. b) Clinical record review revealed the agency failed to ensure the RN documented an accurate and complete clinical note regarding the size and location of Patient B's change in skin integrity. Review of a SN note for Patient B on 8/24/22 and 9/6/22 showed RN #6 documented Patient B's right fourth toe wound measured 0.5 cm in length by 0.5 cm in width and zero depth. Review of a picture sent to the agency management staff via a secured text messaging system from RN #6 on 8/24/22 showed Patient B's right foot had a wound located on her right fourth toe. The picture also showed a wound tape measure labeled with Patient B's name, dated 8/24/22, labeled right fourth toe and had documented measurements of 0.4 cm in length and 0.4 cm in width by zero depth. Review of a picture sent to the agency management staff via a secured text messaging system from RN #6 on 9/6/22 showed Patient B's right foot had a wound located on her right fourth toe. The picture also showed a wound tape measure labeled with Patient B's name, dated 9/6/22, labeled right fourth toe and had documented measurements of 0.3 cm in length by 0.3 cm in width by zero cm in depth. Review of a SN note for Patient B written on 9/26/22 showed RN #6 documented in the narrative section of the note that Patient B had a second toe open with drainage minimal and a large blister with purple discoloration. RN #6 failed to document which of Patient B's toe had a large blister with purple discoloration. Review of a picture sent to the agency management staff via a secured text messaging system from RN #6 on 9/26/22 showed Patient B's right foot had a blister with purple discoloration on her right first toe. The picture also showed the backside of a wound tape measure with Patient B's name, the date and labeled as big toe. During an interview on 10/5/22 at 4:06 p.m., RN #6 stated she must have had accidentally entered Patient's B right fourth toe measurement on her 8/24/22 and 9/6/22 note as 0.5 cm by 0.5 cm as the measurements should have matched the measurements located on the wound tape measure in the pictures from 8/24/22 and 9/6/22. RN #6 stated her documentation on 9/26/22 was unclear about the location of the blister of Patient B's right first toe and she should have identified Patient B as having a wound on her right big toe in her note. RN #6 stated she understood the importance of accurate documentation and she would work to improve her documentation. Findings include: TEXT REFERENCE According to the handbook of Home Health Standards and Documentation Guidelines for Reimbursement, T.M Marelli, Third Edition, page 36: "The clinical record is the only source of written communication, and sometimes the only source of any communication for all team members." AGENCY POLICY According to the agency policy titled, Documentation guidelines, dated 11/21/12, n pertinent parts: "For all patients receiving service, professional (registered nurses) will perform complete physical, functional, support system and environmental assessments applicable to the specific disciplines on admission and every sixty days. Nursing will use standardized Plan of Care provided by Lifespring In-Home Care Network. All standardized Plan of Cares will be individualized for specific patients. Submitted documentation will be reviewed for completeness. Any documentation not completed is returned to the professional to be completed within 24 hours. " 1. The clinical record for Patient #5 was reviewed on 10/4/22. The plan of care for the certification periods dated 8/5/22 to 10/3/22 and 10/4/22 to 12/2/22, revealed a start of care date of 5/5/22; diagnoses included; varicose veins of right lower extremity with inflammation, varicose veins of left lower extremity with inflammation, heart failure unspecified and lymphedema not elsewhere classified. The plan of care order included skilled nurse (SN) services once a week for one week, three times weekly for eight weeks, then once a week for one week, to provide skilled assessment, wound care, and patient education. Wound care orders not included on the plan of care stated to: applying hydrofiber or alginate or petroleum gauze to the wound bed, applying an absorbent dressing to cover, then applying a compression wrap or elasticated tubular bandage, change two times per week or more often if necessary. a) Clinical record review revealed the agency failed to ensure the registered nurse (RN) documented any wound care assessment or wound care that had been provided to Patient #5. Review of a physician order, dated 8/3/22 and received by the agency from the wound care clinic, revealed the physician had ordered the agency to provide wound care twice weekly to include: cleanse with soap and water, apply multilayer wrap to left and right lower extremities, type: Unna boots (optilock on outside of Coban layer to right ankle). Review of the initial Home Health Certification and plan of Care dated 8/5/22, indicated the SN was to perform a skilled observation and assessment of the integumentary system, with skilled observation of skin lesions on lower extremities. It failed to provide any orders for wound care. Review of SN clinical notes dated; 8/5/22, 8/8/22, 8/10/22, 8/12/22, 8/15/22, 8/17/22, 8/25/22, 8/29/22, 8/31/22, 9/6/22, 9/8/22, 9/12/22, 9/15/22, 9/21/22, /9/26/22, 9/27/22. 9/28/22, and 10/3/22 completed by RN #6 failed to reveal RN #6 documented a skilled integumentary assessment had been completed, nor did it reveal what wound care had been provided, only that wound care had been performed. Review of the clinical record on 10/4/22, revealed wound care photos dated, 8/8/22 right and left lower leg, 8/15/22 right and left lower leg, 8/18/22 left leg, 9/28/22 right leg, 10/3/22 right leg. The clinical record failed to reveal any wound descriptions. During an interview on 10/5/22 at 11:29 a.m. RN #6 stated she took pictures of the wounds weekly and sent them into the office to the administrator who then uploaded them into the clinical record. She stated she does not do any more documentation than the pictures and thought the pictures were enough. She further stated she does not document a full integumentary system assessment each visit. During an interview 10/5/22 at approximately 9:34 a.m. the alternate administrator stated she was not clinical and had no knowledge of wound documentation. The administrator was not available for an interview.