Every finding on record at Health Watch Health Care of SW Oklahoma LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 10/31/23 to 11/02/23.No deficiencies were cited as a result of the Medicare Emergency Preparedness Program.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 10/31/23 to 11/02/23.An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered.Staff A and B were identified as the contact persons for clinical and administrative issues.Findings were discussed during an informal exit conference with Staff A and B and by phone Staff C, D, E, F and G.Deficiencies were cited as a result of the re-certification survey. GLOSSARY:CHHA Certified Home Health AidePOC Plan of CarePt/Pts Patient/PatientsSN Skilled Nurse PT/PTA Physical Therapy/ Physical Therapy Assistant

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 record review and interview, the agency failed to ensure; 1. the skilled nurse notified the physician of pain levels outside the ordered parameters for one (Patient #2) of seven patients, and 2. the skilled nurse notified the physician of blood pressure levels outside the ordered parameters for one (Patient #5) of seven patients. Patient #1 A review of the plan of care dated 10/14/23 to 12/12/23 showed and order for the physician to be notified of pain levels greater than 7 on the classic 1-10 pain scale. A review of the clinical record showed the following: A physical therapy assessment dated 10/14/23 documented a pain level of 8 on the classic 1-10 pain scale with no physician notification. A physical therapy assessment dated 10/17/23 documented a pain level of 9 on the classic 1-10 pain scale with no physician notification. A physical therapy assessment dated 10/19/23 documented a pain level of 8 on the classic 1-10 pain scale with no physician notification. A physical therapy assessment dated 10/22/23 documented a pain level of 9 on the classic 1-10 pain scale with no physician notification. Patient #5 A plan of care dated 07/31/23 to 09/28/23 documented the physician was to be notified of a diastolic blood pressure less than 60. A skilled nurse assessment dated 08/30/23 documented a diastolic blood pressure of 58 with no physician notification. On 11/02/23 at 1:15 pm, Staff A stated: 1. there was no documentation of notification to the physician of pain levels out of parameters for Patient #1. 2. there was no documentation of notification to the physician of the diastolic blood pressure out of parameters for Patient #5.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure accuracy of wound documentation for one (Patient #2) of seven patients. Patient #2 A review of the plan of care dated 08/03/23 to 10/01/23 showed a skilled nurse frequency of one visit per week for one week and one visit every two weeks for six weeks. A physician's order dated 09/05/23 documented a wound to the right hip of the patient. A review of the clinical record showed the following: A skilled nurse assessment dated 08/16/23 documented wound care provided to the patient's left hip. A skilled nurse assessment dated 08/31/23 documented wound care provided to the patient's left hip. A skilled nurse assessment dated 09/12/23 documented wound care provided to the patient's left hip. A skilled nurse assessment dated09/27/23 documented wound care provided to the patient's left hip. On 11/02/23 at 1:00 pm, Staff A stated the skilled nurse assessments did not accurately document the location of the wound ordered to be provided treatment.