Every finding on record at Jb Kummer Enterprises LLC

On 3/20/23, a complaint survey was conducted. This resulted in a standard survey at JB Kummer Enterprises. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. H80339336C/96733 was substantiated deficiencies were issued at G536 as a result of the complaint investigation

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to provide policies that guide clinical staff in the event there is a concern identified with a patient’s medication that should be reported to the physician for 2 of 3 (P2, P3) patients reviewed when patients were found to have medication errors that were not reported to the physician. R2’s agency incident report dated 2/22/23, the description of incident indicated that R2’s Mother called the director or nursing (DON) stating “the new nurse,” registered nurse (RN)-A did not set-up R2’s medication correctly. The DON was asked to come out and fix the medications. The DON found that the doses of R2’s medications were set-up correctly, but the medications scheduled for the p.m. were set-up in the a.m. medication slot. R2 reported a headache, no other signs or symptoms. R2 did not seek medical treatment and her physician was not notified. The corrective action indicated the DON fixed the medications, documented the medications errors, and addressed the concern with RN-A. The report did not indicate how many incorrect doses R2 had taken. R2’s medication sheet dated 2/23/23 indicated Ability 30 milligrams (mg) 1 tablet to be taken in the p.m., aspirin 81 mg 1 tablet to be taken in the a.m., cetirizine 10 mg 1 tablet in the a.m. Vitamin D3 25 mg 1 capsule to be taken in the a.m., Ferrous sulfate 65 mg, 1 tablet twice daily a.m. and p.m., Fluoxetine 60 mg, 3 capsules in the p.m., levothyroxine 175 micrograms (mcg) 1 tablet in the a.m., multivitamin 1 tablet in the a.m., Trileptal 600 mg 1 tablet in the p.m., Quetiapine 50 mg, 1 tablet in the p.m., Trazodone 75 mg 1.5 tablets in the p.m. R2’s Home Health Certificate and Plan of Care (POC) dated 3/2/23, indicated R2 was diagnosed with paranoid schizophrenia and type II diabetes. R2’s orders indicated R2 received skilled nursing visits every other week for medication set-up and monitor, monitor mental/emotional stability and well-being, vital sign monitoring and physical assessment. Upon interview on 3/20/23, at 10:35 a.m. R2 stated she was having headaches and she noticed her medications were set-up incorrectly, so she told her mother, and her mother reported the incident to the agency, and the agency fixed the errors. R3’s agency incident reported dated 2/10/23 indicated the description of the incident was R3 contacted her Independent Living Skills worker (ILS) stating R3 had been very tired and seemed “off” lately. R3 stated to ILS worker that she didn’t think her medications were set-up correctly. R3 was not familiar with her medications, but stated something just didn’t seem “right.” Agency investigation revealed, R3 had 300 milligrams (mg) of trazadone set-up in her medication set instead of 150 mg which was prescribed. R3 also had 75 mg + 37.5 mg of Effexor set-up, R3 was tapering on her Effexor and the order was for 75 mg. R3’s propranolol was set-up for once a day in the a.m. medication slot. The order for propranolol was to be taken as needed only. The corrective action was the assistant director or nursing (ADON) fixed the medications at the home and documented the errors. The client was re-assigned a new nurse per her request. The physician was not informed. The report did not indicate how many incorrect doses, R3 had taken. R3’s POC dated 2/23/23, indicated R3 was diagnosed with Takotsubo syndrome (a condition characterized by sudden dysfunction of the left ventricle of the heart), type II diabetes, and hypertension (high blood pressure). R3’s orders indicated R3 received skilled nursing visits every other week for medication set-up and monitoring, monitoring of mental/emotional stability and well-being. Upon interview on 3/20/23, at 10:51 a.m. R3 stated that multiple medications errors had occurred, she could not identify exactly the errors. R3 stated that the errors were so frequently she “finally” mentioned to her ILS worker about her concerns. The ILS worker notified the agency the agency, fixed the errors from that reported incident and provided R3 with a new nurse. Upon interview on 3/20/23, at 12:20 p.m. registered nurse (RN)-A stated she didn’t exactly remember the medication errors that occurred for either R2 or R3, however she was given education to follow the electronic medication administration record (Emar), instead of the medication profile sheet in the homes. RN-A stated she was not involved in the correcting of the medication error and did not believe R2 or R3 were harmed. RN-A was unaware if the agency notified the physician and stated, “I would think it just common practice to notify the physician.” Upon interview on 3/20/23, at 1:22 p.m. registered nurse (RN)-B stated in the event of a medication error the physician should be notified, but RN-B was uncertain if the agency had a policy indicating when to notify the physician or not. Upon interview on 3/20/23, at 2:05 p.m. the DON stated, “I would say in these instances the physician should have notified.” An agency policy titled Medication Management, undated, indicated all medication adverse effects and errors will be documented on the agency forms. Staff are educated and encouraged to report all events and near misses and follow-up will be done to identify system or process change needed. Findings will be compiled and reported to the performance improvement team for review and recommendation. The facility did not indicate when to notify the physician for medication concerns.