Every finding on record at Klarus Home Care, LLC

An investigation of incident 364943 was initiated on 7/20/2022. The census was LCH-360.

An investigation of incident 364943 was initiated on 7/20/2022. The census was LCH-360. Abbreviations Registered Nurse (RN), Licensed Vocational Nurse (LVN) Home Health Aide (hha) Plan of Care (POC) (485) Skilled Nursing Services (SN) RN CLM-Clinical Manager RN CM-Case Manager WES-Weekend Supervisor OASIS –Outcome and Assessment Information Set PRN – as needed

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to update of the comprehensive assessment (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline in the patient's health status for 1 (Patient #1) of 3 active Patients reviewed with wounds. The failure put the Patient at risk for deterioration of a wound, wound infection and hospitalization Patient #1 Record review for Patient #1 revealed a Plan of Care dated 6/27/2022 to 8/25/2022. The Plan of Care listed Myopathy, unspecified as the primary diagnosis. The Plan of Care contained an order for skilled nursing visits 1 time a week for 9 weeks, physical therapy 2 times a week for 9 weeks and occupational therapy 1 time a week for 4 weeks. The plan of care included orders for the skilled nurse for instructions/reinforcement of diabetic care to include diet, skin care administration of insulin blood glucose testing and diabetic foot care. The plan of care did not include wound care orders. The skilled nurse visit note dated 7/05/22 contained the following information: On 7/5/2022 LVN #1 made a home visit. LVN #1 documented findings of the 2nd and 3rd digits of the left foot were necrotic. The chart contained a picture of Patient #1’s necrotic 2nd and 3rd digits of the left foot in the attachment section of the electronic record. LVN #1 documented calling the physician and leaving a message and would follow up in the morning. The chart did not contain any documentation of a follow up with the physician or reporting to any other agency staff. An interview was conducted on 7/20/2022 at 3:00 pm with LVN #1. The surveyor reviewed the 7/5/2022 note with LVN #1. LVN #1 said that on 7/6/2022 he called the doctor’s office and was put on hold for too long and he hung up. LVN #1 said he called the agency and reported the findings to RN CLM #1. LVN #1 said he sent a photo of the necrotic 2nd and 3rd digits of Patient #1’s left foot through Forcura, a mobile phone application to the agency medical records department. LVN #1 failed to document his 2nd call to the physician or his called in report to RN CLM #1 on 7/6/2022 on a coordination note. The skilled nurse visit note dated 7/14/2022 contained the following information: On 7/14/2022 LVN #2 made a skilled nurse visit to Patient #1. The nurse’s note included documentation that integument was assessed and indicated wounds. The skilled nurses note did not include wound location, description or care provided. An interview via phone on 7/21/22022 at 11:17 a.m. with LVN #2 was conducted. The surveyor reviewed LVN #2 nurses note for 7/14/2022. LVN #2 said that Patient #1 refused for the LVN #2 to assess his toes. The surveyor commented that there was no documentation of Patient #1 refusing the assessment. LVN #2 said she didn’t think to document that. LVN #2 said she had not reported Patient #1’s wounds to his toes to anyone because he refused to let me assess his them. The surveyor asked LVN #2 what the risks to the Patient are when findings are not reported, documented and coordinated with others involved in a Patient’s care. LVN #2 said the wound could worsen or become infected. An interview was conducted on 7/21/2022 at 12:13 p.m. with RN CLM #1. Surveyor reviewed the above interview with RN CLM #1 of LVN #1 calling and reporting to RN CLM #1 the necrotic toes and sent a picture of Patient #1’s toes on 7/6/22 from his visit made on 7/5/22. Surveyor discussed with RN CLM #1 that a significant change in condition occurred but no RN went to see Patient #1 until 7/17/2022. RN CLM #1 said that he did not have a note, a picture, or any record of LVN #1’s report about Patient #1. RN CLM #1 went on to state, “I am not saying it didn’t happen, I just don’t have a record of it.” RN CLM #1 said he became aware of Patient #1 necrotic toes on 7/15/2022, when Patient #1’s stepdaughter called in and reported Patient #1’s left great toe was draining a significant amount. RN CLM #1 said that LVN #2 attempted to make a visit on 7/15/2022 and 7/16/2022 but Patient #1 refused the visits. The surveyor reviewed that the chart did not contain documentation of the attempted visits and Patient #1’s refusal of the visits. RN CLM #1 did not comment. The surveyor asked what the risks were to a patient if the coordination of care was not documented. RN CLM #1 said there could be a delay in care being provided. An interview was conducted on 7/28/2022 at 10:28 a.m. via phone with RN CM #1. Surveyor reviewed Patient #1 chart findings. RN CM #1 said she did not know why a visit wasn’t made to assess Patient #1’s toes for 48 hours from the time the agency was made aware of Patient #1 necrotic toes, that she does not make the schedule or assign visits. RN CM #1 said she became aware of the necrotic toes when she was assigned to make a prn visit to assess and take a picture of Patient #1’s wounds on 7/17/2022. RN CM #1 said she reported her findings to the WES. RN CM #1 said she didn’t know she needed to document her report to the WES. The surveyor asked what the risks are to a patient’s wounds when coordination of care was not documented. RN CM #1 said the follow-up would be slow. An interview with the Administrator/Supervising Nurse was conducted on 7/22/2022 at 2:25 pm. The surveyor discussed the chart findings that a registered nurse failed to see Patient #1 due to lack of coordination of the findings on the LVN #1’s 7/5/2022 skilled nurse visit of the necrotic toes. The Administrator said that she was unclear about why the information did not get relayed appropriately. Agency Policy: “Patient/Client Reassessment/Recertification/Significant Change in Condition/Post Hospital Assessment PE.4” read in part: “…PURPOSE To establish criteria for reassessment of the patient/client and revision of the plan of care based on this assessment…II…B For a significant change in condition (SCIC) not envisioned in the original Plan of Care…”

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in 2 (Patient #1 and #2) of 3 patients with wounds. This failure could place the agency patients at risk of receiving inadequate and inappropriate care and services that could result in negative health outcomes for the patients. Patient #1 Record review: Record review for Patient #1 revealed a Plan of Care dated 6/27/2022 to 8/25/2022. The Plan of Care listed Myopathy, unspecified as the primary diagnosis. Definition: The myopathies are neuromuscular disorders in which the primary symptom is muscle weakness due to dysfunction of muscle fiber. Other symptoms of myopathy can include include muscle cramps, stiffness, and spasm. The Plan of Care contained an order for skilled nursing visits 1 time a week for 9 weeks, physical therapy 2 times a week for 9 weeks and occupational therapy 1 time a week for 4 weeks. The plan of care included orders for the skilled nurse for to provide instructions/reinforcement of diabetic care to include diet, skin care, administration of insulin, blood glucose testing and diabetic foot care. The plan of care did not include wound care orders. The skilled nurse visit note dated 7/05/2022 contained the following information: On 7/05/2022 LVN #1 made a home visit. LVN #1 documented findings of the 2nd and 3rd digits of the left foot were necrotic (definition: necrosis is the death of cells in an organ or tissue). The chart contained a picture of Patient #1’s necrotic 2nd and 3rd digits of the left foot in the attachment section of the electronic record. LVN #1 documented calling the physician and leaving a message and would follow-up in the morning. The chart did not contain any documentation of a follow-up with the physician or reporting to any other agency staff. In an interview on 7/20/2022 at 3:00 pm the surveyor reviewed the 7/5/2022 note with LVN #1. The LVN #1 said he called the doctor’s office on 7/5/2022 and left a message including his assessment findings of Patient #1’s toes. LVN #1 called again on 7/6/2022, but hung up after being placed on hold. LVN #1 said he called the agency and reported the findings to RN CLM #1 on 7/6/2022. LVN #1 said he sent a photo of the necrotic 2nd and 3rd digits of Patient #1’s left foot through Forcura, a mobile phone application to the agency medical records department. LVN #1 failed to document his 2nd call to the physician or his called in report to RN CLM #1 on 7/6/2022 on a coordination note. An interview was conducted on 7/21/2022 at 12:13 p.m. with RN CLM #1. Surveyor reviewed the above interview with RN CLM #1 of LVN #1 calling and reporting to RN CLM #1 the necrotic toes and sent a picture of Patient #1’s toes on 7/6/22 from his visit made on 7/5/22. RN CLM #1 said that he did not have a note, a picture, or any record of that occurring. RN CLM #1 went on to state, “I am not saying it didn’t happen, I just don’t have a record of it.” RN CLM #1 said he became aware of Client #1 necrotic toes on 7/15/2022, when Patient #1’s stepdaughter called in and reported Patient #1’s left great toe was draining a significant amount.. RN CLM #1 said that LVN #2 attempted to make a visit on 7/15/2022 and 7/16/2022 but Patient #1 refused the visits. The surveyor reviewed that the chart did not contain documentation of the attempted visits and Patient #1’s refusal of the visits. RN CLM #1 did not comment. The surveyor asked what the risks were to a patient if the coordination of care was not documented. RN CLM #1 said there could be a delay in care being provided. The skilled nurse visit note dated 7/14/2022 contained the following information: On 7/14/2022 LVN #2 made a skilled nurse visit to Patient #1. The nurse’s note included documentation that integument was assessed and indicated wounds. The skilled nurses note did not include wound location, description or care provided. An interview via phone on 7/21/2022 at 11:17 a.m. with LVN #2 was conducted. The surveyor reviewed LVN #2’s nursing note for 7/14/2022. LVN #2 said that Patient #1 refused for the LVN to assess his toes. The surveyor commented that there was no documentation of Patient #1’s refusing the assessment. LVN #2 said she didn’t think to document that. LVN #2 said she didn’t think to document that Patient #1 had refused. The surveyor asked LVN #2 what the risks to the patients are when findings were not reported, documented, and coordinated with others involved in a patient’s care. LVN #2 said the wound could worsen or become infected. The coordination note report dated 7/15/2022 contained the following information: A call was received from a stepdaughter of Patient #1 reporting concerns over Patient #1’s “left foot, darkened and has drainage.” LVN #3 reported to physician and received an order for a prn visit to assess Patient #1’s wounds. On 7/15/2022 an order was written for a prn skilled nurse visit to assess wound. The skilled nurse visit note dated 7/17/2022 contained the following information: On 7/17/2022 RN RN CM #1 made a prn visit to Patient #1. RN CM #1 documented 2nd and 3rd toe to left foot, tender to palpation, scant drainage and both digits discolored (black). RN CM #1 recommended Patient #1 go to the emergency room for a thorough assessment of wounds. RN CM #1 called physician to give report, office closed and no on call set up to leave message. RN CM #1 recommended Patient #1 go to the hospital for thorough assessment of wounds. Patient #1’s son said, “I will take him now.” An interview was conducted on 7/28/2022 at 10:28 a.m. via phone with RN RN CM #1. RN CM #1 said she did not know why a visit wasn’t made to assess Patient #1’s toes for 48 hours from the time the agency was made aware of Patient #1 necrotic toes, that she does not make the schedule or assign visits. RN CM #1 said she became aware of the necrotic toes when she was assigned to make a prn visit to assess and take a picture of Patient #1’s wounds on 7/17/2022. RN CM #1 said she reported her findings to the WES. RN CM #1 said she didn’t know she needed to document her report to the WES. The surveyor asked what the risks are to a patient wounds when coordination of care was not documented. RN CM #1 said the follow-up would be slow. An interview was conducted via phone on 7/28/2022 at 12:14 p.m. with LVN #1. Surveyor discussed the chart findings. LVN #1 said he had not reported his findings to RN CM #1. LVN #1 stated he had not documented his 2nd call to the physician and to RN CLM #1 on 7/6/2022. LVN #1 said, “I should have written a coordination note.” The surveyor asked LVN #1 what the risks are to a patient when changes are not reported and documented. LVN #1 said the patient would not get taken care of properly. An interview with the Administrator/Supervising Nurse was conducted on 7/22/2022 at 2:25 pm. The surveyor discussed the chart findings that a registered nurse failed to see Patient #1 due to lack of coordination of the findings on the LVN #1’s 7/5/2022 skilled nurse visit of the necrotic toes. The Administrator said that she was unclear about why the information did not get relayed appropriately. Patient #2 Record review for Patient #2 revealed a Plan of Care dated 6/11/2022 to 8/9/2022. The Plan of Care listed Type 1 Diabetes Mellitus with Hyperglycemia as the primary diagnosis. The Plan of Care contained an order for physical therapy 2 times a week for 8 weeks and 1 time a week for 1 week, occupational therapy 1 time a week for 1 week, and home health aide 2 times a week for 5 weeks. The plan of care included orders for physical therapy to provide monitoring for the presence of skin lesions on the lower extremities and teaching/reinforcement regarding proper diabetic foot care. The plan of care did not include wound care orders. The record contained a coordination noted dated 7/11/2022 entered by LVN #3. The coordination note stated the hha reported a wound to the right foot, 5th toe and that LVN #3 notified Patient #2’s physician. An order for a prn visit was received from the physician and documented by LVN #3. A prn visit was conducted on 7/15/2022 by RN CM #2 The skilled nurse visit note dated 7/15/2022 contained the following information: A visit was made on 7/15/2022 by RN CM #2. RN CM #2 conducted a significant change in condition OASIS. RN CM #2 documented an assessment of a traumatic wound to the right dorsal surface of the foot with 4+ pitting edema over the full dorsal surface of the foot. RN CM #2 documented and sent a report to Patient #2’s physician along with a picture of the wound. An interview was conducted on 7/22/2022 at 11:55 a.m. with LVN #3. The surveyor reviewed LVN #3’s statement of “notified all staff involved with care.” LVN #3 said that when opened, Patient #2’s chart, the coordination note she documented would pop up on their screen. LVN #3 said she coordinated the information with RN CLM #2. LVN #3 said RN CLM #2 asked her to call the doctor’s office with the report and ask for an order for a prn visit. LVN #3 said she documented the order when received it for the prn visit. An interview was conducted on 7/22/2022 at 12:20 p.m. with RN CLM #2. The surveyor reviewed the chart findings that an order was received from the physician for a visit on 7/11/2022 but no visit was conducted by an RN due to a change in condition until 7/15/2022. RN CLM #2 said she overlooked or failed to see the order, so the visit was not scheduled. The surveyor asked RN CLM #2 what the risks are to a patient if the RN failed to see a patient timely. RN CLM #2 said the patient may not get timely or appropriate care. An interview was conducted on 7/22/2022 at 2:25 p.m. with the Administrator/Supervising Nurse. The surveyor reviewed that a prn visit was not made timely to Patient #2 after the order was received on 7/11/2022. The Administrator/Supervising Nurse said it appeared that the order was entered and not approved in a timely manner. An interview was conducted on 7/28/2022 at 10:18 a.m. via phone with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse said patients could have an exacerbation and resulting in hospitalization if they do not receive the needed care timely. Agency Policy: “Monitoring Client Care/Coordination of Care PC.11” read in part:”…PURPOSE To ensure coordination of client/client care and treatment…PROCEDURE I. The Agency will: A. Ensure communication with all physicians and/or non-physician practitioners, involved in the plan of care. B. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to ensure the coordination of all services and interventions provided to the client/client…III. Agency staff are expected to contact the Agency to report client/client needs and changes. This will be documented on a communication note and will serve as coordination of care…”