Every finding on record at Lake Regional Health Systems

A complaint investigation (61710) was completed on 02/08/2022 at Lake Regional Home Health. The agency had 85 current patients. The complaint is substantiated. One or more of the allegations reported are verified and standard level deficiencies were cited that are related to the allegations being investigated.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in one (Record/Patient #2) of three full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled “Care Planning,” dated 12/14/2021 showed that: - Each patient admitted to the agency will have plan of care documents to develop and coordinate care of patients among the disciplines; - The organization has a process to identify patient problems, establish individual patient goals and implement identifications and interventions; and - The 485 (serves as a plan of care and certification for patient home health care) will be used as the care planning documents, individual care provider goals will be documented on the 485 or initial physician interim orders to establish service. RECORD/PATIENT #2: Review of the comprehensive start of care assessment dated 07/20/2021 showed, in part: - Primary diagnosis: Encounter for change or removal of nonsurgical wound dressing; - Other diagnosis included, but not limited to, Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) of sacral region (located below the lumbar spine and above the tailbone), encounter for attention to colostomy (an artificial exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) and encounter for fitting and adjustment of urinary device; - Stage 4-pressure ulcer to the right buttock with small amounts of drainage on dressing, the patient’s family member changed the dressing; - The patient has a Foley catheter (thin, flexible catheter used to drain urine from the bladder), last changed 07/14/2021 and size 16 French (size of Foley catheter); - Patient has a colostomy; - Location of pain left shoulder, rated a six (zero representing no pain and 10 representing the worst pain possible); - Medications make the pain better; - Medications are mildly effective (discrepancy with medications make the pain better); - Pain a five after taking medications and patient’s pain goal is a two; and - Pain interferes with activity or movement all of the time. Review of the patient's plan of care dated 07/20/2021 to 09/17/2021, failed to show the following: - Instruction on how to treat the wound, what supplies to use, and how often to change the dressing; - Size of Foley catheter and how often to change the Foley catheter; - Type and size of ostomy system; and - Specific individualized interventions for pain control. During an interview on 02/08/2022 at 10:45 AM, the director of nursing stated that he/she expected all treatment orders be specific and if they are not, staff are to contact the physician for specific treatment orders. No further information was provided.

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 record review and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled “Home Health Assessment and Reassessment of Patients,” dated 05/03/2021, showed that therapy and nurse to notify physician if the patient reports pain that is three or more numbers higher than previously reported without relief from pain medication. RECORD/PATIENT #2: Review of the patient's plan of care dated 07/20/2021 to 09/17/2021, showed the following: - Primary diagnosis: Encounter for change or removal of nonsurgical wound dressing; - Other diagnosis included, but not limited to, Stage 4 pressure ulcer of sacral region (located below the lumbar spine and above the tailbone) and long term use of opiate analgesic (used for pain relief); - SN (skilled nurse) to instruct the patient and caregiver on signs/symptoms of wound infection to report to physician unrelieved pain greater that eight on a zero to 10 scale (a scale used to rate pain, zero means no pain and 10 means the worst possible pain). Review of the comprehensive start of care assessment dated 07/20/2021 at 10:55 AM showed, in part: - The agency provided the comprehensive assessment which included an undated photo of the stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the patient's right buttock, the photo showed three small open abrasions (area damaged by scraping or wearing away) below the stage four pressure and two small abrasions to the left of the pressure ulcer (no documentation regarding these abrasions); - There was no physician notification of the abrasions to the patient’s lower right buttock; and - Location of pain left shoulder, rated a six (zero representing no pain and 10 representing the worst pain possible). Review of the physical therapy (PT) evaluation dated 07/20/2022 at 2:00 PM, showed that: - The patient reported a pain of 10 to his/her back (no further information documented); - The physical assessment showed a “pressure sore from coccyx to the upper posterior thigh” (no further information documented); and - The physician was not notified of the patient’s pain and “pressure sore from the coccyx and to the upper posterior thigh.” During an interview on 02/08/2022 at 10:45 AM, the director of nursing and home health coordinator, looked at the photo and stated that the areas below the stage four pressure ulcer were excoriated areas and looked like they were from shearing (force generated when skin is moved against a fixed surface). He/she would have expected the physician to be notified of the areas, and the photo sent to the physician. There was a lot of communication on this patient but was not documented. The patient did not have a pressure ulcer on his/her upper posterior thigh. There was no further information provided.