Every finding on record at Laketop Inc

Recertification survey completed. Standard Level deficiencies cited.

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 clinical record review, observation and staff interview, it was determined the Agency failed to conform with Physician orders. This was found in 3 of 7 (Patients #2, 5, and 6) clinical records reviewed. Findings include: 1. Patient #2 was admitted to Home health services on 10/16/23 with a diagnosis of Hypertensive Heart Disease with Heart failure. The clinical record was reviewed on 10/24/23. The signed physician order dated 10/16/23 included orders for Skilled Nurse to check oxygen saturation every visit and report any abnormal range less than 92% to the physician as soon as possible. The Start of care assessment dated 10/16/23, lacked an assessment of oxygen saturation as ordered. During the home visit with Skilled Nurse on 10/25/23, it was observed that the Skilled Nurse did not assess oxygen saturation, as ordered. 2. Patient #5 was admitted to Home health services on 05/10/23 with a diagnosis of Diabetes Mellitus and Osteoarthritis of knee. The clinical record was reviewed on 10/25/23. The signed physician orders effective 05/10/23 required Skilled Nurse to notify physician for pain greater than 6. The Skilled Nurse visit notes dated 10/11/23 and 10/18/23, lacked an assessment for pain. 3. Patient #6 was admitted to Home health services on 03/07/23 with a diagnosis of Bilateral Primary Osteoarthritis of Hip. The clinical record was reviewed on 10/25/23. The signed physician orders effective 07/05/23, required Skilled Nurse to notify physician for pain greater than 6. The Skilled Nurse visit note dated 07/25/23, documented current pain intensity of 7. There was no documentation of physician notification related to pain level greater than 6. 4. During an interview with the Administrator and Director of Nursing on 10/26/23 at 11:30 AM, the Director of Nursing confirmed the above findings of not following physician orders.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview it was determined that Agency failed to ensure all entries to the clinical record were complete. This was found in 5 of 7 clinical records reviewed. (Pts # 7,1,2,5, and 6) 2. Patient #1 was admitted to Home health services on 10/17/23. Diagnosis: Hypertensive Heart disease with Heart failure. The clinical record was reviewed on 10/24/23. The consent for Home care services was signed by Patient #1 and dated 10/17/23. The form lacked indication of patient consent to treatment, acknowledgment for receiving information regarding Advance directives, whether Patient has Advance directives (Living Will or Durable Power of Attorney), or if patient wished to receive assistance in preparing Advance directives. The flu/pneumonia vaccine log consent was signed by Patient. #1 and dated 10/17/23. The form lacked complete documentation/response to inquiry regarding patient’s interest in receiving influenza and pneumonia vaccine. 3. Patient #2 was admitted to Home health services on 10/16/23. Diagnosis: Hypertensive Heart Disease with Heart failure. The clinical record was reviewed on 10/24/23. The consent for Home care services was signed by Patient #2 and dated 10/16/23. The form lacked indication of whether patient has Advance directives or wished to receive assistance in preparing Advance directives. The flu/pneumonia vaccine log consent was signed by Patient #2 and dated 10/16/23. The form lacked complete documentation/response to inquiry regarding patient’s interest in receiving influenza and pneumonia vaccine. 4. Patient #5 was admitted to Home health services on 05/10/23. Diagnosis: Diabetes Mellitus and Osteoarthritis of Knee. The clinical record was reviewed on 10/25/23. The flu/pneumonia vaccine log consent was signed by Patient #5 and dated 05/10/23. The form lacked complete documentation/response to inquiry regarding patient’s interest in receiving influenza and pneumonia vaccine. 5. Patient #6 was admitted to Home health services on 03/07/23. Diagnosis: Bilateral Primary Osteoarthritis of Hip. The clinical record was reviewed on 10/25/23. The consent for Home care services was signed by Patient #6 and dated 03/07/23. The form lacked indication of patient consent to treatment, acknowledgment for receiving information regarding Advance directives, whether patient has Advance Directives (Living Will or Durable Power of Attorney), or if patient wished to receive assistance in preparing Advance directives. The pneumonia vaccine log consent was signed by Patient #6 and dated 03/07/23. The form lacked complete documentation/response to inquiry regarding patient’s interest in receiving pneumonia vaccine. 6. During interviews with the Administrator on 10/25/23 from 1:30 to 2:00 PM, the Administrator confirmed the above findings of incomplete clinical records. Findings include: 1. Patient # 7 was admitted 03/28/23 with Diagnosis of Primary Osteoarthritis, right wrist. The clinical record was reviewed on 10/25/23 at 9:30 AM. The clinical record contained an incomplete document titled “Disaster Preparedness / Directions / Coordination of Care” completed on 03/28/23, the document lacked the Home Health triage level. Patient #7 clinical record also contained an incomplete document completed on 03/28/23 titled “Emergency Contacts”. The document lacked the patient Emergency contact information.