Every finding on record at Madison Home Care

An onsite recertification and follow up survey was conducted 09/11/23-09/12/23. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification and follow up survey was conducted 09/11/23-09/12/23. Deficiencies to the Medicare Conditions of Participation were identified. The following tags were put back into compliance: G464, G466, G574, G704, G710, G716, and G1022.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to notify the physician of increased weakness and low blood pressures in 1 of 2 discharged patients (#2). Findings included: A policy, “Coordination of Services” (12/2019), was provided by the agency director on 9/12/23 at 1:30 p.m. The policy stated, “[Agency name] coordinates the provision of home care and hospice services…communication between staff and the patient’s physician is documented in the daily note, verbal order form, miscellaneous communication note, or Practice Partner’s electronic records.” Patient #2 was admitted on 3/14/23 with diagnoses of stage 2 pressure ulcers (partial-thickness skin loss that resulted from pressure) of right and left buttock, type 2 diabetes, and autoimmune hepatitis (inflammation of the liver that occurs when the body’s immune system attack liver cells). The Plan of Care (POC) for 3/14/23-5/12/23 included orders for skilled nursing one time for one week, twice weekly for two weeks, weekly for six weeks, and three visits as needed. The POC also included orders for skilled nursing to assess blood pressure (BP) and apical and radial pulses, assess pain, and assess fatigue and response to activity. The initial assessment was conducted 3/14/23 by RN #6. The visit note stated, “[Vital signs within normal limits] except BP low 102/70 at rest, dropped to 90/70 after standing…” the physician office was notified. On 3/22/23, the visit note stated, “…will notify PCP [primary care provided] of continued elevated HR [heart rate] and low BP, weakness and lethargy…” Communication notes with the physician office on 3/23/23 revealed the nurse notified the physician office that the caregiver only monitored two blood pressures and the readings were within normal limits. The nurse also notified the physician the “patient very weak and needed 2 person assist to stand safely.” The provider responded, “Recommend appt [appointment] to evaluate.” On 3/24/23, the visit note stated, “Wife reported patient has been in bed since breakfast due to back pain…[daughter] reported BP readings last 2 days 87/66-105/65…reported patient fell to ground while in lawyer’s office and EMS/first responders were called to get patient up…Patient did not want [home health nurse] to assess sacral area due to pain…Instructed [daughter to continue monitoring HR [heart rate] and BP.” There was no evidence the physician’s office was notified of the low blood pressure readings or the fall. On 3/28/23, the RN visited. The visit note stated, “Reported poor [oral] intake…Wife unable to get meter [to monitor blood sugar] work this am.” The patient also complained of pain and weakness. The nurse checked blood sugar and got a reading of 467. Called EMS for transport to the emergency department. Blood sugar was repeated with a reading of 538. The patient was admitted to the hospital with mild diabetic ketoacidosis (a serious complication of diabetes that can be life-threatening). The transfer summary in the 3/29/23 note, stated that the physician was contacted on 3/29/23. An interview with the agency director on 9/12/23 at 1:00 p.m. confirmed there was no evidence of communication related to the home visit findings on 3/24/23.

An unannounced complaint investigation was conducted 10/10/22. The allegations were substantiated and deficiencies to the Medicare CoP were identified.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to notify the patient of pending discharge for cause prior to discharge for 1 of 1 patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care for the certification period 7/25/22 to 9/22/22 included plans for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. Review of the clinical record revealed RN # 2 discharged the patient for cause on 9/13/22. The last SN visit was made on 9/8/22 by RN # 2. Review of the Patient Concern Log revealed the following documentation, “The Patient Concern Log revealed the following entry, “…Date patient concern became apparent – 9/14/22…Description of Patient Concern-Pt [patient] visited LPTA [licensed physical therapy assistant] residence after going to the store. Pt had not been invited by LPTA. LPTA was in a swimsuit washing her vehicle. LPTA reports that she felt violated by the pt. Action Plan/Resolution- Notified WTC [wound clinic] of pt not homebound as he is driving to the store and out to locate his previous LPTA. Notified pt of same and that WTC would contact him regarding his wound care.” There was no evidence the patient was notified of discharge and no evidence the Notice of Medicare Non-Coverage document was provided . Review of the communications section of the clinical record revealed the following information: 9/13/22 6:39 pm [on call] RN # 3 documented, “SN received call from ______ [pt’s dtr-patient’s daughter]. ______ wants to know why RN was a no call/no show today for visit…SN called _____ [RN # 2]. ________ [RN # 2] reports pt is D/C [discharge pending] for not being home bound. SN called ______ [daughter] back and reported this to her…” The patient nor the daughter were notified of the pending discharge for cause prior to the patient being discharged. During an interview with RN # 2 on 10/10/22 at 4 pm, the RN confirmed the patient did not receive any advance notice of a pending discharge for cause, but the patient/daughter was advised the patient was being discharged for not being homebound.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to attempt to resolve an issue concerning the patient before discharging for cause for 1 of 1 patient discharged for cause [#1]. The findings included: The policy, Discharge of Patients [revised 3/07], was provided by RN # 2 on 10/10/22 at 2 pm. The policy stated, “…The following steps are documented in all situations where _________ [name of agency] and hospice decides to discharge patient: ______ [agency name] professional staff and the clinical supervisor attempt to resolve situations that threaten _______ [agency name] staff with the patient and or caregiver. Advance notification of at least 48 hours is given to the patient when services are to be reduced or terminated except when the patient is in agreement of the changes or the physician terminates services…Documentation will be entered into the service record for all discharges and discharge plans that includes, at a minimum, the date and reason for the discharge, a summary of services that were provided…” Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. The patient was discharged for cause on 9/13/22. There was no evidence in the clinical record the agency attempted to resolve the problem before the patient was discharged. During an interview with RN # 2 on 10/10/22 at 4 pm, she confirmed the agency failed to attempt to resolve the issue prior to discharge.

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 clinical record review and staff interviews the Plan of Care failed to include all medications/complete directions for use the patient was using at the time of admission for 1 of 3 patients [#1]. The findings included: 1A. Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care [POC] for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition] and “…Visiting professional will notify MD of the following clinical findings during nursing visits blood sugar less than 70 or greater than 400. Notify the primary physician within 7 day of blood sugar greater than 250…” Review of the medication section of the POC listed NovoLOG Insulin [for diabetes] Flexpen 100 units per 1 milliliter. Inject 0-6 units 4 times per day sliding scale [amount of insulin given depends on blood sugar reading] before meals and bedtime.” An interview was conducted with RN # 2 on 10/10/22 at 4 pm. During the interview, RN # 2 confirmed the order for NovoLOG insulin was incomplete on the POC. 1B. Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care [POC] for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. Review of the clinical record revealed RN # 1 8/1/22 documented, “…patient not wearing oxygen. States he only wears at night…” During an interview with RN # 1 on 10/10/22 at 3:30 pm, RN # 1 confirmed the patient used supplemental oxygen at night, but the oxygen was not listed on the medication section of the POC. During an interview with RN # 2 on 10/10/22 at 4 pm, she confirmed the oxygen should have been listed on the POC.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency protocol, clinical record review and staff interviews the RN [registered nurse failed to obtain weekly wound measurements for 1 of 2 patients with a wound [#1]. The findings included: The agency protocol, “________ [agency name] Home Care and Hospice Wound Protocol 2021, was provided by RN # 2 on 10/10/22 at 2:30 pm. The protocol stated, “ALL WOUNDS must be measured EVERY WEEK. Using wound care tool…” Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition] and “Clean venous stasis ulcer to left lower anterior leg/shin with mild soap and water. Apply Cutlimed Sorbact [sic], cover with plain foam, apply lotion to peri-wound. Secure with 3-layer compression. Dressing changes 2 times per week.” Initial wound measurements of 2.5 centimeters [cm] x 1.5 cm x 0.1 cm were obtained on 7/29/22. No other wound measurements were obtained until 9/8/22 [date of last SN visit]. An interview was conducted with RN # 1 on 10/10/22 at 3:30 pm. During the interview the RN confirmed RN # 1 failed to obtain wound measurements in accordance with the agency protocol.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the RN [registered nurse] failed to provide blood sugar monitoring/assessment in accordance with the physician’s order for 1 of 2 diabetic patients [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care [POC]for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing [SN] 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. Further review of the POC revealed an SN intervention to “Assess blood sugar monitoring and results. Notify MD [physician] as indicated.” Review of the clinical record revealed the SN only recorded blood sugar readings 4 of the 11 visits. During an interview with RN # 1 on 10/10/22 at 3:30 pm the RN stated, “yes, I usually did ask him to see his blood sugar log. I recorded all of the ones I got in the flow sheet section of the chart.” During an interview with RN # 2 on 10/10/22 at approximately 4 pm, RN # 2 confirmed only 4 blood sugars were obtained. The blood sugars were not obtained/monitored in accordance with the physician’s order.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency’s Patient Concern Log, clinical record review and staff interviews the RN [registered nurse] failed to document consistent information related to patient discharge from the agency for 1 of 1 of patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care for the certification period 7/25/22 to 9/22/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. Review of the Patient Concern Log revealed an entry dated 9/14/22 by RN # 2. The Patient Concern Log revealed the following entry, “…Date patient concern became apparent – 9/14/22…Description of Patient Concern-Pt [patient] visited LPTA [licensed physical therapy assistant] residence after going to the store. Pt had not been invited by LPTA. LPTA was in a swimsuit washing her vehicle. LPTA reports that she felt violated by the pt. Action Plan/Resolution- Notified WTC [wound clinic] of pt not homebound as he is driving to the store and out to locate his previous LPTA. Notified pt of same and that WTC would contact him regarding his wound care.” Review of the clinical record revealed Patient # 1 lived alone and was in need to get medications from the drugstore. Review of the agency discharge report provided by the agency dated 10/10/22 revealed patient was discharged for cause on 9/13/22. Review of the communications section of the clinical record revealed the following information: 9/13/22 at 2 pm RN # 1 entered an order discontinue SN services for wound care. 9/13/22 6:39 pm [on call] RN # 3 documented, “SN received call from ______ [pt’s dtr-patient’s daughter]. ______ wants to know why RN was a no call/no show today for visit…SN called _____ [RN # 2]. ________ [RN # 2] reports pt is D/C [discharge pending] for not being home bound. SN called ______ [daughter] back and reported this to her…” 9/14/22 entry for 9/13/22 [no time] RN # 1 documented – “Attempted to contact patient 9/13/22 x 2 regarding dc [discontinue] from agency…” 9/14/22 9:36 am RN # 2 documented entry for 9/13/22 at 4 pm- “Contacted ______ [name] Wound Clinic to report patient dc’d [discontinued] from hh [home health] due to not being homebound…” During an interview with RN # 2 on 10/10/22 at 1 pm, RN # 2 stated, “He was discharged for cause. None of my staff would go back out and see him. I don’t know how he got the LPTA’s address. It’s a small area, we all live close. I was not told he said anything inappropriate to the LPTA. “RN # 2 confirmed the clinical record was inconsistent regarding the reason for discharge.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to complete a discharge summary for 1 of 1 patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene [blood vessel disease caused by high blood sugar levels], Chronic Venous Hypertension with ulcer of left lower extremity, non-pressure chronic ulcer of other part of left lower leg and Type 2 Diabetes Mellitus with hyperglycemia. Review of the Plan of Care for the certification period 7/25/22 to 9/22/22 included plans for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks and 3 PRN [as needed for changes in condition]. Review of the clinical record revealed the patient was discharged for cause on 9/13/22. Further review of the clinical record revealed the discharge summary was still being “edited” as of 10/10/22 at 3 pm. During an interview with RN # 2 on 10/10/22, the RN confirmed the discharge summary was not complete and had not been forwarded to the physician.

An onsite recertification survey was conducted June 16-18, 2021. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted June 16-18, 2021. Standard level deficiencies to the Medicare Conditions of Participation were identified.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to conduct with initial assessment within 48 hours of referral or a physician ordered start of care date for 3 of 10 patients (#3, 5, and 6). Findings include: Patient #3 had a referral date of 5/14/21. The patient was discharged from the hospital after a total laparoscopic hysterectomy. The referral was for skilled nursing and physical therapy. The initial assessment was conducted on 5/17/21 by the RN. An interview with the intake coordinator conducted on 6/18/21 at 10:45 a.m. revealed the patient was discharged on a Friday afternoon and she thinks the patient declined admission over the weekend. An interview with the agency director on 6/18/21 at 10:45 a.m. confirmed there was no documentation that stated why the initial assessment was not conducted within 48 hours of referral. Patient #5 had a referral date of 5/7/21 with a requested start of care date of 5/11/21. The referral was for skilled nursing services. An interview with the intake coordinator on 6/18/21 at 10:45 a.m. revealed the RN was going to see patient, but when he called, the patient had a doctor’s appointment that day. An interview with the agency director on 6/18/21 at 10:45 a.m. confirmed there was no documentation that stated why the initial assessment was not conducted on the requested start of care date. Patient #6 had a referral date of 5/14/21. The referral was for skilled nursing, physical therapy, and occupational therapy. The initial assessment was conducted on 5/17/21 by the RN. An interview with the intake coordinator on 6/18/21 at 10:45 a.m. revealed the agency asked about starting patient services on Monday, May 17, 2021. The agency stated there was no documentation in the clinical record regarding this. An interview with the agency director on 6/18/21 at 10:45 a.m. revealed that there was documentation in the medical center chart (not the home health agency record) that stated the physician agreed to opening on Monday if the patient was ok with that. There was no evidence in the record that the patient was contacted regarding changing the start of care

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview the agency instructed on/provided treatments that were not included on the Plan of Care for 3 of 10 patients (#2, 4, and 6). Findings include: The “Patient Plan of Care” policy was provided by the agency director on 6/21/21 at 12:54 p.m. The policy stated, “The plan of care includes…The tasks to be performed by each level service personnel…Medication and treatments…The plan of care is incorporated into the medical record.” 1A. Patient #2 was admitted on 4/27/21 with diagnoses of surgical wound, colostomy, and colon cancer. The Plan of Care for 4/27/21-6/25/21 included orders for skilled nursing 1 time for initial assessment, then 1 time for 1 week, 2 times per week for 3 weeks, and 1 time per week for 5 weeks. The initial assessment identified a surgical wound to the lower abdomen measuring 13 cm x 3.75 cm x 3 cm with 3 cm undermining/tunneling at 3:00. RN #1 conducted a visit on 4/29/21. The visit note stated, “[instructed] to obtain zinc 50 mg po qd [by mouth daily] to aid in wound healing.” An interview with RN #1 on 6/18/21 at 9:55 a.m. confirmed there was no physician order for Zinc obtained “because it’s over the counter.” 1B. RN #1 conducted a visit on 5/31/21. During the wound assessment the RN noted “yeasty rash at lat [lateral] edges”. The RN applied Nystop powder (anti-fungal) and skin prep layer. The visit note on 6/2/21 stated, “yeasty rash noted under dressing built up base of nystop and skin prep.” The visit on 6/4/21 conducted by RN #1, stated “yeast slowly resolving”. In an interview with RN #1 on 6/18/21 at 9:55 a.m. it was confirmed there was not evidence of an order for Nystop in the clinical record. 2. Patient #4 was admitted on 5/22/21 with diagnosis of a hip fracture. The Plan of Care for 5/22/21-7/20/21 included orders for skilled nursing, physical therapy, and occupational therapy. The patient was readmitted to the hospital on 5/24/21 with an adverse reaction to a medication. The patient had a resumption of care (ROC) visit conducted on 5/28/21. The ROC orders included skilled nursing assessment then 2 times per week the following week and weekly for the next 6 weeks. The orders also included wound care for the right dorsal hand: clean with wound cleanser, apply non-stick dressing, secure with film dressing, may use skin prep, secure with Kerlix and stretch net, change every 3 days and as needed. The ROC visit identified a “right hand deep laceration from fall.” A visit from RN #1 was conducted on 6/2/21. The note stated, “pt [patient] will not keep dressing in place after numerous attempts abtx [antibiotic] ointment applied…” RN #1 conducted a visit on 6/4/21 and documented “[continue] to apply abtx ointment as needed.” RN #1 conducted a visit on 6/10/21. The visit note revealed the patient had fallen and sustained rib fractures. The note also stated, “multiple scabbed areas on bilateral upper extremities cg [caregiver]attempted to dress but pt continues to remove them and possibly causing more damage…suggested using abtx oint prn [as needed] …” An interview with RN #1 on 6/18/21 at 9:55 a.m. confirmed there was no order for antibiotic ointment. She stated, “They had it in the home.” 3. Patient #6 was admitted on 5/17/21 with a diagnosis of hypertensive urgency. The Plan of Care for 5/17/21-7/15/21 included orders for skilled nursing, physical therapy, and occupational therapy. The patient was admitted to the hospital on 6/4/21. A resumption of care (ROC) visit was conducted on 6/9/21. RN #2 conducted the ROC assessment which revealed a stage 2 pressure area on the right buttocks measuring 0.4 cm x 0.3 cm x 0.1 cm. Extra Protective Cream was applied. An interview with RN #2 on 6/18/21 at 10:20 a.m. confirmed there was no order for extra protective cream.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to update the physician on changes/significant findings in patient condition for 3 of 10 patients (#5, 6, and 9). Findings include: Patient #5 was admitted on 5/14 with diagnoses of chronic obstructive pulmonary disease (COPD—respiratory disease) and lung cancer. The Plan of Care for 5/14/21-7/12/21 included orders for skilled nursing 1 time for an initial assessment then weekly for 9 weeks. The initial assessment conducted on 5/14/21 noted lungs sounds clear bilaterally with a productive cough with a moderate amount of clear sputum. RN #2 conducted a visit on 5/20/21. The visit note stated, “lung sounds with wheeze to right upper lobe and clear all other. Productive cough at time of thick clear mucus. Pt has pulmonary appt tomorrow and instructed pt/cg to consult with md at pulmonary [sic] of increased mucus production and inability at time to cough up…” An interview with RN #2 was conducted on 6/18/21 at 10:20 a.m. The interview confirmed the physician was not notified by the agency since the patient had an appointment the following day. 2. Patient #6 was admitted on 5/17/21 with a diagnosis of hypertensive urgency. The Plan of Care (POC) for 5/17/21-7/15/21 included orders for skilled nursing, physical therapy, and occupational therapy. The POC did not include vital sign parameters. The initial assessment on 5/17/21 revealed a blood pressure (BP) of 118/78. On 5/19/21, OT #3 conducted the OT evaluation. The documentation stated, “At time of this evaluation his BP was 91/58 in sitting and 67/44 in standing.” On 5/20/21, during the PT evaluation, the patient “report he is ‘just about back to normal, but I just stagger about some.’” The patient’s BP while sitting was 116/68 sitting and 98/60 standing. On 5/26/21, during the OT visit, the BP was 90/62. On 6/2/21, the RN took a BP of 98/60. The OT note on 6/2/21 stated, “He agreed that his low BP had been and “issue” and that he was a bit wobbly at times with his balance.” BP was 100/64. On 6/4/21, the RN took BP of 100/58. The patient was admitted to the hospital from 6/4/21-6/8/21 with diagnoses of hypotension and altered mental status. There was no evidence the physician was notified of the low BP. In an interview on 6/18/21 at 10:20, RN #2 said she was not aware of the BP of 67/44. In an interview with OT on 6/18/21 at 12:30, she stated she “called the RN but did not document.” She confirmed she did not notify the physician. 3. Patient #9 was admitted on 2/5/21 with a diagnosis of diabetes. The Plan of Care (POC) for 2/5/21-4/5/21 included orders for skilled nursing 2 times per week for 1 week, then 1 time per week for 7 weeks. The POC did not include parameters for blood sugar readings. The initial assessment on 2/5/21 had blood sugar (BS) range 350-400. It also stated, “Frequency checked: 2-3 times a day.” RN #4 conducted a visit on 2/10/21. The note stated, “Patient reported his BS have been [greater than] 600 for past 3 nights. He does not record readings in log. Reported FBS [fasting blood sugar] this am 71. Told HHN [home health nurse] his endocrinologist/________ is aware of his high readings…HHN will contact endocrinologist to report high readings.” There was no evidence in the record that the RN had called the physician about the high blood sugar readings. An interview with RN #4 on 6/18/21 at 10:40 a.m., RN stated she tried to call but no answer. She confirmed she did not call primary care physician because the endocrinologist was managing the patient’s diabetes. On the 2/12/21 nurse visit, the patient had not checked BS and declined to check while nurse was there. On 2/17/21, RN #4 documentation stated, “Reported BS continue to be [greater than] 600. He has not called endocrinologist to report readings. Did not check his BS this am.” On 2/19/21 RN #4 stated, “Reported again his readings have been [greater than] 600.” On 2/26/21, the BS was 239 in the morning, but no BS history reported. On 3/1/21, RN #5 conducted the visit. The patient reported the BS was “unreadable” and the “meter would only read ‘H’ [too high to register] …Patient encouraged to see doctor…” The patient was admitted to the hospital on 3/1/21 with volume overload. The patient had a resumption of care assessment completed on 3/3/21 with no documentation of blood sugar readings. The visit on 3/4/21 revealed a BS of 400 the previous evening. On 3/8/21, the morning BS was 299. On 3/10/21, the patient stated he had not checked BS that morning and could not remember the previous BS reading. RN #4 visit note on 3/12/21 stated, “HHS reviewed glucometer. Ranges noted in last 7 days 213 to “high” (over 500—too high for meter) with recent readings noted of 396 to 499.” On 3/15/21, BS reading was noted to be 598. A note on 3/19/21 revealed patient had been in the hospital for 4 days due to blood sugar being greater than 1,000. Patient to discharge from the hospital on 3/19/21. On 3/23/21, the RN entered in into home for resumption of care assessment. The patient was sick and send back to the emergency department. He was subsequently discharged.