Every finding on record at Mercy Hospital Fort Smith

. On 2/13/23 at 11:35 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 12/16/23 at 10:00 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 Clinical Record review, and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 3 (#1, #7, and #13) of 17 (#1 - #17) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Review of Clinical Record #1 revealed the following: A. Document titled “Client Medication Record” listed “Nitroglycerin 0.4 mg” with directions to “take as needed” (Nitroglycerin is prescribed for occasional chest pain). B. According to a commonly used web site, Drugs.com, which is used to show dosing of certain medications, the standard instructions are for placing a tablet under the tongue at onset of the chest pain. If the pain continues after 5 minutes, another tablet may be placed under the tongue. This may be repeated for three tablets (or 15 minutes). If no relief after the third dose, the patient should call 911 for emergent evaluation. There was no evidence dosing instructions were included on the Patient's medication profile. 2. Review of Clinical Record #7 revealed the following: A. Documentation from the Client's visits to the Chemotherapy clinic showed Client #1 was receiving chemotherapy (drugs used to treat cancer), every 21 days. B. Document titled “Client Medication Report” showed no evidence that the chemotherapeutic agents were listed. C. During an interview with Agency staff 2/15/23 at 3:00 P.M. Agency Representative #3 stated, “No. The chemo medication isn’t on the medication list.” 3. Review of Clinical Record #13 revealed the following: A. Document titled “ Home Health Plan of Care” dated 1/10/23 showing a primary diagnosis of “ Malignant neoplasm of pancreas unspecified”, (cancer diagnosis). B Document titled “Case Communication dated 1/28/23 in which the Skilled Nurse (SN) documented “ CG (Caregiver) requested that pt (patient) remain as undisturbed as possible due to exhaustion from Chemo [Chemo Therapy drugs treatment] yesterday.” C. Document titled “Client Medication Report” showed no evidence that the chemotherapeutic agents were listed. 4. During an interview on 2/16/2023 at 9:30 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1, and #2 confirmed the Agency staff did not include all medications the patients were currently using during a review of medications.

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 Agency staff interviews, the Agency Staff failed to ensure the patient's Plan of Care (POC) included the required elements of patient specific treatments, services, measurable outcomes and goals identified by the Home Health Agency (HHA) in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed. This deficient practice had the potential to result in harm for all patients on census by inhibiting the SN and Physicians ability to make informed decisions regarding the patient specific interventions and goals. Review of Clinical Record #8 revealed the following: A. Aide visits dated 1/6/23, 1/9/23. 1/15/23. 1/19/23. 1/23/23. 2/2/23. 2/6/23. 2/9/23.and 2/13/23. There was no evidence the Plan of Care (POC) included orders for the Aide treatments, services or goals. 2 . During an interview on 2/16/23 at 9:30 AM with Agency staff, Agency Personnel #1 and #2 confirmed the above findings and stated POC did not include any orders for the Aide to provide any services for Patient #8. .

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 Clinical Record review and staff interview, it was determined the Registered Nurse (RN) failed to notify the Physician when the updated Comprehensive Assessment indicated a change in condition in 2 (#5 and #6) of 17 (#1 - #17) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals. 1. A review of Clinical Record #5 revealed the following: A. Document titled “Home Health Certification And Plan of Care”, dated 12/7/22 to 2/24/23 which contained an order for “Skilled Nurse to perform general assessment to include vital signs and to report any abnormalities or concerns to the Physician." Pulse (heart beats per minute) parameters for reporting were ordered at 50 - 110. B. Skilled Nurse (SN) visit on 1/24/2023 showed documentation that the pulse was recorded at 123. There was no evidence the physician was notified of the out-of-range ordered pulse parameter. During an interview, Agency Staff was asked if the nurse reported the pulse to the doctor. Agency Staff #3 stated, “No. There doesn’t seem to be any communication from the nurse to the doctor about it.” 2. Review of Clinical Record #6 revealed the following: A. Document titled “Home Health Certification And Plan of Care dated 1/27/23 to 3/27/23, contained a physician’s order for “MD [Medical Doctor] should be notified of all instances of vital signs outside the set parameters. Pulse parameters were ordered at 50-110.. B. SN visit dated 1/31/2023 contained documentation that the pulse was recorded at 118. There is no evidence in the Medical Record indicating the physician was notified of the out-of-range pulse. 3. During an interview on 2/16/23 at 9:30 A.M., Agency Staff were given an opportunity to provide additional information. With no additional information provided, Agency Personnel #2 confirmed the Physician was not notified of the out of range pulse parameters for Patients #5 and #6.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation during home visits, staff interviews, Agency Policy, review of regulation text and interpreive guidelines for CMS standard G0682, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 2 (#3 and #4) of 7 (#1 - #7) home visits conducted. This deficient practice had the potential to place these patients with dressing changes at risk for adverse outcomes, infection. and/or hospitalization. Observations during a home visit on 2/13/23 at 11:30 A.M. with Patient #3 revealed the following: A. The Surveyor observed the Skilled Nurse (SN) providing wound care. The SN placed a clean pad and towel on the Patient's table to provide a barrier and a field for wound care.The SN cleaned scissors prior to using them to remove the old, contaminated dressing. The SN then placed the soiled/contaminated scissors under the moisture barrier and towel. The SN failed to resanitize the scissors prior to cutting the clean bandage that was used to cover Patient #3 wound. B. According to CMS Standard G682 Infection Control, "the HHA [Home Health Agency] must ensure that HHA staff are trained to: (1) maintain separation between clean and soiled equipment to prevent cross contamination; and (2) follow the manufacturer’s instructions for use and current standards of practice for patient care equipment transport, storage, and cleaning/disinfecting". There was no evidence during observations of the home visit that the SN followed these guidelines for cleaning scissors utilized for Patient #3 wound care. 2. Observations during a home visit on 2/14/23 at 10:30 A.M. with Patient #4 revealed the following: A. The Surveyor observed the SN providing care and dressing change for a PICC (peripherally inserted central catheter- used to give medication directly into the blood stream). The Surveyor observed the SN (Skilled Nurse) ineffectively position the patient in such a manner that the PICC insertion site was not stable. The patient sat on the side of the bed with no back support. The patient kept moving around, and the arm where the sterile dressing change was to occur was not secure and had the potential to contaminate the sterile field. The patient was wearing oxygen and the oxygen tubing kept falling close to and around the area the PICC was located causing potential for contamination. B. Review of Agency policy for PICC line dressing change showed "Position the Patient with the arm extended away from the body to gain access to the insertion site." There was no evidence the SN followed the Agency's policy regarding the dressing change. 4. This is a repeat deficiency from the previous survey.