Every finding on record at Mobile Nursing Services

The Department of Inspections and Appeals conducted a complaint survey, complaint #97652-C from 7/6/21 through 7/14/21. The complaint survey identified the following: the agency was operating out of compliance with the following Conditions of Participation: 1) 42 CFR 484.60 Care Planning, Coordination and Quality of Care 2) 42 CFR 484.110 Clinical Records The complaint investigation survey identified allegations related to the following Medicare Conditions of Participation: 1) 42 CFR 484.50 Patient Rights, was substantiated with related deficiencies (see G0478 and G0484); and, 2) 42 CFR 484.60 Care Planning, Coordination and Quality of Care, was substantiated with related deficiencies (see G0574, G0576, G0580, G0590, G0604 and G0608). As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 7/15/21 and ending on 7/15/23.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient representative and staff interview, the agency failed to ensure the investigation of a complaint made by an agency patient or the representative of the patient for 1 of 3 sampled patients (Patient #2) with an interview. The agency reported a census of 78 at the time of the survey. The agency had a no documented complaints since January 2021. Failure to investigate complaints made by agency patients or their representatives allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. This allows problems to continue and worsen over time because patterns are not identified and addressed to improve patient care. Findings include: Review of the agency's admission packet identified an informational section, titled Patient Bill of Rights/Responsibilities, revealed the patient had a right to have complaints investigated. The agency must document both the existence and resolution of the complaint. Review of the agency's policy, titled Complaint Resolution, dated 3/2019, revealed agency staff will investigate complaints made by a patient, family, caregiver or patient representative for treatment or care that is or fails to be furnished, is furnished inconsistently or is furnished inappropriately, for neglect or abuse, misappropriation of property, a lack of respect of property or person. Review of the agency's complaint log on 7/6/2021 revealed no patient related complaints since 8/3/2020. The complaint, dated 8/3/2020, identified the patient had been upset with the home health aide providing services and the agency had changed staff. On 7/6/21 at 3:00 PM, during an interview, the Administrator/Clinical Manager reported she had not received any complaints in 2021 and confirmed she had not received any patient related complaints since August 2020. She reported she had spoke to Patient #2's family member/caregiver about a schedule change in relation to the homemaker, but this had not been a complaint. Patient #2 had a start of care date of 11/13/18. Review of the clinical record on 7/7 through 7/8/21 revealed the following: a. The Plans of Care, dated 5/1/2021 to 6/29/2021 and 6/30/2021 to 8/28/2021, included orders for skilled nursing and home health aide services. b. The clinical record included documentation of skilled nursing visits completed by Staff B, Registered Nurse (RN), dated 4/28, 4/29, 4/30, 5/3, 5/5, 5/7, 5/10, 5/12, 5/14, 5/17 and 5/21/21. c. The clinical record included documentation of skilled nursing visits completed by Staff C, RN, dated 5/17, and then 5/24, 5/26, 5/28, 6/2, 6/4, 6/8 and 6/29/21. The clinical record included documentation of another nurse completing a visit on 6/15/21 and no visits documented the week of 6/20/21. On 7/8/21 at 12:00 PM, in an interview after a home visit observation with Staff C, RN, the patient's self-identified Power of Attorney (POA) (and primary caregiver) reported complaining to the agency's Administrator around mid May 2021 about Staff B, RN. The POA reported the nurse would not listen to the POA, treated the POA with a lack of respect and made the POA feel like the POA was worthless. The POA reported constantly "butting heads" with Staff B, RN. The POA explained during a visit on 5/14/21, it was so bad, the POA had asked Staff C, RN, to leave. The POA did not tell the Administrator, but voiced concerns with Staff C, RN, about wasting topical medications by squeezing too much out of the tube and messing up the patient's medications at the pharmacy. The POA went on to explain the patient's medication were still messed up and the patient was getting extra doses of Lasix (a medication used to treat fluid retention); the pharmacy was sending 60 milligrams (mg) twice a day, and the patient was supposed to get only 40 mg twice per day. On 7/13/21 at 8:02 AM, during an interview, the patient's pharmacy staff reported the patient's primary care physician had ordered an increase in Lasix from 40 mg to 60 mg twice per day starting 5/4/21. On 7/13/21 at 8:21 AM, during an interview, Staff B, RN, denied the patient's POA had complained about her, but then went on to explain she had received a call from the nurse at the patient's physician's office. The physician's nurse told her the POA complained Staff B, RN, "knew too much" about the patient, thought Staff B, RN, was trying to say the POA was a bad caregiver and wanted to send the patient to a nursing home. Staff B, RN, explained this was not true and she never had any intention or tried to get the patient admitted to the nursing home. Staff B, RN, reported she only talked with the POA about a plan for how they could keep the patient at home. Staff B, RN, denied the POA ever asked her to leave the home. Staff B, RN, reported the patient asked to switch nurses because she felt there was an issue between the POA and Staff B, RN. On 7/13/21 at 10:00 AM, during an interview, Staff C, RN, reported she had gone to see the patient one time during the week for Staff B, RN. She denied the POA had complained to her about Staff B, RN, but did ask for her to become the patient's RN Case Manager due to "not seeing eye to eye" with Staff B, RN. Staff C, RN, assumed care the following week for the patient. Staff C, RN, reported the POA had never complained to her about the Lasix dose being wrong. The POA had been putting the patient's topical medications in small daily use containers since she had been going into the home and had not heard any complaints about medication waste. On 7/13/21 at 11:48 AM, during an interview, the Administrator/Clinical Manager reported being unaware of any complaints made by the POA for Patient #2. She explained she thought the nurse for the patient changed due to the location of the nurses; Staff C, RN, lives closer to the patient and this made more sense. The Administrator reported Staff B, RN, did tell her that the POA was mad at Staff B, RN, for calling the patient's physician, but did not know about anything else. She was unaware Staff C, RN, took over for Staff B, RN, due to the POA and Staff B, RN, not getting along. Agency staff failed to investigate concerns of the POA for Patient #2 having problems with Staff B, RN. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, review of the agency complaint log, patient representative and staff interview, the agency failed to ensure the documentation of a complaint and the resolution of a complaint made by an agency patient or the representative of the patient for 1 of 3 sampled patients (Patient #2) with an interview. The agency reported a census of 78 at the time of the survey. The agency had a no documented complaints since January 2021. Failure to document and maintain evidence of complaints and the resolution of the complaints allows the problems to persist without being addressed and prevents the home health agency from critically evaluating the nature of the complaints, the investigation, and the resolution of the complaints. This allows problems to continue and worsen over time because patterns are not identified and addressed to improve patient care. Findings include: See G0478 The agency failed to document both the existence of the complaint and the resolution of the complaint. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, patient and patient representative interview and agency staff interview, the agency: 1) failed to ensure the Plan of Care accurately reflected care, treatment and services provided to the patient (G0574); 2) failed to ensure agency staff included all physician orders, including verbal orders in the Plan of Care (G0576); 3) failed to ensure agency staff provided treatment only as ordered by a physician or health care practitioner (G0580); 4) failed to ensure agency staff promptly alerted the physician to changes in the patient's condition or a change in needs that could result in a change to the Plan of Care (G0590); 5) failed to ensure agency staff integrated orders from all physicians involved in the Plan of Care to assure the coordination of interventions provided to the patient (G0604); and, 6) failed to ensure agency staff coordinated the delivery of care to meet the needs of the patient in relation to a patient receiving wound care (G0608). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 78 patients.

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, agency policy review, home visit observation, patient and patient representative interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 4 of 4 sampled patients (Patients #1, #2, #3 and #4). The agency reported a current census of 78 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: Review of the agency's policy, titled Plan of Care- CMS 485 and Physician Orders, dated 3/2019, revealed agency staff provide care and services to the patient in accordance with an individualized Plan of Care (POC). The individualized POC must specify the care and services necessary to meet the needs of the patient. The POC must include all medications and treatments, supplies and equipment required and all patient care orders, including verbal orders. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, identified the patient used the following medical equipment and supplies: grab bars, tub/shower bench, wheelchair, trapeze, wheelchair cushion, Prevaron boot, air mattress, urinary catheter/supplies and wound care supplies. A update to the POC, dated 6/30/21, identified the patient also used Intravenous (IV) supplies. On 7/7/21 at 9:26 AM, during a home visit observation with Staff B, Registered Nurse (RN), the surveyor observed the patient had the following additional medical equipment and supplies: a reacher, bedside table, incontinent briefs and disposable chux, handheld shower and a ramp. Staff B, RN, also applied Tubigrips to each lower extremity after completion of wound care. In an interview during the same home visit observation, Staff B, RN, and the patient both reported the patient had been using the Tubigrips for a "long time" except for a 3 to 4 week period of time after the amputation of the lower left leg. The patient reported use of the reacher, ramp, handheld shower and incontinent briefs for more than 3 years. The POC failed to identify all necessary medical equipment and supplies used by the patient. b. The POC, dated 5/10/21 to 7/8/21, included an order for the skilled nurse to change the patient's suprapubic urinary catheter as needed for non-patency and complications. The POC failed to specify the size of catheter the nurse should use and the bulb (balloon-like device inserted into the bladder to hold the catheter in place) inflation size/amount. On 7/7/21 at 9:26 AM, in an interview during a home visit observation, Staff B, RN, reported the agency nurses have changed the suprapubic catheter when needed, but usually the patient gets the catheter changed at the urology clinic. 2. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following: a. The POCs, dated 5/1/2021 to 6/29/2021 and 6/30/2021 to 8/28/2021, identified the patient used a cane, wheelchair, walker, grab bars and a tub/shower bench. The update to the comprehensive assessment completed at the time of recertification, dated 4/28/21, identified the patient was incontinent of urine. A skilled nursing visit note, dated 4/29/21, identified the patient used incontinent products. On 7/8/21 at 12:00 PM, during a home visit observation with Staff C, RN, the surveyor observed the patient was wearing incontinent briefs. The POCs failed to identify the patient used incontinent briefs. b. An update to the comprehensive assessment completed at the time of recertification, dated 6/29/21, identified the patient had 2 wounds on the buttocks, one on the right and one on the left. Staff C, RN, documented the completion of the assessment and documented she contacted the physician for orders to continue services. The POC, dated 6/30/2021 to 8/28/2021, included a signature of completion of the POC, dated 7/4/21, and an order for Mupirocin 2 percent apply a small amount to buttock wound three times daily with a start date of 5/24/21. The clinical record included documentation of a faxed document, dated 7/6/21, from the patient's physician's office. The fax included documentation of the patient's office visit, dated 6/30/21, and an order for Calazime Paste 3.5 percent-0.2 percent-69 percent- 16.5 percent apply topically to the pressure ulcer daily, dated 6/30/21. On 7/8/21 at 12:00 PM, during a home visit observation with Staff C, RN, the surveyor observed Staff C, RN go into the bathroom with the patient. The surveyor observed Staff C, RN, assess the patient's buttocks. The patient's buttocks had a open wound on the right middle buttock near the gluteal fold approximately 1 centimeters (cm) in length, 2 cm in width and 0.1 cm in depth. In an interview during the same home visit observation, Staff C, RN, reported she was unable to do wound care because she did not have orders. The patient's Power of Attorney (POA) explained she had been putting Calmoseptine (an over the counter protective barrier cream) on the wound one time per day per the patient's physician orders given on 6/30/21. The POA had gotten Calmoseptine instead of the Calazime Paste. The POA reported the patient's physician did not want Mupirocin put on the current buttock wound. On 7/8/21 at 2:33 PM, during an interview, the Office Manager for the clinic of the patient's physician reported the patient's physician had discontinued the Mupirocin on 6/30/21. The Office Manager reported the physician had received a POC, dated 6/30/2021 to 8/28/2021, via fax on 7/4/21, but the patient's physician had not signed it yet. On 7/13/21 at 10:00 AM, during an interview, Staff C, RN, explained while she had gotten a verbal order for recertification of services, she had not spoke with the patient's physician about wound care or using the Mupirocin. She had accidentally done the recertification visit on 6/24/21, discovered the new wounds then and reported it to the physician's office. The physician did not want to order wound care at that time until he saw the patient in his office. She went back on 6/29/21 to complete the update to the comprehensive assessment for recertification, but this visit was prior to the patient seeing the physician on 6/30/21. She reported the order for Mupirocin should not have put on the POC, dated 6/30/2021 to 8/28/2021, and should have been discontinued after the previous wounds healed. She explained the physician had ordered a new medication, but the POA for the patient had gotten an over the counter cream instead. c. The POC, dated 6/30/2021 to 8/28/2021, included orders for Furosemide 40 mg in the morning and take an additional 20 mg in the evening for 3 days and then 40 mg daily by mouth and a start date of 4/28/21. In an interview on 7/8/21 at 12:00 PM, the POA reported the patient's Furosemide was all screwed up. She said the pharmacy kept sending extra 20 mg doses. On 7/13/21 at 8:02 AM, during an interview, a representative from the patient's pharmacy reported the patient's physician had ordered Furosemide 60 mg twice per day and a start date of 5/4/21. On 7/13/21 at 10:00 AM, during an interview, Staff C, RN, reported on 6/30/21 she got a copy of a visit note from the patient's physician for an office visit, dated 6/10/21. She explained the visit note had an order for Furosemide 40 mg twice per day. Staff C, RN, thought she corrected this on the POC, and did not realize it was still incorrect. Review of the clinical record revealed a fax from the patient's physician office, dated 7/6/21, which included documentation of an office visit, dated 6/30/21. The office visit included orders for Furosemide 40 mg twice per day and a start date of 6/10/21. The RN failed to update the POC with the correct order for the Furosemide. 3. Patient #3 had a start of care date of 4/2/19. Review of the clinical record revealed the following: a. The POC, dated 3/22/2021 to 5/20/2021, identified the patient used the following medical equipment and supplies: a wheelchair and wound care supplies. The POC, dated 5/21/2021 to 7/19/2021, identified the patient used the following additional medical equipment and supplies: hospital bed, slide board, suprapubic catheter and ostomy supplies. On 7/8/21 at 10:45 AM, during a home visit observation with Staff C, RN, the surveyor observed the following additional medical equipment and supplies: air mattress, reacher, ramp, bedside table and personal wipes. In an interview, during the same home visit observation, the patient reported the patient just got the bedside table, the air mattress 6 to 7 months ago, and the rest of the equipment she had been using for years. The POC failed to identify all necessary medical equipment and supplies used by the patient. b. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock. Both POCs included the following wound care orders with a start date of 7/1/2020: cleanse wound prior to each dressing change with normal saline, wound cleanser or baby shampoo, rinse and pat dry, ensure wound is dry prior to applying dressing, pack wound with moistened gauze with Dakin's solution 0.125 percent, cover with dry gauze, wrap with wrap gauze, secure with tape, change dressing daily, caregiver to change daily, skilled nurse to complete wound care one time weekly. A skilled nursing visit note, dated 3/25/21, included the following documentation: Dakin's discontinued 3/23/21 per University of Iowa Surgeon; use water in place of Dakin's, continue with previous wound care done as ordered with water. All subsequent skilled nursing visit notes through 7/1/21 (last note documented in the record), contained this same message. On 7/8/21 at 10:45 AM, during a home visit observation, Staff C, RN, completed wound care to the patient's left buttock wound (observed to be in the left ischial area). The wound was covered with an abdominal (ABD) pad and tape to hold the dressing in place. Staff C, RN, used Cavilon Skin Prep to help remove the tape from the dressing. She then cleansed the wound with gauze soaked in sterile water, soaked another 4 by 4 gauze in sterile water and packed this into the wound, covered the wound with an ABD pad and secured the dressing with tape. In an interview, during the same home visit observation, the patient reported the wound care physician did not want the Dakin's solution used in the wound. The patient confirmed Staff C, RN, did the correct wound care. The POC failed to include accurate wound care orders. 4. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: The POC, dated 2/17/2021 to 4/17/2021, identified a diagnosis of congestive heart failure and identified the patient had discharged from the hospital on 2/16/21. The POC included orders for skilled nursing 1 to 3 times per week. The POC did not include any orders for the nurse to complete laboratory blood draws. The POC included a signature of completion by the RN, dated 2/22/21. A skilled nursing visit, dated 2/18/21, included the following documentation: "Labs drawn and sent to the hospital per order." The visit note did not identify what labs the nurse drew. The clinical record and POC lacked orders for the skilled nurse to complete any laboratory blood draws. The clinical record included documentation of labs completed on 2/16/21 including a basic metabolic panel, blood phosphorus and magnesium levels. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further evidence to refute this finding. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, home visit observation, patient interview and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 3 of 4 sampled patients with interim physician orders (Patients #1, #3 and #4). The agency reported a current census of 78 patients at the time of the survey. Failure to update the Plan of Care increased the potential for inaccuracy in the delivery of the provision of care. Findings include: Review of the agency's policy, titled Plan of Care- CMS 485 and Physician Orders, dated 3/2019, revealed agency staff provide care and services to the patient in accordance with an individualized Plan of Care (POC). The individualized POC must specify the care and services necessary to meet the needs of the patient. The POC must include all medications and treatments, supplies and equipment required and all patient care orders, including verbal orders. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/10/2021 to 7/8/2021, included an updated order, dated 5/20/21, for the skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection including redness, drainage and edema and for the dressing to be changed weekly and as needed. The order failed to identify what type of dressing the patient used. b. A skilled nursing visit note, dated 6/10/21, included documentation the nurse called the orthopedic surgeon. The orthopedic surgeon ordered wound care to be per the wound clinic and to continue to wrap the knee with an Ace Wrap until the patient was seen by the wound clinic. The clinical record included documentation of a wound clinic visit, dated 6/18/21, with wound care orders for the left lateral knee wounds. The POC included an order added on 6/30/21 to discontinue the following order on 6/18/21: following removal of surgical staples, skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection including redness, drainage and edema, Ace wrap for compression to effected extremity daily. The POC, dated 5/10/2021 to 7/8/2021, failed to include the physician order dated on 6/10/21. 2. Patient #3 had a start of care date of 4/2/19. Review of the clinical record on 7/8/21 revealed the following: a. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock. Both POCs included the following wound care orders with a start date of 7/1/2020: cleanse wound prior to each dressing change with normal saline, wound cleanser or baby shampoo, rinse and pat dry, ensure wound is dry prior to applying dressing, pack wound with moistened gauze with Dakin's solution 0.125 percent, cover with dry gauze, wrap with wrap gauze, secure with tape, change dressing daily, caregiver to change daily, skilled nurse to complete wound care one time weekly. b. A skilled nursing visit note, dated 3/25/21, included the following documentation: Dakin's discontinued 3/23/21 per University of Iowa Surgeon; use water in place of Dakin's, continue with previous wound care done as ordered with water. All subsequent skilled nursing visit notes through 7/1/21 (last note documented in the record), contained this same information about the wound care change. c. An interim physician order written by the agency nurse, dated 3/25/21, included an order to discontinue the Dakin's solution, but failed to include an order to do the same wound care, but use water in place of the Dakin's. On 7/8/21 at 10:45 AM, during a home visit observation, Staff C, RN, completed wound care to the patient's left buttock wound (observed to be in the left ischial area). The wound was covered with an abdominal (ABD) pad and tape to hold the dressing in place. Staff C, RN, used Cavilon Skin Prep to help remove the tape from the dressing. She then cleansed the wound with gauze soaked in sterile water, soaked another 4 by 4 gauze in sterile water and packed this into the wound, covered the wound with an ABD pad and secured the dressing with tape. In an interview, during the same home visit observation, the patient reported the wound care physician did not want the Dakin's solution used in the wound. The patient confirmed Staff C, RN, did the correct wound care. The POC, dated 3/22/2021 to 5/20/2021, failed to include the updated wound care orders received on 3/23/21. 3. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: a. The POC, dated 2/17/2021 to 4/17/2021, included orders for skilled nursing services and a medication order for Insulin Glargine (Lantus) 100 units per milliliter (ml), 10 units subcutaneous (sq) every bedtime. The skilled nursing visit note, dated 3/17/21, identified the patient had an order for an increase in Lantus insulin to 16 units daily. The POC lacked documentation of an update to the patient's Lantus insulin order to 16 units daily. b. A faxed physician's progress note, dated 2/24/21 (for the visit) and 3/1/21 (for a fax date to the agency), revealed an order for the agency nurse to complete a repeat blood draw for a basic metabolic panel (BMP) lab in 1 week (due 3/3/21). The POC lacked documentation of an update to the patient's POC to include the lab draw for the repeat BMP and lacked documentation of a completed laboratory draw for the BMP on or around that date. The Administrator/Clinical Manager received the above findings. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further information to refute the findings.

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 clinical record review, agency policy review, patient representative interview, physician interview and agency staff interview, the agency failed to administer medications and treatments only as ordered by the physician for 4 of 4 sampled patients (Patients #1, #2, #3 and #4). The agency reported a current census of 78 patients at the time of the survey. Failure to ensure staff obtain physician orders for administration of treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment. Findings include: Review of the agency's policy, titled Plan of Care- CMS 485 and Physician Orders, dated 3/2019, revealed agency staff provide care and services to the patient in accordance with an individualized Plan of Care (POC). The individualized POC must specify the care and services necessary to meet the needs of the patient. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, included orders for the skilled nurse to complete wound care daily and to assess vitals Monday, Wednesday and Friday and as needed and to include blood pressure, heart rate, lung sounds and blood oxygen saturation level per pulse oximeter. A skilled nursing visit note, dated 5/31/21 (a Monday) lacked documentation the nurse assessed the patient's vitals. A skilled nursing visit note, dated 6/25/21 (a Friday), lacked documentation the nurse assessed the patient's blood pressure. On 7/14/21 at 10:35 AM, during an interview, the Administrator/Clinical Manager, reported the nurse did the patient's vitals on the previous day instead of 5/31/21. She confirmed the nurse forgot to include documentation of assessing the patient's blood pressure on 6/25/21. b. The POC, dated 5/10/2021 to 7/8/2021, included interim orders with a start date of 5/20/21 for the skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection and for the dressing to be changed weekly and as needed. 1) A physician's order, dated 6/8/21, included the following wound care orders: right ischium (lower buttock fold area) to cleanse with Saline, apply Gentamicin 0.1 percent ointment to the wound, apply Prisma to the wound bed, cover with soft roll Drawtex (type of wound dressing), secure with tape and change daily; left ischium to cleanse with Saline, apply Silverlon Rope, apply Cavilon Skin Prep to peri wound, cover with soft roll Drawtex, secure with tape and change daily; and, right posterior heel to cleanse with Saline, apply Gentamicin 0.1 percent ointment to wound, cover with Optifoam (type of wound dressing), secure with tape and change daily. 2) A communication note completed by a registered nurse (RN), dated 6/8/21, included documentation of communication with the orthopedic surgeon's nurse. The agency nurse reported she had been applying Gentamicin to the left outer knee, covering with a small abdominal (ABD) pad under the Ace wrap. The agency nurse reported the patient was supposed to have the wound clinic look at the patient's left knee, but did not mention this to them. The agency nurse asked for further wound care orders to the left outer knee. 3) The clinical record lacked documentation of wound care orders to use Gentamicin and and ABD pad to the left knee. 4) A skilled nursing visit note, dated 6/9/21, included documentation the nurse completed wound care. The nurse documented she used Gentamicin (no order for this) on the wound on the left ischium along with the Silverlon rope and Drawtex. The nurse documented she used Prisma (not ordered) and Drawtex (not ordered) on the right posterior heel wound along with the Gentamicin, and not the Optifoam dressing ordered by the physician. 5) A skilled nursing visit note, dated 6/10/21, included documentation of the nurse not being able to use Cavilon Skin Prep on the left ischium, as this was not available. The nurse documented she used Prisma and Drawtex on the right posterior heel (no order for either) along with the Gentamicin. The nurse documented she applied Gentamicin and Drawtex to the left knee along with an Ace wrap. The clinical record lacked documentation of a physician order to use Gentamicin and Drawtex on the left knee. The nurse documented she called the orthopedic surgeon for the left knee amputation. The nurse documented the orthopedic surgeon ordered the continued use of the Ace wrap and to wait until the patient was seen by the wound clinic to do any other wound care to the left knee. The nurse documented she left a message with the wound clinic that she was almost out of tape, needed Skin Prep and soft roll Drawtex. 6) A skilled nursing visit note, dated 6/11/21, included documentation the patient did not have any Optifoam available, so she used Drawtex on the right posterior heel. The visit note lacked documentation the nurse contacted the physician to change the wound care order based on a lack of supplies. The nurse documented she was waiting for supplies for the left ischium and used Gentamicin (no order for use) along with Silverlon Rope and Drawtex. 7) A skilled nursing visit note, dated 6/12/21, lacked documentation the nurse assessed the patient's left knee amputation or applied the Ace wrap. 8) The skilled nursing visit notes, dated 6/14, 6/15 and 6/16/21, included documentation the nurse performed wound care on the left ischium by using Silverlon Rope and Drawtex, but lacked documentation the nurse used Cavilon Skin Prep. 9) The skilled nursing visit notes, dated 6/17 and 6/18/21, included documentation the nurse performed wound care on the left ischium by using Silverlon Rope and Drawtex, but lacked documentation the nurse used Cavilon Skin Prep. The nurse documented she used Drawtex on the right posterior heel (the physician ordered Optifoam). On 6/18, the nurse documented the patient had an appointment at the wound clinic later that day. 10) A communication note, dated 6/18/21, included documentation the nurse received the following orders from the wound clinic physician: cleanse both right and left ischium with Saline, apply Gentamicin 0.1 percent, Prisma, soft roll Drawtex and tape daily; cleanse the right posterior heel with Saline, apply Gentamicin 0.1 percent, cover with soft roll Drawtex and tape daily; cleanse the left lateral knee, apply mixture of Gentamicin 0.1 percent with Santyl ointment to wound bed, cover with soft roll Drawtex, Ace wrap does not need to be reapplied will not be using Tubigrip. 11) A skilled nursing visit note, dated 6/19/21, included documentation the nurse applied Prisma (not ordered) to the right posterior heel along with the Gentamicin and Drawtex. The nurse documented she used Prisma (not ordered) on the left lateral knee wound along with the Gentamicin and Santyl mixture and Drawtex. The nurse documented she applied Tubigrips to the left stump and over the right posterior heel wound. The clinical record lacked documentation of an order for the Tubigrips. 12) A skilled nursing visit note, dated 6/20/21, included documentation the nurse applied Prisma (not ordered) to the right posterior heel along with the Gentamicin and Drawtex. The nurse documented she used Prisma (not ordered) on the left lateral knee wound along with the Gentamicin and Drawtex. The nurse documented she did not use Santyl, because the surrounding wound had a thin layer of raw, red tissue and the area was wider. The nurse documented she applied Tubigrips to the left stump and over the right posterior heel wound. The visit note lacked documentation the nurse contacted the physician about the change in condition of the left lateral knee wound. 13) A skilled nursing visit note, dated 6/23/21, included documentation the nurse applied Gentamicin and Drawtex to the left ischium wound, but lacked documentation the nurse used Prisma as ordered. 14) A skilled nursing visit note, dated 6/26/21, included documentation the nurse applied Gentamicin and Drawtex to the right ischium wound, but lacked documentation the nurse used Prisma as ordered. 15) A skilled nursing visit note, dated 6/30/21, included documentation the nurse applied Gentamicin and Prisma to the right ischium wound, but lacked documentation the nurse used Drawtex. 16) A skilled nursing visit note, dated 7/2/21, included documentation the nurse noted an area measuring 1 centimeter (cm) by 1 cm scab with redness surrounding the area on the back of the patient's right calf. The nurse documented she covered the area with Drawtex to protect it. She did not document contacting the patient's physician or the wound clinic. 17) A skilled nursing visit note, dated 7/6/21, included documentation the nurse applied Gentamicin and Drawtex to the right ischium wound, but lacked documentation the nurse used Prisma as ordered. The nurse documented the right posterior calf had a beefy red wound bed and she applied Gentamicin and used a Drawtex dressing. The clinical record lacked documentation of physician contact or orders to treat the right calf wound. On 7/7/21 at 9:26 AM, during a home visit observation, Staff B, RN, completed wound cares. The surveyor observed an open wound on the right posterior calf. Staff B, RN, cleansed the wound with Saline and covered the wound with a Drawtex dressing. For the right ischium wound, the RN cleansed the wound with Saline, applied Gentamicin to the wound bed and covered the wound with Drawtex. She did not use Prisma as ordered. Staff B, RN, also applied Tubigrip stockings to the right lower extremity and left knee amputation. In an interview, during the same home visit observation, the nurse explained the wound clinic would not prescribe a treatment for the right calf wound until they saw it, so she was just covering it with Drawtex until the patient went to the wound clinic. The patient was supposed to go yesterday, but the did not have transportation. The nurse explained the wound on the right ischium was getting too small for the Prisma, and so she did not apply it. The nurse reported she gives the wound clinic an update on the wounds the day the patient goes to the wound clinic. After further discussion with the surveyor, Staff B, RN, reported she was going to call the wound clinic today. She reported the patient had been using Tubigrips for a long time. On 7/7/21 at 1:17 PM, during an interview, Staff B, RN, reported she obtained new orders from the wound clinic to cleanse the right posterior calf wound with Normal Saline, apply Gentamicin ointment and cover with Drawtex. She also received an order to discontinue the use of the Prisma in the right ischium wound. On 7/14/21 at 10:35 AM, during an interview, the Administrator/Clinical Manager reported her agreement with the skilled nursing visit notes, dated 6/9, 6/11 and 6/12/21, not having documentation of the correct wound care. She reviewed additional skilled nursing visit notes with the surveyor, and agreed some had the correct documentation and some of the notes did not. She agreed staff should have followed up or called the physician for wound care changes when the correct wound supplies were not available. 2. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following on 7/7/21: a. The POCs, dated 3/2/2021 to 4/30/2021 and 5/1/2021 to 6/29/2021, included physician orders for Blamed Adult Care topical cream apply to affected areas daily as needed for skin rash. b. The update to the comprehensive assessment completed at the time of recertification, dated 4/28/21, included documentation the nurse assessed the patient had increased redness and open areas on the buttocks, sacral area and perineal region. The nurse noted there were 2 to 3 open areas. The nurse identified there were 2 wounds that were Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer or blister). c. A skilled nursing visit note, dated 4/29/21, included documentation the nurse assessed a right buttock wound measuring 1.5 cm in length, 0.4 cm in width and 0.2 cm in depth with moderate amount of thin, clear drainage (serous). The nurse documented she cleansed the wound with "wipes", applied Blamed cream and covered the wound with a non-stick Telfa dressing and tape to secure. The nurse documented the wound care needed to be done 3 times per day and then follow the directions of the patient's physician. The nurse did not document the existence or treatment of any other wounds. d. The clinical record lacked documentation of wound care orders or orders to use the Blamed cream for a pressure ulcer. e. A skilled nursing visit note, dated 4/30/21, included documentation the nurse cleansed the right buttock wound with "wipes", applied Blamed cream and covered the wound with a non-stick Telfa dressing and tape to secure. f. A skilled nursing visit note, dated 5/1/21, included documentation the nurse assessed the right buttock wound had a small amount of blood-tinged drainage and a pink wound bed. The nurse documented she cleansed the wound with Normal Saline and covered the wound with a Mepilex dressing. She documented the patient had a few scabbed areas to the bottom and peri area. g. A skilled nursing visit note, dated 5/3/21, included documentation the nurse assessed the right buttock wound had a small amount of serous drainage and the surrounding tissue was discolored. She documented she cleansed the wound with soap and water, applied Blamed cream and covered it with a gauze dressing. The nurse also noted the patient had several abraded areas on the buttocks. h. An interim physician order, dated 5/4/21, included an order for wound treatment to a Stage 2 pressure ulcer on the right buttock and to assess the skin integrity to the Stage 2 pressure ulcer. The physician ordered the wound cleansed with soap and water, apply Honey Med Mel (Medihoney) to the wound and cover with a gauze dressing. i. A skilled nursing visit note, dated 5/5/21, included documentation the nurse assessed the right buttock wound had a small amount of serous drainage and the surrounding tissue was discolored. She documented she cleansed the wound with soap and water, applied Blamed cream and covered it with a gauze dressing. j. A skilled nursing visit note, dated 5/7/21, included documentation the nurse assessed the wound on the right buttock measured 2.5 cm in length, 0.5 cm in width and 0.2 cm in depth and had a small amount of serous drainage. The nurse documented she cleansed the wound with soap and water, applied Blamed cream and covered with a gauze dressing. k. The skilled nursing visit notes, dated 5/10, 5/12 and 5/14/21, included documentation the nurse assessed the wound on the right buttock had a small amount of serous drainage and discolored surrounding tissue. The nurse documented she cleansed the wound with soap and water, applied Blamed cream and covered with a gauze dressing. On 5/14/21, the nurse documented the wound measured 1.2 cm in length, 0.3 cm in width and 0.2 cm in depth and was not healing. l. A skilled nursing visit note, dated 5/17/21, included documentation the nurse assessed the wound on the right buttock had a small amount of serous drainage and discolored surrounding tissue. The nurse documented she cleansed the wound with soap and water, applied Blamed cream and covered with a gauze dressing. The nurse assessed the patient also had 2 new areas on the left buttock. She measured one wound on the left buttock to be 0.3 cm in length, 0.2 cm in width and 0.1 cm in depth with serous drainage and a red wound bed. She cleansed the wound with soap and water, applied Blamed cream and covered with a gauze dressing. The visit note lacked documentation she notified the physician of the patient's new left buttock wound or obtained orders for wound care to this wound. m. A skilled nursing visit note, dated 5/19/21, lacked documentation the nurse assessed the patient's wounds or provided wound care. n. A skilled nursing visit note, dated 5/21/21, included documentation the nurse assessed the right buttock wound had a red wound bed with a small amount of serous drainage. She documented she cleansed the wound with just water (soap not identified) and covered with Blamed cream, gauze and a Tegaderm dressing. She assessed an open area on the proximal left buttock. She cleansed the left buttock wound with water, applied Blamed cream and covered the wound with gauze and Tegaderm. The nurse also assessed an open wound on the left buttocks, distal. The nurse documented she cleansed the wound, but not what she used to cleanse it. She documented she applied Blamed cream, gauze and Tegaderm to the wound. o. An interim physician order, dated 5/24/21, included orders to apply Mupirocin 2 percent to buttocks wounds three times per day. p. A skilled nursing visit note, dated 5/24/21, included documentation the nurse assessed 2 wounds on the left buttocks, applied Mupirocin and covered the wounds with gauze. The clinical record lacked an order to use gauze to cover the wounds. The nurse failed to document an assessment or wound treatment to the right buttock. q. A skilled nursing visit note, dated 5/26/21, included documentation the nurse assessed the right buttock wound measured 0.8 cm in length and 0.2 cm in width and a left buttock wound measured 0.5 cm in length and 0.3 cm in depth. The visit note lacked documentation of an assessed depth for the right and left buttocks wounds. The visit note lacked documentation of wound treatment to all identified wounds. r. A skilled nursing visit note, dated 6/2/21, and signed by the RN, dated 6/29/21, identified the patient had "wounds", but lacked any further assessment or documentation of treatment of the wounds. s. A skilled nursing visit note, dated 6/4/21, lacked a signature of completion by the RN, identified the patient had a wound, but lacked documentation of wound care or an assessment of any wounds. t. A skilled nursing visit note, dated 6/8/21, and signed by the RN, dated 6/29/21, identified the patient had a "wound", but lacked any further assessment or documentation of treatment of the wounds. On 7/14/21 at 10:35 AM, during an interview, the Administrator/Clinical Manager, reported the documentation for wound assessment and care was present in the visit notes, dated 6/2, 6/4 and 6/8/21. On 7/14/21 at 2:00 PM, the Administrator/Clinical Manager provided a copy of a skilled nursing visit note, dated 6/2/21, and signed by the RN, dated 7/7/21, which now included an assessment of the right buttock pressure ulcer which measured 0.5 cm in length, 0.2 cm in width and 0.1 cm in depth and had a small amount of bloody red drainage. The nurse documented she applied Mupirocin and covered the wound with gauze (no order to use gauze). She documented she assessed a wound on the left buttock which measured 0.3 cm in length, 0.1 cm in width and 0.1 cm in depth. She documented she applied Mupirocin and gauze to the left buttock wound. The Administrator/Clinical Manager provided a copy of the skilled nursing visit note, dated 6/4/21, and signed by the RN, dated 7/7/21. This 6/4/21 visit note now included an assessment of the right and left buttocks wounds and documentation the nurse applied Mupirocin to the wounds. The Administrator/Clinical Manager provided a copy of the skilled nursing visit note, dated 6/8/21, and signed by the RN, dated 7/7/21 at 8:26 PM. The visit note now included documentation the left and right buttocks wounds had scabbed and there were no open areas. The nurse documented she did not treat the right and left buttocks since there were no open wounds. The visit note lacked documentation of physician contact to see if the physician wanted the nurse to discontinue wound care with the Mupirocin. u. A skilled nursing visit note, dated 6/15/21, included documentation the buttocks had a few dried scabs from wound that had healed and the nurse applied "cream". v. A skilled nursing visit note, dated 6/24/21, included documentation the nurse assessed the patient had new open buttock wounds with one on the right buttock measuring 3.4 cm in length, 0.5 cm in width and 0.1 cm in depth. The visit note lacked an assessment of a second wound. The nurse documented she did not have orders to do wound care, so she did not do wound care. She contacted the physician for orders. w. An update to the comprehensive assessment for recertification, dated 6/29/21, included documentation the nurse assessed the patient had 2 buttocks wounds, one on the left buttock measuring 1.4 cm in length, 0.8 cm in width and 0.1 cm in depth, and one on the right buttocks measuring 1.8 cm in length, 0.7 cm in width and 0.1 cm in depth. She cleansed both wounds with soap and water, applied Mupirocin and covered the wounds with gauze. y. The POC, dated 6/30/2021 to 8/28/2021, included a signature of completion of the POC by the nurse, dated 7/4/21, and an order for Mupirocin 2 percent apply a small amount to buttock wound three times daily with a start date of 5/24/21. x. The clinical record included documentation of a faxed document, dated 7/6/21, from the patient's physician's office. The fax included documentation of the patient's office visit, dated 6/30/21, and an order for Calazime Paste 3.5 percent-0.2 percent-69 percent- 16.5 percent apply topically to the pressure ulcer daily, dated 6/30/21. On 7/8/21 at 12:00 PM, during a home visit observation with Staff C, RN, the surveyor observed Staff C, RN go into the bathroom with the patient. The surveyor observed Staff C, RN, assess the patient's buttocks. The patient's buttocks had a open wound on the right middle buttock near the gluteal fold approximately 1 centimeters (cm) in length, 2 cm in width and 0.1 cm in depth. In an interview during the same home visit observation, Staff C, RN, reported she was unable to do wound care because she did not have orders. The patient's Power of Attorney (POA) explained she had been putting Calmoseptine (an over the counter protective barrier cream) on the wound one time per day per the patient's physician orders given on 6/30/21. The POA had gotten Calmoseptine instead of the Calazime Paste. The POA reported the patient's physician did not want Mupirocin put on the current buttock wound. On 7/8/21 at 2:33 PM, during an interview, the Office Manager for the clinic of the patient's physician reported the patient's physician had discontinued the Mupirocin on 6/30/21. The Office Manager reported the physician had received a POC, dated 6/30/2021 to 8/28/2021, via fax on 7/4/21, but the patient's physician had not signed it yet. On 7/13/21 at 10:00 AM, during an interview, Staff C, RN, explained while she had gotten a verbal order for recertification of services, she had not spoke with the patient's physician about wound care or using the Mupirocin. She had accidentally done the recertification visit on 6/24/21, discovered the new wounds then and reported it to the physician's office. The physician did not want to order wound care at that time until he saw the patient in his office. She went back on 6/29/21 to complete the update to the comprehensive assessment for recertification, but this visit was prior to the patient seeing the physician on 6/30/21. She reported the order for Mupirocin should not have put on the POC, dated 6/30/2021 to 8/28/2021, and should have been discontinued after the previous wounds healed. She explained the physician had ordered a new medication, but the POA for the patient had gotten an over the counter cream instead. Agency nurses failed to provide wound care as ordered on multiple occasions. 3. Patient #3 had a start of care date of 4/2/19. Review of the clinical record on 7/8/21 revealed the following: a. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock. Both POCs included the following wound care orders with a start date of 7/1/2020: cleanse wound prior to each dressing change with normal saline, wound cleanser or baby shampoo, rinse and pat dry, ensure wound is dry prior to applying dressing, pack wound with moistened gauze with Dakin's solution 0.125 percent, cover with dry gauze, wrap with wrap gauze, secure with tape, change dressing daily, caregiver to change daily, skilled nurse to complete wound care one time weekly. b. A skilled nursing visit note, dated 3/25/21, included the following documentation: Dakin's discontinued 3/23/21 per University of Iowa Surgeon; use water in place of Dakin's, continue with previous wound care done as ordered with water. The nurse documented she used a water soaked gauze to pack the wound and covered the wound with an abdominal (ABD) pad. All subsequent skilled nursing visit notes through 7/1/21 (last note documented in the record), contained the same message to use water in place of the Dakin's. c. An interim physician order written by the agency nurse, dated 3/25/21, included an order to discontinue the Dakin's solution, but failed to include an order to do the same wound care, but use water in place of the Dakin's. d. The skilled nursing visit notes, dated 4/1 and 4/16/21, included documentation the nurse soaked gauze in water and packed the wound and then covered the wound with an ABD pad. e. The skilled nursing visit notes, dated 4/6, 4/22, 5/13 and 6/16/21, lacked documentation the nurse completed wound care or a reason why she failed to complete wound care. f. The skilled nursing visit notes, dated 4/28, 5/5, 5/25, 6/3, 6/8 and 6/24/21, included documentation the nurse soaked gauze in Normal Saline and packed the wound and covered the wound with an ABD pad. On 7/8/21 at 10:45 AM, during a home visit observation, Staff C, RN, completed wound care to the patient's left buttock wound (observed to be in the left ischial area). The wound was covered with an ABD pad and tape to hold the dressing in place. Staff C, RN, used Cavilon Skin Prep to help remove the tape from the dressing. She then cleansed the wound with gauze soaked in sterile water, soaked another 4 by 4 gauze in sterile water and packed this into the wound, covered the wound with an ABD pad and secured the dressing with tape. In an interview, during the same home visit observation, the patient reported the wound care physician did not want the Dakin's solution used in the wound. The patient confirmed Staff C, RN, did the correct wound care. The clinical record lacked orders to support the wound care provided by agency nurses. 4. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: a. The POC, dated 2/17/2021 to 4/17/2021, identified a diagnosis of congestive heart failure and included orders for skilled nursing services. b. A faxed physician's progress note, dated 2/24/21 (for the visit) and 3/1/21 (for a fax date to the agency), revealed an order for the agency nurse to complete a repeat blood draw for a basic metabolic panel (BMP) lab in 1 week (due 3/3/21). The clinical record lacked documentation of a completed laboratory draw for the BMP on or around that date. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

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, agency policy review, home visit observation, staff interview and physician interview, the agency failed to promptly alert the relevant physician(s) to any changes in the patient's condition or that the plan of care should be altered, for 3 of 4 sampled patients (Patients #1, #2 and #4). The agency reported a census of 78 patients at the time of the survey. Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: Review of the agency's undated policy, titled Coordination of Care of the Patient, identified agency staff provide the physician with patient information on an ongoing basis regarding current condition and changes in condition, Plan of Care (POC) and physician's orders. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, included orders for the skilled nurse to complete wound care daily. b. A physician's order, dated 6/8/21, included the following wound care orders: right ischium (lower buttock fold area) to cleanse with Saline, apply Gentamicin 0.1 percent ointment to the wound, apply Prisma to the wound bed, cover with soft roll Drawtex (type of wound dressing), secure with tape and change daily; left ischium to cleanse with Saline, apply Silverlon Rope, apply Cavilon Skin Prep to peri wound, cover with soft roll Drawtex, secure with tape and change daily; and, right posterior heel to cleanse with Saline, apply Gentamicin 0.1 percent ointment to wound, cover with Optifoam (type of wound dressing), secure with tape and change daily. c. A skilled nursing visit note, dated 6/10/21, included documentation of the nurse not being able to use Cavilon Skin Prep on the left ischium, as this was not available. The nurse documented she left a message with the wound clinic that she was almost out of tape, needed Skin Prep and soft roll Drawtex. d. A skilled nursing visit note, dated 6/11/21, included documentation the patient did not have any Optifoam available, so she used Drawtex on the right posterior heel. The visit note lacked documentation the nurse contacted the physician to change the wound care order based on a lack of supplies. The nurse documented she was waiting for supplies for the left ischium and used Gentamicin (no order for use) along with Silverlon Rope and Drawtex. e. The skilled nursing visit notes, dated 6/14, 6/15, 6/16, 6/17 and 6/18/21, included documentation the nurse performed wound care on the left ischium by using Silverlon Rope and Drawtex, but lacked documentation the nurse used Cavilon Skin Prep. The clinical record lacked documentation the agency nurse had tried to follow up after 6/10/21 regarding not having the Cavilon Skin Prep. f. A communication note, dated 6/18/21, included documentation the nurse received the following orders from the wound clinic physician: cleanse both right and left ischium with Saline, apply Gentamicin 0.1 percent, Prisma, soft roll Drawtex and tape daily; cleanse the right posterior heel with Saline, apply Gentamicin 0.1 percent, cover with soft roll Drawtex and tape daily; cleanse the left lateral knee, apply mixture of Gentamicin 0.1 percent with Santyl ointment to wound bed, cover with soft roll Drawtex, Ace wrap does not need to be reapplied will not be using Tubigrip. g. A skilled nursing visit note, dated 6/20/21, included documentation the nurse documented she used Prisma (not ordered) on the left lateral knee wound along with the Gentamicin and Drawtex. The nurse documented she did not use Santyl, because the surrounding wound had a thin layer of raw, red tissue and the wound area was wider. The nurse documented she applied Tubigrips to the left stump and over the right posterior heel wound. The visit note lacked documentation the nurse contacted the physician about the change in condition of the left lateral knee wound. h. A skilled nursing visit note, dated 7/2/21, included documentation the nurse noted an area measuring 1 centimeter (cm) by 1 cm scab with redness surrounding the area on the back of the patient's right calf. The nurse documented she covered the area with Drawtex to protect it. She did not document contacting the patient's physician or the wound clinic. i. A skilled nursing visit note, dated 7/6/21, included documentation the nurse applied Gentamicin and Drawtex to the right ischium wound, but lacked documentation the nurse used Prisma as ordered. The nurse documented the right posterior calf had a beefy red wound bed and she applied Gentamicin and used a Drawtex dressing. The clinical record lacked documentation of physician contact or orders to treat the right calf wound. On 7/7/21 at 9:26 AM, during a home visit observation, Staff B, RN, completed wound cares. The surveyor observed a small open wound on the right posterior calf. Staff B, RN, cleansed the wound with Saline and covered the wound with a Drawtex dressing. For the right ischium wound, the RN cleansed the wound with Saline, applied Gentamicin to the wound bed and covered the wound with Drawtex. She did not use Prisma as ordered. In an interview, during the same home visit observation, the nurse explained the wound clinic would not prescribe a treatment for the right calf wound until they saw it, so she was just covering it with Drawtex until the patient went to the wound clinic. The patient was supposed to go yesterday, but the did not have transportation. The nurse explained the wound on the right ischium was getting too small for the Prisma, and so she did not apply it. The nurse reported she gives the wound clinic an update on the wounds the day the patient goes to the wound clinic. After further discussion with the surveyor, Staff B, RN, reported she was going to call the wound clinic today. On 7/14/21 at 10:35 AM, during an interview, the Administrator/Clinical Manager confirmed the nurses needed to follow up with the physician when they are unable to perform wound care as ordered. 2. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following on 7/7/21: a. The POCs, dated 3/2/2021 to 4/30/2021 and 5/1/2021 to 6/29/2021, included physician orders for Blamed Adult Care topical cream apply to affected areas daily as needed for skin rash. b. The update to the comprehensive assessment completed at the time of recertification, dated 4/28/21, included documentation the nurse assessed the patient had increased redness and open areas on the buttocks, sacral area and perineal region. The nurse noted there were 2 to 3 open areas. The nurse identified there were 2 wounds that were Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer or blister). c. An interim physician order, dated 5/4/21, included an order for wound treatment to a Stage 2 pressure ulcer on the right buttock and to assess the skin integrity to the Stage 2 pressure ulcer. The physician ordered the wound cleansed with soap and water, apply Honey Med Mel (Medihoney) to the wound and cover with a gauze dressing. d. A skilled nursing visit note, dated 5/5, 5/7, 5/10, 5/12 and 5/14/21, included documentation the nurse cleansed the right buttock wound with soap and water, applied Blamed cream and covered it with a gauze dressing. e. A skilled nursing visit note, dated 5/17/21, included documentation the nurse assessed the wound on the right buttock had a small amount of serous drainage and discolored surrounding tissue. The nurse documented she cleansed the wound with soap and water, applied Blamed cream and covered with a gauze dressing. The nurse assessed the patient also had 2 new areas on the left buttock. She measured one wound on the left buttock to be 0.3 cm in length, 0.2 cm in width and 0.1 cm in depth with serous drainage and a red wound bed. She cleansed the wound she measured with soap and water, applied Blamed cream and covered with a gauze dressing. The visit note lacked documentation she notified the physician of the patient's new left buttock wounds or obtained orders for wound care to these wounds. f. A skilled nursing visit note, dated 5/19/21, lacked documentation the nurse assessed the patient's wounds or provided wound care. g. A skilled nursing visit note, dated 5/21/21, included documentation the nurse assessed the right buttock wound had a red wound bed with a small amount of serous drainage. She documented she cleansed the wound with just water (soap not identified) and covered with Blamed cream, gauze and a Tegaderm dressing. She assessed an open area on the proximal left buttock. She cleansed the left buttock wound with water, applied Blamed cream and covered the wound with gauze and Tegaderm. The nurse also assessed an open wound on the left buttocks, distal. The nurse documented she cleansed the wound, but not what she used to cleanse it. She documented she applied Blamed cream, gauze and Tegaderm to the wound. h. An interim physician order, dated 5/24/21, included orders to apply Mupirocin 2 percent to buttocks wounds three times per day. The clinical record lacked documentation the nurse contacted the patient's physician about not being able to use Medihoney on the right buttock wound. The clinical record lacked documentation the nurse contacted the patient's physician about the increase in the number of pressure ulcers until 5/24/21. i. A skilled nursing visit note, dated 6/8/21, included documentation the left and right buttocks wounds had scabbed and there were no open areas. The nurse documented she did not treat the right and left buttocks since there were no open wounds. The visit note lacked documentation of physician contact to see if the physician wanted the nurse to discontinue wound care with the Mupirocin. On 7/8/21 at 2:33 PM, during an interview, the Office Manager for the clinic of the patient's physician reported the patient's physician had discontinued the Mupirocin on 6/30/21. The Office Manager reported they received a call from the agency nurse on 5/18/21 to notify the physician of the inability to get the Medihoney due to insurance not covering the medication. The agency nurse did not inform the physician at this time about the new wounds. On 7/13/21 at 8:21 AM, during an interview, Staff B, RN, reported she was unsure if she had gotten orders to use the Blamed cream. She explained she would have to go back and check the orders. She reported the patient had been using the Blamed cream as a protective cream. On 7/13/21 at 5:12 PM, during an interview, the patient's physician reported he had been unaware the agency nurses were using the Blamed cream to treat the pressure ulcers in May prior to the start of the Mupirocin. 3. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: a. The POC, dated 2/17/2021 to 4/17/2021, identified a diagnosis of congestive heart failure and chronic kidney disease (both conditions associated with fluid retention and weight gain) and included orders for skilled nursing services. The POC included orders for the skilled nurse to monitor the patient's daily weight recordings and a nursing goal for the patient's weight to be maintained and report weight gains of greater than 2 to 3 pounds. b. A skilled nursing visit note, dated 3/12/21, included documentation the patient weighed 292 pounds. The subsequent skilled nursing visit note, dated 3/15/21, included documentation the patient weighed 296 pounds. The clinical record lacked documentation the nurse followed up with the patient's physician or ensured the patient had contacted the physician. c. A skilled nursing visit note, dated 3/22/21, included documentation the patient weighed 295 pounds. The subsequent skilled nursing visit note, dated 3/24/21, included documentation the patient weighed 300 pounds. The clinical record lacked documentation the nurse followed up with the patient's physician or ensured the patient had contacted the physician. d. A skilled nursing visit note, dated 3/31/21, included documentation the patient weighed 303 pounds. The subsequent skilled nursing visit note, dated 4/2/21, included documentation the patient weighed 308 pounds. The clinical record lacked documentation the nurse followed up with the patient's physician or ensured the patient had contacted the physician. e. A skilled nursing visit note, dated 4/5/21, included documentation the patient weighed 305 pounds. The subsequent skilled nursing visit note, dated 4/7/21, included documentation the patient weighed 308 pounds. The clinical record lacked documentation the nurse followed up with the patient's physician or ensured the patient had contacted the physician. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further evidence to refute this finding for Patient #4. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, home visit observation, patient interview and agency staff interview, the agency failed to coordinate care provided by all physicians and integrate orders from the non-primary physician to the primary physician for 2 of 2 (Patients #1 and #3) sampled patients receiving wound care with more than one physician involved in the patient's care. The agency reported a census of 78 patients at the time of the survey, including 5 patients receiving wound care. Failure to coordinate care provided by all physicians and to integrate physician orders and services puts the patients at risk for inappropriate services and interventions or unmet home health care needs. Findings include: Review of the agency's undated policy, titled Coordination of Care of the Patient, identified agency staff must assure communication and integration of orders with all physicians involved in the Plan of Care (POC) to assure the coordination of all services and interventions the agency provides to the patient. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, included orders for the skilled nurse to complete wound care daily. The POC included an updated order, dated 5/20/21, for the skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection including redness, drainage and edema and for the dressing to be changed weekly and as needed. b. A skilled nursing visit note, dated 6/10/21, included documentation the nurse called the orthopedic surgeon. The orthopedic surgeon ordered wound care to be per the wound clinic and to continue to wrap the knee with an Ace Wrap until the patient was seen by the wound clinic. c. A communication note, dated 6/18/21, included documentation the nurse received the following orders from the wound clinic physician: cleanse both right and left ischium with Saline, apply Gentamicin 0.1 percent, Prisma, soft roll Drawtex and tape daily; cleanse the right posterior heel with Saline, apply Gentamicin 0.1 percent, cover with soft roll Drawtex and tape daily; cleanse the left lateral knee, apply mixture of Gentamicin 0.1 percent with Santyl ointment to wound bed, cover with soft roll Drawtex, Ace wrap does not need to be reapplied will not be using Tubigrip. d. A skilled nursing visit note, dated 6/19/21, included documentation the nurse applied Prisma (not ordered) to the right posterior heel along with the Gentamicin and Drawtex. The nurse documented she used Prisma (not ordered) on the left lateral knee wound along with the Gentamicin and Santyl mixture and Drawtex. The nurse documented she applied Tubigrips to the left stump and over the right posterior heel wound. The clinical record lacked documentation of an order for the Tubigrips. e. A skilled nursing visit note, dated 6/20/21, included documentation the nurse applied Prisma (not ordered) to the right posterior heel along with the Gentamicin and Drawtex. The nurse documented she used Prisma (not ordered) on the left lateral knee wound along with the Gentamicin and Drawtex. The nurse documented she did not use Santyl, because the surrounding wound had a thin layer of raw, red tissue and the area was wider. The nurse documented she applied Tubigrips to the left stump and over the right posterior heel wound. f. A skilled nursing visit note, dated 6/23/21, included documentation the nurse applied Gentamicin and Drawtex to the left ischium wound, but lacked documentation the nurse used Prisma as ordered. g. A skilled nursing visit note, dated 6/26/21, included documentation the nurse applied Gentamicin and Drawtex to the right ischium wound, but lacked documentation the nurse used Prisma as ordered. h. A skilled nursing visit note, dated 6/30/21, included documentation the nurse applied Gentamicin and Prisma to the right ischium wound, but lacked documentation the nurse used Drawtex. i. The POC included the following orders added on 6/30/21: 1) to discontinue the following order on 6/18/21: following removal of surgical staples, skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection including redness, drainage and edema, Ace wrap for compression to effected extremity daily. 2) to start the following order on 6/18/21: cleanse both right and left ischium with Saline, apply Gentamicin 0.1 percent, Prisma, soft roll Drawtex and tape daily; cleanse the right posterior heel with Saline, apply Gentamicin 0.1 percent, cover with soft roll Drawtex and tape daily; cleanse the left lateral knee, apply mixture of Gentamicin 0.1 percent with Santyl ointment to wound bed, cover with soft roll Drawtex. On 7/7/21 at 9:26 AM, during a home visit observation, Staff B, Registered Nurse (RN) applied Tubigrips to each lower extremity after completion of wound care. In an interview during the same home visit observation, Staff B, RN, and the patient both reported the patient had been using the Tubigrips for a "long time" accept for a 3 to 4 week period of time after the amputation of the lower left leg. The verbal physician order by the orthopedic surgeon, dated 6/10/21, did not get added to the POC per how the physician gave the order. The nurse did not update the POC with the wound clinic physician orders, dated 6/18/21, and send notification of this update to the primary care physician until 6/30/21. The nurse documented on 6/18/21 that Tubigrip would not be used, but this did not make it into the order. 2. Patient #3 had a start of care date of 4/2/19. Review of the clinical record on 7/8/21 revealed the following: a. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock. Both POCs included the following wound care orders with a start date of 7/1/2020: cleanse wound prior to each dressing change with normal saline, wound cleanser or baby shampoo, rinse and pat dry, ensure wound is dry prior to applying dressing, pack wound with moistened gauze with Dakin's solution 0.125 percent, cover with dry gauze, wrap with wrap gauze, secure with tape, change dressing daily, caregiver to change daily, skilled nurse to complete wound care one time weekly. b. A skilled nursing visit note, dated 3/25/21, included the following documentation: Dakin's discontinued 3/23/21 per University of Iowa Surgeon; use water in place of Dakin's, continue with previous wound care done as ordered with water. All subsequent skilled nursing visit notes through 7/1/21 (last note documented in the record), contained this same information about the wound care change. c. An interim physician order written by the agency nurse, dated 3/25/21, included an order to discontinue the Dakin's solution, but failed to include an order to do the same wound care, but use water in place of the Dakin's. d. The skilled nursing visit notes, dated 4/1 and 4/16/21, included documentation the nurse soaked gauze in water and packed the wound and then covered the wound with an ABD pad. f. The skilled nursing visit notes, dated 4/28, 5/5, 5/25, 6/3, 6/8 and 6/24/21, included documentation the nurse soaked gauze in Normal Saline and packed the wound and covered the wound with an ABD pad. On 7/8/21 at 10:45 AM, during a home visit observation, Staff C, RN, completed wound care to the patient's left buttock wound (observed to be in the left ischial area). The wound was covered with an abdominal (ABD) pad and tape to hold the dressing in place. Staff C, RN, used Cavilon Skin Prep to help remove the tape from the dressing. She then cleansed the wound with gauze soaked in sterile water, soaked another 4 by 4 gauze in sterile water and packed this into the wound, covered the wound with an ABD pad and secured the dressing with tape. In an interview, during the same home visit observation, the patient reported the wound care physician did not want the Dakin's solution used in the wound. The patient reported having a wound physician, a wound surgeon and then a primary physician (POC physician) involved in the patient's care. The patient confirmed Staff C, RN, did the correct wound care during the home visit. The clinical record lacked a physician order to coincide with the wound care provided to the patient. On 7/8/21 at 2:33 PM, during an interview, the Office Manager for the patient's primary care physician reported the last wound note the physician had from agency nursing staff was in February 2021. The physician had received and signed 2 POCs since then, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021. On 7/13/21 at 8:42 AM, during an interview, the patient's primary care physician was unaware the patient was not using the Dakin's solution for wound treatment until he received a faxed update from the patient's wound surgeon on 6/29/21 which stated the patient should avoid the use of Dakin's. He said he received a fax yesterday (7/12/21) from the home health agency with an order to sign off on to discontinue the Dakin's solution on 3/23/21 given by the wound surgeon. The primary care physician reported he signed this order and sent it back. Agency nurses failed to integrate orders from all physician's and assure the coordination of interventions provided to the patient. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further evidence to refute this finding for Patient #3. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of the patient clinical record review, agency policy review, home visit observation, patient representative interview, physician representative interview and staff interview, the agency failed to ensure agency staff coordinated the delivery of care in a way to meet patient individualized needs for 1 of 3 sampled patients (Patient #2) receiving wound care. The agency reported a census of 78 patients at the time of the survey, including 5 patients receiving wound care. Failure to ensure agency staff effectively coordinated the delivery of care resulted in the patients not receiving care to meet individualized patient needs. Findings include: Review of the agency's undated policy, titled Coordination of Care of the Patient, identified agency staff must coordinate care delivery to meet the needs of the patient, involve the patient, representative and caregiver, as appropriate, in the coordination of care activities. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following on 7/7/21: a. The POC, dated 5/1/2021 to 6/29/2021, included orders for skilled nursing services and identified a diagnosis of a pressure ulcer of the sacral region, Stage 2 (shallow open wound or blister). b. A skilled nursing visit note, dated 5/21/21, included documentation the nurse assessed the right buttock wound had a red wound bed with a small amount of serous drainage. She assessed an open area on the proximal left buttock. The nurse also assessed an open wound on the left buttocks, distal. c. An interim physician order, dated 5/24/21, included orders to apply Mupirocin 2 percent to buttocks wounds three times per day. d. A skilled nursing visit note, dated 6/8/21, included documentation the left and right buttocks wounds had scabbed and there were no open areas. The nurse documented she did not treat the right and left buttocks since there were no open wounds. The visit note lacked documentation of physician contact to see if the physician wanted the nurse to discontinue wound care with the Mupirocin. e. A skilled nursing visit note, dated 6/24/21, included documentation the nurse assessed the patient had new open buttock wounds with one on the right buttock measuring 3.4 cm in length, 0.5 cm in width and 0.1 cm in depth. The visit note lacked an assessment of a second wound. The nurse documented she did not have orders to do wound care, so she did not do wound care. She contacted the physician for orders. f. An update to the comprehensive assessment for recertification, dated 6/29/21, included documentation the nurse assessed the patient had 2 buttocks wounds, one on the left buttock measuring 1.4 cm in length, 0.8 cm in width and 0.1 cm in depth, and one on the right buttocks measuring 1.8 cm in length, 0.7 cm in width and 0.1 cm in depth. She cleansed both wounds with soap and water, applied Mupirocin and covered the wounds with gauze. g. The POC, dated 6/30/2021 to 8/28/2021, included a signature of completion of the POC by the nurse, dated 7/4/21, and an order for Mupirocin 2 percent apply a small amount to buttock wound three times daily with a start date of 5/24/21. h. The clinical record included documentation of a faxed document, dated 7/6/21, from the patient's physician's office. The fax included documentation of the patient's office visit, dated 6/30/21, and an order for Calazime Paste 3.5 percent-0.2 percent-69 percent- 16.5 percent apply topically to the pressure ulcer daily, dated 6/30/21. On 7/8/21 at 12:00 PM, during a home visit observation with Staff C, RN, the surveyor observed Staff C, RN go into the bathroom with the patient. The surveyor observed Staff C, RN, assess the patient's buttocks. The patient's buttocks had a open wound on the right middle buttock near the gluteal fold approximately 1 centimeters (cm) in length, 2 cm in width and 0.1 cm in depth. In an interview during the same home visit observation, Staff C, RN, reported she was unable to do wound care because she did not have orders. The patient's Power of Attorney (POA) explained she had been putting Calmoseptine (an over the counter protective barrier cream) on the wound one time per day per the patient's physician orders given on 6/30/21. The POA had gotten Calmoseptine instead of the Calazime Paste. The POA reported the patient's physician did not want Mupirocin put on the current buttock wound. Staff C, RN, indicated her awareness of the use of Calmoseptine on the wound by the POA prior to this visit. The POA did voice resistance and not wanting the agency nurses calling the patient's physician more than necessary to coordinate patient care. On 7/8/21 at 2:33 PM, during an interview, the Office Manager for the clinic of the patient's physician reported the patient's physician had discontinued the Mupirocin on 6/30/21. The Office Manager reported the physician had received a POC, dated 6/30/2021 to 8/28/2021, via fax on 7/4/21, with the previous Mupirocin order still on it, but the patient's physician had not signed it yet. The physician's office sent a fax to the home health agency on 7/6/21 with a summary of the patient's last office visit and latest physician orders. On 7/13/21 at 10:00 AM, during an interview, Staff C, RN, explained while she had gotten a verbal order for recertification of services, she had not spoke with the patient's physician about wound care or using the Mupirocin. She had accidentally done the recertification visit on 6/24/21, discovered the new wounds then and reported it to the physician's office. The physician did not want to order wound care at that time until he saw the patient in his office. She went back on 6/29/21 to complete the update to the comprehensive assessment for recertification, but this visit was prior to the patient seeing the physician on 6/30/21. She reported the order for Mupirocin should not have put on the POC, dated 6/30/2021 to 8/28/2021, and should have been discontinued after the previous wounds healed. She explained the physician had ordered a new medication, but the POA for the patient had gotten an over the counter cream instead. The clinical record lacked documentation the agency nurse had tried to coordinate between the patient's representative and patient's physician to obtain wound care orders from the date of the patient's last physician office visit, dated 6/30/21, until after the home visit on 7/8/21. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to do the following: 1) ensure agency nursing staff wrote verbal orders, sent verbal orders for signature by the physician providing the order and included other orders given into the clinical record (G1012); and, 2) ensure entries in the clinical record related to interventions provided by staff were current and complete (G1014). The cumulative systemic practices resulted in the failure of the agency to ensure agency staff had a process in place to accurately document care and services provided to the agency's 78 patients.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient and staff interview, the agency failed to ensure the clinical record included the patient's physician orders for 4 of 4 sampled patients (Patients #1, #2, #3 and #4). At the time of the survey, the agency reported a current census of 78 patients. Failure of the agency to ensure the clinical record included all of the patient's current physician orders placed agency patient's at risk to receive inappropriate care or not receive care to meet the needs of the patient. Findings include: Review of the agency's undated policy, titled Timely Submission of Patient Documentation, identified physicians' orders must be submitted to the agency within 7 business days after receipt. Review of the agency's policy, titled Physician's Orders-Verbal Orders, dated 3/2018, identified when agency nursing staff receive a verbal order, they must record the order on the supplemental order form. Agency licensed staff must document and authenticate the order within 3 business days after receipt. Agency staff send the original order to the physician for signature and authentication. Agency staff must receive the physician signed order back within 30 days. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, included orders for the skilled nurse to complete wound care daily. The POC included an updated order, dated 5/20/21, for the skilled nurse to assess left leg amputation surgical incision for signs and symptoms of infection including redness, drainage and edema and for the dressing to be changed weekly and as needed. b. A skilled nursing visit note, dated 6/10/21, included documentation the nurse called the orthopedic surgeon. The nurse of the orthopedic surgeon reported he ordered wound care to be per the wound clinic and to continue to wrap the knee with an Ace Wrap until the patient was seen by the wound clinic. c. The clinical record lacked documentation the nurse wrote the verbal order received from the orthopedic surgeon and lacked documentation she sent the order to the orthopedic surgeon for signature. 2. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following: a. An interim physician verbal order, dated 5/4/21, included documentation of a signature of creation of the order, dated 5/23/21. The interim order included orders for skilled nursing 2 times a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 1 week and 1 time per week for 4 weeks starting on 5/5/21. The order also included wound care orders to cleanse area with soap and water and apply Honey Med Mel to a Stage 2 right buttock pressure ulcer and the for the nurse to assess and instruct on vitals and skin integrity. The order lacked documentation of a physician signature. b. An interim physician verbal order, dated 5/24/21, included orders to apply Mupirocin 2 percent to buttocks wounds three times per day. The order lacked documentation of a physician signature. 3. Patient #3 had a start of care date of 4/2/19. Review of the clinical record on 7/8/21 revealed the following: a. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock. Both POCs included the following wound care orders with a start date of 7/1/2020: cleanse wound prior to each dressing change with normal saline, wound cleanser or baby shampoo, rinse and pat dry, ensure wound is dry prior to applying dressing, pack wound with moistened gauze with Dakin's solution 0.125 percent, cover with dry gauze, wrap with wrap gauze, secure with tape, change dressing daily, caregiver to change daily, skilled nurse to complete wound care one time weekly. b. A skilled nursing visit note, dated 3/25/21, included the following documentation: Dakin's discontinued 3/23/21 per University of Iowa Surgeon; use water in place of Dakin's, continue with previous wound care done as ordered with water. All subsequent skilled nursing visit notes through 7/1/21 (last note documented in the record), contained this same information about the wound care change. c. An interim physician order written by the agency nurse, dated 3/25/21, included an order to discontinue the Dakin's solution, but failed to include an order to do the same wound care, but use water in place of the Dakin's. The interim order lacked a physician signature. d. The skilled nursing visit notes, dated 4/1 and 4/16/21, included documentation the nurse soaked gauze in water and packed the wound and then covered the wound with an ABD pad. f. The skilled nursing visit notes, dated 4/28, 5/5, 5/25, 6/3, 6/8 and 6/24/21, included documentation the nurse soaked gauze in Normal Saline and packed the wound and covered the wound with an ABD pad. On 7/8/21 at 10:45 AM, during a home visit observation, Staff C, RN, completed wound care to the patient's left buttock wound (observed to be in the left ischial area). The wound was covered with an abdominal (ABD) pad and tape to hold the dressing in place. Staff C, RN, used Cavilon Skin Prep to help remove the tape from the dressing. She then cleansed the wound with gauze soaked in sterile water, soaked another 4 by 4 gauze in sterile water and packed this into the wound, covered the wound with an ABD pad and secured the dressing with tape. In an interview, during the same home visit observation, the patient reported the wound care physician did not want the Dakin's solution used in the wound. The patient confirmed Staff C, RN, did the correct wound care during the home visit. The clinical record lacked a physician order to coincide with the wound care provided to the patient. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further evidence to refute this finding for Patient #3. 4. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: The POC, dated 2/17/2021 to 4/17/2021, identified a diagnosis of congestive heart failure and identified the patient had discharged from the hospital on 2/16/21. The POC included orders for skilled nursing 1 to 3 times per week. The POC did not include any orders for the nurse to complete laboratory blood draws. The POC included a signature of completion by the RN, dated 2/22/21. A skilled nursing visit, dated 2/18/21, included the following documentation: "Labs drawn and sent to the hospital per order." The visit note did not identify what labs the nurse drew. The clinical record and POC lacked orders for the skilled nurse to complete any laboratory blood draws. The clinical record included documentation of labs completed on 2/16/21 including a basic metabolic panel, blood phosphorus and magnesium levels. On 7/14/21 at 2:00 PM, during an interview, the Administrator/Clinical Manager reported an inability to find any further evidence to refute this finding. The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patient's clinical record included current and complete documentation of interventions in the patient record for 4 of 4 sampled patients (Patients #1, #2, #3 and #4). The agency reported a census of 78 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and complete documentation of interventions placed agency patient's at risk for not receiving the correct interventions and to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's undated policy, titled Timely Submission of Patient Documentation, identified agency staff must complete visit notes by the next scheduled work day, not to exceed 3 business days or 7 days. On 7/13/21 at 11:48 AM, during an interview, the Administrator/Clinical Manager reported an expectation for staff to complete visit notes at the visit, but a policy to complete them within 7 days. She reported verbal orders should be documented within 2 days. On 7/13/21 at 3:02 PM, during an interview, the Administrator/Clinical Manager reported being aware of the problem with the documentation of late visit notes. She explained the staff were completing the visit notes, but not remembering to sign the notes prior to syncing them to the electronic system. 1. Patient #1 had a start of care date of 12/8/15. Review of the clinical record revealed the following: a. The POC, dated 5/10/2021 to 7/8/2021, identified the patient had diagnosis of pressure ulcer the right and left buttocks, Stage 4 (full thickness tissue loss with possible bone, tendon and/or muscle exposure), left leg amputation below the knee and pressure ulcer of the right heel, Stage 3 (open wound with full thickness loss with possible visual of subcutaneous fat). The POC included orders for daily wound care. b. A skilled nursing visit note, dated 6/13/21, included documentation of a signature of completion, dated 7/4/21 (exceeding the agency's documentation completion policy by 18 days). 2. Patient #2 had a start of care date of 11/13/18. Review of the clinical record revealed the following on 7/7/21: a. The POCs, dated 5/1/2021 to 6/29/2021 and 6/30/2021 to 8/28/2021, identified diagnosis of pressure ulcer of the sacral region, Stage 2 (partial thickness loss of skin presenting as a shallow open ulcer or blister) and heart failure. b. A skilled nursing visit note, dated 4/29/21, included documentation of a signature of completion, dated 5/14/21 (10 days late). c. A skilled nursing visit note, dated 4/30/21, included documentation of a signature of completion, dated 5/14/21 (9 days late). d. A skilled nursing visit note, dated 5/3/21, included documentation of a signature of completion, dated 5/23/21 (17 days late). e. An interim physician verbal order, dated 5/4/21, included documentation of a signature of creation of the order, dated 5/23/21 (16 days late). The interim order included orders for skilled nursing 2 times a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 1 week and 1 time per week for 4 weeks starting on 5/5/21. The order also included wound care orders to cleanse area with soap and water and apply Honey Med Mel to a Stage 2 right buttock pressure ulcer and the for the nurse to assess and instruct on vitals and skin integrity. f. A communication note, dated 5/4/21, included documentation of a signature of completion, dated 5/23/21. The note included documentation the nurse had received verbal orders for skin assessment and wound care 3 times weekly (16 days late). g. A skilled nursing visit note, dated 5/5/21, included documentation of a signature of completion, dated 5/26/21 (16 days late). h. A skilled nursing visit note, dated 5/7/21, included documentation of a signature of completion, dated 5/26/21 (14 days late). i. A skilled nursing visit note, dated 5/10/21, included documentation of a signature of completion, dated 5/26/21 (13 days late). j. A skilled nursing visit note, dated 5/12/21, included documentation of a signature of completion, dated 5/26/21 (9 days late). k. A skilled nursing visit note, dated 5/14/21, included documentation of a signature of completion, dated 5/26/21 (7 days late). l. A skilled nursing visit note, dated 5/17/21, included documentation of a signature of completion, dated 6/3/21 (14 days late). m. A skilled nursing visit note, dated 5/19/21, included documentation of a signature of completion, dated 5/29/21 (5 days late). n. A skilled nursing visit note, dated 5/21/21, included documentation of a signature of completion, dated 6/3/21 (8 days late). o. An interim verbal physician order, dated 5/24/21, included documentation of the creation of the order, dated 5/29/21 for Mupirocin 2 percent a small amount to buttock wounds 3 times daily (2 days late). p. A skilled nursing visit note, dated 5/26/21, included documentation of a signature of completion, dated 7/7/21 (37 days late). q. A skilled nursing visit note, dated 5/28/21, included documentation of a signature of completion, dated 7/7/21 (35 days late). r. A skilled nursing visit note, dated 6/2/21, and signed by the RN, dated 6/29/21, identified the patient had "wounds", but lacked any further assessment or documentation of treatment of the wounds (22 days late). s. A skilled nursing visit note, dated 6/4/21, lacked a signature of completion by the RN, identified the patient had a wound, but lacked documentation of wound care or an assessment of any wounds (28 days late). t. A skilled nursing visit note, dated 6/8/21, and signed by the RN, dated 6/29/21, identified the patient had a "wound", but lacked any further assessment or documentation of treatment of the wounds (18 days late). On 7/14/21 at 10:35 AM, during an interview, the Administrator/Clinical Manager, reported the documentation for wound assessment and care was present in the visit notes, dated 6/2, 6/4 and 6/8/21. On 7/14/21 at 2:00 PM, the Administrator/Clinical Manager provided a copy of a skilled nursing visit note, dated 6/2/21, and signed by the RN, dated 7/7/21 at 8:15 PM, which now included an assessment of the right buttock pressure ulcer which measured 0.5 cm in length, 0.2 cm in width and 0.1 cm in depth and had a small amount of bloody red drainage. The nurse documented she applied Mupirocin and covered the wound with gauze (no order to use gauze). She documented she assessed a wound on the left buttock which measured 0.3 cm in length, 0.1 cm in width and 0.1 cm in depth. She documented she applied Mupirocin and gauze to the left buttock wound. The Administrator/Clinical Manager provided a copy of the skilled nursing visit note, dated 6/4/21, and signed by the RN, dated 7/7/21 at 8:21 PM. This 6/4/21 visit note now included an assessment of the right and left buttocks wounds and documentation the nurse applied Mupirocin to the wounds. The Administrator/Clinical Manager provided a copy of the skilled nursing visit note, dated 6/8/21, and signed by the RN, dated 7/7/21 at 8:26 PM. The visit note now included documentation the left and right buttocks wounds had scabbed and there were no open areas. The nurse documented she did not treat the right and left buttocks since there were no open wounds. The visit note lacked documentation of physician contact to see if the physician wanted the nurse to continue wound care with the Mupirocin. u. A skilled nursing visit note, dated 6/15/21, included documentation of a signature of completion, dated 6/28/21 (10 days late). v. The clinical record lacked documentation of a visit note, dated the week of 6/20/21. On 7/13/21 at 10:00 AM, during an interview, Staff C, Registered Nurse (RN) reported she had accidentally done the recertification visit on 6/24/21. She went back on 6/29/21 to complete the update to the comprehensive assessment for recertification and deleted the information from the 6/24/21 visit. She had not re-documented the documentation in yet for the visit on 6/24/21 in a regular visit note. On 7/14/21 at 2:00 PM, the Administrator/Clinical Manager provided the following: A skilled nursing visit note, dated 6/24/21, included documentation of a signature of completion, dated 7/13/21 (14 days late). 3. Patient #3 had a start of care date of 4/2/19. Review of the clinical record on 7/8/21 revealed the following: a. The POCs, dated 3/22/2021 to 5/20/2021 and 5/21/2021 to 7/19/2021, included a diagnosis of an unstageable pressure ulcer to the left buttock and orders for the skilled nurse to complete wound cares weekly. b. A skilled nursing visit note, dated 4/16/21, included documentation of a signature of completion, dated 5/3/21 (12 days late). c. A communication note, undated, included a signature of completion, dated 5/11/21. d. A skilled nursing visit note, dated 4/28/21, included documentation of a signature of completion, dated 5/11/21 (8 days late). e. A skilled nursing visit note, dated 5/5/21, included documentation of a signature of completion, dated 5/15/21 (5 days late). f. A skilled nursing visit note, dated 5/13/21, lacked documentation of a signature of completion (50 days late at the time of the record review). g. A skilled nursing visit note, dated 5/25/21, included documentation of a signature of completion, dated 6/23/21 (26 days late). h. A skilled nursing visit note, dated 6/8/21, included documentation of a signature of completion, dated 7/6/21 (25 days late). i. A skilled nursing visit note, dated 6/16/21, included documentation of a signature of completion, dated 7/6/21 (15 days late). j. A skilled nursing visit note, dated 6/24/21, included documentation of a signature of completion, dated 7/6/21 (7 days late). 4. Patient #4 had a start of care date of 2/17/21 and discharged from agency services on 4/14/21. Review of the clinical record revealed the following: a. The POC, dated 2/17/2021 to 4/17/2021, identified a diagnosis of congestive heart failure, diabetes and chronic kidney disease and included orders for the skilled nurse to assess the patient's weight and monitor the patient's blood sugar levels. b. A skilled nursing visit, dated 2/18/21, included the following documentation: "Labs drawn and sent to the hospital per order." The visit note did not identify what labs the nurse drew. c. A skilled nursing visit note, dated 2/22/21, included documentation of a signature of completion, dated 3/8/21 (11 days late). d. A skilled nursing visit note, dated 3/8/21, included documentation of a signature of completion, dated 3/21/21 (10 days late). e. A skilled nursing visit note, dated 4/5/21, included documentation of a signature of completion, dated 4/22/21 (14 days late). The Administrator/Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.