Every finding on record at Noble Hospice & Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during the Recertification survey visit from 12/6/2021 through 12/8/2021. Representing the Department: Health Facilities Evaluator Nurses: 38534 and 31403. The sample size was 9 The agency failed to meet the Condition of Participation (CoP) §418.60 Care Planning, Coordination, and Quality of Care (See G 572, G 590, and G 592).

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to maintain privacy during care for one of nine sampled selected patients (Patient 6) when Registered Nurse (RN) 1 entered Patient 6's room without knocking on the door and started to perform a physical exam without providing privacy. This deficient practice did not ensure the Patient's right for dignity and privacy during care. During a review of Patient 6's "Plan of care" dated 11/29/21 indicated Patient 6 was admitted to the agency with multiple diagnoses, including functional or mental deficits.During an observation on 12/7/21 at 11:45 p.m., RN 1 entered Patient 6's room without knocking on the door or asking for permission to enter the room. RN 1 started performing a physical exam on Patient 6 without closing the door. Patient 6 was exposed and visible from the hallway.During an interview with RN 1 on 12/7/21 at 1:30 p.m., RN 1 confirmed he did not knock on the door or ask permission when he entered Patient 6's room, and did not close the door before performing the physical exam. RN 1 further stated he should watch for privacy and get permission before going inside Patient 6's room to maintain Patient 6's dignity and right to privacy.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform one of nine sampled selected patients (Patient 3) about the change in plan of care and discharged the patient from the agency sooner than the planned discharge date. This deficient practice resulted in excluding Patient 3 from participating and being informed of changes to the plan of care. During a review of Patient 3's record "plan of care" indicated Patient 3 was admitted to the agency with multiple diagnosis including pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 3's record "chart 1, episode #1 9/4/21-11/2/21" indicated: 1. Licensed Vocational Nurse (LVN) 1 did not follow the frequency which was ordered by the physician and her last visit was on 10/13/21 and then stopped visiting Patient 3 furthermore did not give Patient 3 any notification of discharged. 2. Occupational therapist (OT) visited Patient 3 on 9/8/21 and did not have any visits after that date, there was no notes from the OT to indicated why OT stopped visiting Patient 3. 3. OASIS (Outcome and Assessment Information Set) discharged was not completed by any clinicians. 4. SN visited Patient 3 for 2w1 (2 times in 1 week), 3w1, 1w4. 5. OT visited Patient 3 one time on 9/8/21. During a review of Patient 3's Physician's orders, dated 9/6/21 indicated "SN (Skilled Nurse) frequency 2w1 (2 times for 1 week) 3w2 2w4 effective 9/6/21". During a review of Patient 3's Physician's orders, dated 9/8/21 indicated “OT/COTA (Certified Occupational Therapy Assistant) 1w1, 2w3 effecting 9/8/21". During an interview with LVN 1 on 12/6/21, at 1:36 p.m., stated she did not communicate with the case manager or the physician about stopped visiting Patient 3 and she should inform them about the change of the plan of care. During an interview with Registered Nurse (RN) 1 on 12/6/21, at 2:17 p.m., stated LVN 1 should call the physician and case manager and discussed about her change of visit's frequency, also stated he did not finish his documents because he did not have time to finish them and furthermore stated he did not notified Patient 3 about change of care plan and he should do that because that is the Patient's right to know about discharge or any change of plan of care. During an interview with OT on 12/6/21 at 1:30 p.m., stated Patient 3 refused to see OT and he forgot to document the discipline discharge note and stated that is important to document all the communications with the patients because the team should know what was going on with them. During a review of the agency's policy and procedures: 1. "Clinical Documentation" undated indicated "... 3. Additional information that is pertinent to the patient's care plan or change of condition may be documented on the clinician visit note or communication note... 6. Services not provided and the reason for the missed visits will be documented and reported to the physician." 2. "Patient discharge process"... 1. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. The patient/family will participate in this process..." During a review of Patient 3's record, "Plan of Care" indicated Patient 3 was admitted to the agency with multiple diagnoses, including pressure ulcer or bed sore (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 3's record, "Chart 1, episode #1 9/4/21-11/2/21" indicated as follows: 1. The Licensed Vocational Nurse (LVN) 1 did not follow the frequency ordered by the physician and her last visit was on 10/13/21. LVN 1 stopped visiting Patient 3 and did not give Patient 3 a discharge notice.2. The Occupational therapist (OT) visited Patient 3 on 9/8/21. OT did not have any visits after 9/8/21. There was no documentation indicating why OT stopped visiting Patient 3. 3. OASIS (Outcome and Assessment Information Set) discharged was not completed by a clinician.4. A SN (skilled nurse) visited Patient 3 for 2w1 (2 times in 1 week), 3w1 (3 times in 1 week), 1w4 (once in 4 weeks).5. OT visited Patient 3 once on 9/8/21. During a review of Patient 3's physician orders, dated 9/6/21 indicated, "SN (Skilled Nurse) frequency 2w1 (2 times for 1 week) 3w2 (3 times for 2 weeks) 2w4 (2 times in 4 weeks) effective 9/6/21."During a review of Patient 3's physician orders, dated 9/8/21 indicated, “OT/COTA (Certified Occupational Therapy Assistant) 1w1 (1 in 1 week), 2w3 (2 in 3 weeks) effective 9/8/21." During an interview with OT on 12/6/21 at 1:30 p.m., OT stated Patient 3 refused to see OT but forgot to document this in the discipline discharge note. OT further stated it is important to document all communications with the patients because the team should know what was is going on.During an interview with LVN 1 on 12/6/21, at 1:36 p.m., LVN 1stated she did not communicate with the case manager or the physician about having stopped visiting Patient 3 and she should inform them about the change of the plan of care.During an interview with Registered Nurse (RN) 1 on 12/6/21, at 2:17 p.m., RN 1 stated LVN 1 should call the physician and case manager to discuss about LVN 1's visit frequency changes. RN 1 stated he did not finish his documents and had not notified Patient 3 about the change of care plan and should have because it is the Patient's right to know about changes in discharge planning.During a review of the agency's policy and procedures as follows: 1. "Clinical Documentation" (undated) indicated "... 3. Additional information that is pertinent to the patient's care plan or change of condition may be documented on the clinician visit note or communication note... 6. Services not provided and the reason for the missed visits will be documented and reported to the physician." 2. "Patient discharge process"... 1. Planning for discharge is provided as part of the ongoing assessment of needs and in accordance with expected care outcomes. The patient/family will participate in this process..."

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 interview and record review for one, (Patient 9) of nine sampled patients, the home health agency (HHA) failed to meet the Condition of Participation for Care Planning, Coordination, Quality of Care when the agency licensed nursing staff did not report to the doctor and manage effectively Patient 9's elevated blood pressures. Refer to deficiencies G 572, G 590 and G 592. The cumulative severity and intensity of these deficiencies resulted in the failure of the facility to meet 418.60 Care Planning, Coordination, Quality of Care. See tags 572, 590 and 592 See tags 572, 590 and 592

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency’s licensed staff did not follow the plan of care for one of nine sampled patients (Patient 9). The licensed staff did not meet Patient 9’s blood pressure (BP) goals according to the plan of care when the BP was elevated and not within specific parameters as outlined in the plan of care. This failure resulted in licensed staff not notifying the physician for timely medical interventions and modification to the plan of care which contributed to Patient 9 developing a subarachnoid (bleeding in the space between the brain and the tissue covering the brain) hemorrhage (blood loss) or potential stroke (damage to the brain from interruption of its blood supply). Record review on 12/6/2021 at 1:15 p.m. of the policy and procedure “Care Plans,” (not dated) showed, “Each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs.” The purpose is to "Focus the interventions and frequency and duration based on the effectiveness of interventions and progress toward goals.” Review of the document “Plan of Care” showed Patient 9’s start of care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. Diagnoses included history of a stroke. Interventions included maintaining the systolic blood pressure (top number) between 90 and 160 and the diastolic (lower number) between 60 and 90. Review of the document “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s blood pressure was 172/88. Review of the visit note dated 10/20/2021 showed a blood pressure of 178/87. There was no documentation in the clinical record which showed Licensed Vocational Nurse 1 (LVN 1) had notified the doctor. Review of the nursing visit note dated 11/16/2021 showed Patient 9's blood pressure was 170/91. In an interview at 11:29 a.m. on 12/7/2021, the Director of Patient Care Services (DPCS) confirmed Patient 9’s blood pressures had been outside of the parameters as established in the plan of care which put him at risk for a stroke. In an interview at 1:55 p.m., Medical Doctor 1 (MD 1) stated she had not been notified regarding the elevated blood pressures on 10/13/2021 and 10/20/2021. MD 1 stated it was important to maintain Patient 9's blood pressure within the established parameters on the plan of care in order to minimize the risk of stroke. In an interview at 4:20 p.m., LVN 1 confirmed Patient 9's established blood pressure parameters were outside the established range as outlined in the plan of care and she had not communicated this information to the doctor. Review of the document "(hospital name) Emergency Department Note," dated 11/16/2021, showed Patient 9's blood pressure was 181/130 with the diagnosis of a new subarachnoid hemorrhage. Record review on 12/6/2021 at 1:15 p.m. of the policy and procedure, “Care Plans,” (not dated) showed, “Each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs.” The purpose indicated to "Focus the interventions and frequency and duration based on the effectiveness of interventions and progress toward goals.” Review of the document, “Plan of Care” showed Patient 9’s Start of Care was 10/2/2021 and the current certification period 10/2/2021 to 11/30/2021. The diagnoses included history of a stroke and interventions included maintaining the systolic BP (top number) between 90 and 160 and the diastolic (lower number) between 60 and 90. Review of the document, “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s BP was 172/88. Review of the visit note dated 10/20/2021 showed BP of 178/87. There was no documentation in the clinical record indicating the Licensed Vocational Nurse 1 (LVN 1) had notified the doctor. Review of the nursing visit note dated 11/16/2021 showed Patient 9's BP was 170/91. In an interview on 12/7/2021 at 11:29 a.m., the Director of Patient Care Services (DPCS) confirmed Patient 9’s BP's were outside of the parameters established in the plan of care which placed Patient 9 at risk for a stroke. In an interview on 12/7/2021 at 1:55 p.m., the Medical Doctor 1 (MD 1) stated she was not notified regarding the elevated BP's on 10/13/2021 and 10/20/2021. MD 1 stated it was important to maintain Patient 9's BP within the established parameters on the plan of care in order to minimize the risk of stroke. In an interview on 12/7/2021 at 4:20 p.m., LVN 1 confirmed Patient 9's established BP parameters were outside the established range as outlined in the plan of care and had not communicated this information to the doctor. Review of the document, "(hospital name) Emergency Department Note" dated 11/16/2021, showed Patient 9's BP was 181/130 and diagnosis of a new subarachnoid hemorrhage.

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 interview and record review, the home health agency’s licensed staff did not notify the doctor for a change in condition for one of nine sampled patients (Patient 9). Patient 9’s blood pressure (BP) became abnormally elevated and staff failed to notify the doctor as ordered. This failure contributed to Patient 9 developing a subarachnoid hemorrhage (bleeding in the brain or stroke). “A stroke happens when blood flow to the brain is blocked. This prevents the brain from getting oxygen and nutrients, brain cells begin to die within minutes. Sudden bleeding in the brain can also cause a stroke if it damages brain cells. Risk factors include high blood pressure…” Signs and symptoms of a stroke may include, “Sudden confusion or trouble speaking or understanding speech.” [National Heart, Lung, and Blood Institute – nhlbi.nih.gov/health-topics/stroke – 10/28/2020] Record review on 12/8/2021 of the agency’s policy and procedure “Medical Supervision,” (not dated) showed the physician will be notified when, “Condition changes” and “Expected response to treatment or medication changes.” Review of the document “Plan of Care” showed Patient 9’s start of care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. Diagnoses included history of a stroke. Review of the document “Physician Orders,” dated 10/2/2021, showed staff were to notify the physician if the systolic blood pressure (top number) was greater than 160 and the diastolic (lower number) was greater than 90. Review of the document “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s blood pressure was 172/88. Review of the visit note dated 10/20/2021 showed a blood pressure of 178/87. There was no documentation in the clinical record which showed Licensed Vocational Nurse 1 (LVN 1) had notified the doctor. In an interview on 12/7/2021 at 11:29 a.m., the Director of Patient Care Services (DPCS) stated staff had been instructed to notify him if any patient had a change in condition. The DPCS stated LVN 1 had not reported the elevated blood pressures and confirmed there was no documentation in the clinical record which showed the doctor had been notified. The DPCS stated it was important to notify the doctor because Patient 9 had a history of high blood pressure and was at risk for a stroke. In an interview at 1:55 p.m., Medical Doctor 1 (MD 1) stated she had not been notified regarding the elevated blood pressures on 10/13/2021 and 10/20/2021. MD 1 stated it was important for staff to notify the doctor when a blood pressure is elevated due to the risk of a stroke. In an interview at 4:20 p.m., LVN 1 stated she had not communicated with the doctor regarding the elevated blood pressures. Review of the nursing visit note dated 11/16/2021 at 2 p.m. showed Patient 9’s blood pressure was 170/91. Patient 9 had been described as alert and oriented to person and place. There were no documented swallowing or speech difficulties. Review of the document, “(Hospital Name) Emergency Department (ED) Note,” dated 11/16/2021 at 5:28 p.m., showed Patient 9 arrived at the ED with complaints of aphasia (difficulty speaking) and a blood pressure of 181/130. Review of the document, “Hospitalist Discharge Summary and Transfer Instruction,” dated 11/20/2021, showed Patient 9 was unable to engage in speech therapy and had failed swallowing evaluations due to the fact that he had become “obtunded.” (comatose) Record review on 12/8/2021 of the agency’s policy and procedure, “Medical Supervision” (not dated) showed, the physician will be notified when the “Condition changes” and when “Expected response to treatment or medication changes.” Review of the document, “Plan of Care” showed Patient 9’s Start of Care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. The diagnoses included a history of stroke. “A stroke happens when blood flow to the brain is blocked. This prevents the brain from getting oxygen and nutrients, brain cells begin to die within minutes. Sudden bleeding in the brain can also cause a stroke if it damages brain cells. Risk factors include high blood pressure…” Signs and symptoms of a stroke may include, “Sudden confusion or trouble speaking or understanding speech.” [National Heart, Lung, and Blood Institute – nhlbi.nih.gov/health-topics/stroke – 10/28/2020] Review of the document, “Physician Orders” dated 10/2/2021, showed staff were to notify the physician if the systolic BP (top number) was greater than 160 and the diastolic BP (lower number) was greater than 90. Review of the documents, “Skilled Nurse Visit Note” dated 10/13/2021, showed Patient 9’s BP was 172/88. Further review indicated on 10/20/2021, the BP was 178/87. There was no documentation in the clinical record which showed the Licensed Vocational Nurse 1 (LVN 1) had notified the doctor. In an interview on 12/7/2021 at 11:29 a.m., the Director of Patient Care Services (DPCS) stated staff had been instructed to notify him if the patient had a change in condition. DPCS stated LVN 1 had not reported the elevated BPs and confirmed there was no documentation in the clinical record that the doctor was notified. DPCS stated it was important to notify the doctor because Patient 9 had a history of high BP and stroke. In an interview on 12/7/2021 at 1:55 p.m., the Medical Doctor 1 (MD 1) stated she was not notified regarding Patient 9’s elevated BPs on 10/13/2021 and 10/20/2021. MD 1 further stated it was important for staff to notify the doctor because Patient 9 had a high risk for stroke and could have adjusted Patient 9’s medications and change the plan of care. In an interview on 12/7/2021 at 4:20 p.m., LVN 1 stated she called the doctor but did not document the call. Review of the nursing visit note dated 11/16/2021 at 2 p.m. showed Patient 9’s BP was 170/91. Patient 9 had been described as alert and oriented to person and place. Review of the document, “(Hospital Name) Emergency Department (ED) Note,” dated 11/16/2021 at 5:28 p.m., showed Patient 9 arrived at the ED with complaints of aphasia (difficulty speaking) and the BP was 181/130. Review of the document, “Hospitalist (physician) Discharge Summary and Transfer Instruction” dated 11/20/2021, showed Patient 9 was unable to engage in speech therapy and had failed swallowing evaluations because he became “obtunded” (decreased consciousness).

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency’s licensed staff did not update the plan of care for one of nine sampled patients (Patient 9). Patient 9’s blood pressure (BP) was not maintained within specific established parameters. This failure resulted in not meeting Patient 9's goal as prescribed by the physician and no interventions to seek medical care for the abnormally elevated BP. Patient 9 developed a subarachnoid (bleeding in the brain or stroke). Record review of the policy and procedure “Care Plans” (not dated) showed “Each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. The care plan shall be reviewed, evaluated, and revised (minimally every sixty (60) days and as needed) based upon the patient’s health status and/or environment, ongoing patient assessments, caregiver support systems, and the effectiveness of the interventions in achieving progress toward goals.” Review of the document “Plan of Care” showed Patient 9’s start of care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. Diagnoses included history of a stroke. Interventions included maintaining the systolic blood pressure (top number) between 90 and 160 and the diastolic (lower number) between 60 and 90. Review of the document “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s blood pressure was 172/88. Review of the visit note dated 10/20/2021 showed a blood pressure of 178/87. There was no documentation in the clinical record which showed Licensed Vocational Nurse 1 (LVN 1) had notified the doctor or updated the plan of care. In an interview at 11:29 a.m. on 12/7/2021, the Director of Patient Care Services (DPCS) confirmed Patient 9’s blood pressures had been outside of the parameters and the care plan had not been updated to reflect that change. In an interview at 4:20 p.m., LVN 1 stated she had not communicated the elevated blood pressures to the doctor or updated the plan of care. Review of the document "(hospital name) Emergency Department Note," dated 11/16/2021, showed Patient 9's blood pressure was 181/130 with the diagnosis of a new subarachnoid hemorrhage. Record review of the policy and procedure, “Care Plans” (not dated) showed, “Each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. The care plan shall be reviewed, evaluated, and revised (minimally every sixty (60) days and as needed) based upon the patient’s health status and/or environment, ongoing patient assessments, caregiver support systems, and the effectiveness of the interventions in achieving progress toward goals.” Review of the document, “Plan of Care” showed Patient 9’s Start of Care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. The diagnoses included history of stroke. The interventions included maintaining the systolic BP (top number) between 90 and 160 and the diastolic BP (lower number) between 60 and 90. Review of the document, “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s BP was 172/88. Review of the visit note dated 10/20/2021 showed a BP of 178/87. There was no documentation in the clinical record which showed the Licensed Vocational Nurse 1 (LVN 1) had not updated the plan of care. In an interview on 12/7/2021 at 11:29 a.m., the Director of Patient Care Services (DPCS) confirmed Patient 9’s BP had been outside of the parameters and the care plan had not been updated to reflect those changes. In an interview on 12/7/2021 at 4:20 p.m., LVN 1 stated she had not updated the plan of care for Patient 9's elevated BPs and had not identified or evaluated the goals which were not met to maintain the BP within the prescribed BP ranges. Review of the document "(hospital name) Emergency Department Note," dated 11/16/2021, showed Patient 9's BP was 181/130 and had diagnosis of a new subarachnoid hemorrhage.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and record review the agency failed to follow accepted standards of practice and standard precautions (minimum infection prevention practices that apply to all patient care which include hand hygiene, gloves mask or eyewear), for one of nine sampled, selected patients (Patient 6). The Registered Nurse (RN) 1 visited Patient 6 and did not use hand hygiene after contact with possible contaminated objects. This deficient practice had the potential to spread germs. During a review of Patient 6's "plan of care" dated 11/29/21, indicated Patient 6 was admitted to the facility with multiple diagnosis including functional or mental deficit. During an observation on 12/7/21 at 11:45 a.m., RN 1 wore gloves and started physical exam and touched the urine bag then, with the same gloves removed his phone from his pocket, checked the time, removed his notebook from his pocket, wrote done note on that and put the phone and notebook back into his pocket and continued to provide care for Patient 6 with the same gloves. During an interview with RN 1 on 12/7/21 at 1:30 p.m., stated is going to see other patients that day, RN 1 confirmed that he touched his phone and notebook with the same gloves that he touched Patient 6's body and urine bag and stated he could transfer disease from patient to patient with that act. During a review of the agency's policy and procedure " Hand washing..." undated, indicated "...3. indications for hand washing and hand antisepsis: … d. Between tasks on the same patient.... q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the patient..." During a review of Patient 6's "Plan of Care" dated 11/29/21, indicated Patient 6 was admitted to the facility with multiple diagnoses, including functional or mental deficit.During an observation on 12/7/21 at 11:45 a.m., RN 1 wore gloves and started the physical exam of Patient 6. RN 1 touched the urine bag, then removed his phone from his pocket, checked the time, removed his notebook from his pocket, wrote a note and put the phone and notebook back into his pocket. RN 1 continued to provide care for Patient 6 with the same gloves on and did not perform hand hygiene.During an interview with RN 1 on 12/7/21 at 1:30 p.m., RN 1 confirmed that he touched his phone and notebook with the same gloves that he touched Patient 6's body and urine bag and planned to visit other patients which could transfer germs.During a review of the agency's policy and procedure, " Hand washing..." (undated) indicated, "...3. indications for hand washing and hand antisepsis: … d. Between tasks on the same patient.... q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the patient..."

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure a registered nurse (RN) supervised the care provided by licensed vocational nurses (LVNs) when two of nine sampled, selected patients (Patient 3 and Patient 9) did not have a supervisory visit during the time period that they received care from the agency. This failure resulted in a lack of RN supervision over the care of Patients 3 and 9 with elevated blood pressure (BP) that were not addressed for Patient 9. 1. During a review of Patient 3's record "plan of care" indicated Patient 3 was admitted to the agency with multiple diagnosis including pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 3's chart "Episode #1 9/4/21-11/2/21" indicated RN's first visit was on 9/4//21 and then LVN visited Patient 3 until 10/13/21 and between 9/4/21 and 10/13/21 RN did not do any supervisory visits for LVN 1. During an interview with the Director of Patient Care Services (DPCS) on 12/6/21 at 1:00 p.m., stated RNs need to do supervisory visits for LVNs every 30 days and confirmed that RN did not do supervisory visits for Patient 3 for the entire time that she was under the care of the agency (between 9/4/21 and 10/13/21). During a review of the agency's policy and procedure "Supervision of Staff" undated, indicated "... 1...Registered Nurse will make a supervisory visit to the patient's residence at least every 30 days..." 2. Record review of the document “Plan of Care” showed Patient 9’s start of care was 10/2/2021 with the current certification period 10/2/2021 to 11/30/2021. Diagnoses included history of a stroke. Review of the document “Physician Orders,” dated 10/2/2021, showed staff were to notify the physician if the systolic blood pressure (top number) was greater than 160 and the diastolic (lower number) was greater than 90. Review of the document “Skilled Nurse visit Note,” dated 10/13/2021, showed Patient 9’s blood pressure was 172/88. Review of the visit note dated 10/20/2021 showed a blood pressure of 178/87. There was no documentation in the clinical record which showed Licensed Vocational Nurse 1 (LVN 1) had notified the doctor. In an interview on 12/7/2021 at 4:20 p.m., LVN 1 stated she had not communicated with the doctor regarding the elevated blood pressures. Review of the scheduled visit notes showed no RN supervisory visits for Patient 9 from 10/9/2021 to 11/16/2021. In an interview at 12:15 p.m. on 12/8/2021, the agency’s Director of Patient Care Services (DPCS) stated RN supervisory visits were to take place every 30 days. The purpose was to ensure the LVN was providing the appropriate care. The DPCS confirmed there had been no supervisory visit for Patient 9 between 10/9/2021 to 11/16/2021 when Patient 9’s blood pressure had been elevated. Review of the document, “(Hospital Name) Emergency Department (ED) Note,” dated 11/16/2021 at 5:28 p.m., showed Patient 9 arrived at the ED with complaints of aphasia (difficulty speaking) with a blood pressure of 181/130. He was diagnosed with a stroke (bleeding in the brain). 1. During a review of Patient 3's record "Plan of Care" indicated Patient 3 was admitted to the agency with multiple diagnoses, including pressure ulcer or bed sore (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). During a review of Patient 3's chart, "Episode #1 9/4/21-11/2/21" indicated RN's first visit was on 9/4//21 and the LVN visited Patient 3 on 10/13/21. Between 9/4/21 and 10/13/21, RN did not conduct any supervisory visits for LVN 1. During an interview with the Director of Patient Care Services (DPCS) on 12/6/21 at 1:00 p.m., DPCS stated RNs need to do supervisory visits for LVNs every 30 days, and confirmed RN did not do the supervisory visits for Patient 3 between 9/4/21 and 10/13/21. During a review of the agency's policy and procedure, "Supervision of Staff" (undated) indicated, "... 1...Registered Nurse will make a supervisory visit to the patient's residence at least every 30 days..." 2. Record review of the document, “Plan of Care” showed Patient 9’s Start of Care was 10/2/2021 and the current certification period 10/2/2021 to 11/30/2021. The diagnoses included history of stroke (blood flow interrupted in the brain). Review of the document, “Physician Orders” dated 10/2/2021, showed staff were to notify the physician if the systolic blood pressure (BP, top number) was greater than 160 and the diastolic BP (lower number) was greater than 90. Review of the document, “Skilled Nurse Visit Note” dated 10/13/2021, showed Patient 9’s BP was 172/88. Review of the visit note dated 10/20/2021 showed the BP was 178/87. There was no documentation in the clinical record which showed the LVN 1 had notified the doctor. In an interview on 12/7/2021 at 4:20 p.m., LVN 1 stated she had not communicated with the doctor regarding the elevated blood pressures. Review of the scheduled visit notes showed no RN supervisory visits for Patient 9 from 10/9/2021 to 11/16/2021. In an interview on 12/8/2021 at 12:15 p.m., with the agency’s Director of Patient Care Services (DPCS), DPCS stated RN supervisory visits were to take place every 30 days to ensure LVN was providing the appropriate care. DPCS confirmed there were no supervisory visits for Patient 9 between 10/9/2021 to 11/16/2021 when Patient 9’s BP had been abnormally elevated. Review of the document, “(Hospital Name) Emergency Department (ED) Note” dated 11/16/2021 at 5:28 p.m., showed Patient 9 arrived at the ED with complaints of aphasia (difficulty speaking) and BP of 181/130. Patient 9 was diagnosed with a stroke (bleeding in the brain).