Every finding on record at North Kansas City Hospital

A complaint investigation, 100538, was completed on 09/14/2023 at the home health provider. The home health provider had 283 current patients. The complaint (100538) is substantiated. One or more of the allegations reported are verified and standard deficiencies were cited that are related to the allegations being investigated.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, job description review, record review, and interview, the home health provider failed to ensure that skilled professional services prepared appropriate and timely clinical notes, when a nurse failed to document that a patient's tracheostomy device came out unexpectedly in, one of three full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, "Home Health- The Medical Record,” showed, in part: - An accurate and up-to-date record will be maintained in paper or electronic format to document the service provided to each patient; - Documentation should be completed within the timelines below: * Routine visits, evaluations, and all OASIS visits not requiring coding to be completed by 7:00 AM of the second morning; * Start of Care and OASIS visits requiring coding to be sent to coder by 7:00 AM of the second morning; - The medical record may contain, but not be limited to: * Initial assessment/reassessment; * Visit and progress notes with assessments relevant to care, treatment, or services; * The patient’s response to care, treatment, or services; and * Communication with the physician, other disciplines, and patient/caregiver. Review of the provider’s undated policy titled, "Home Health- Initial Assessment," showed, in part: - A comprehensive assessment will be conducted during the initial visit and documented in the medical record; - The initial assessment findings are communicated by the documentation in the medical records; and - Unless ordered at the time of referral, additional assessments will be completed by appropriate staff if warranted by the initial findings after consulting with the physician and receiving appropriate orders. Review of the provider’s job description, titled, "RN (registered nurse) Home Health RN," showed, in part: - Coordinate and communicate with other team members, ensuring that all members of the healthcare team are aware of any patient medical, physical or psychosocial conditions requiring change in the plan of care; and - Provide timely and accurate documentation of care provided, care communication and care coordination. RECORD/PATIENT #1: Review of the SOC (start of care) comprehensive OASIS (Outcome and Assessment Information Set) assessment, dated 06/06/2023 at 9:00 AM, showed: - The patient rated pain at a 2 out of 10 (0 being no pain and 10 being the worst pain); - In the pain comment section, “Pt (patient) has new trach (tracheostomy- a surgically created hole in the windpipe that provides an alternative airway for breathing) which is still healing and causing pain,” was noted; - Tracheostomy was marked with a yes and the size/type of tracheostomy had Shiley (tracheostomy tube that helps maintain airway patency) #6 (size 6- length of 74mm (millimeters), inner diameter of 6.4mm, and outer diameter of 10.8mm) documented; - Clinical visit summary showed: * Pt has new size 6 shiley trach; * Educated/demonstrated to (spouse) and pt who does want to be able to perform cleanings (himself/herself) to take some burden off (spouse) on how to do a sterile cleaning of the inner cannula and suctioning; * Educated (spouse) only to go into the trach twice and suction as (he/she) pulled back; * Educated how to clean around insertion site with just NS (normal saline) and gauze and how to change out trach collar (a soft plastic device that goes over and around the tracheostomy tube and helps provide humidification and supplemental oxygen if needed); * Educated spouse how to connect O2 (oxygen) tubing of nasal cannula and how to work the compressor; - RN (registered nurse) taught (spouse) how to clean properly the inner cannula. (Spouse) was able to verbalize understanding. (Spouse) was able to suction via trach with verbal cues from the nurse; and - Pt/CG (patient and caregiver) educated on infection control guidelines related to handwashing, medical equipment cleaning, devices, supplies, and limiting exposure to contagious diseases per (agency) admission booklet. Review of a care coordination note, dated 06/12/2023 at 4:47 PM, showed the following: - Message left to inform PCP (primary care provider) that this nurse (RN A) accidently removed the entire trach on SOC visit when attempting to clean; - RN immediately put (trach) in sterile saline, cleaned using a sterile technique, and replaced back without any issues; and - (Spouse) informed to only remove the inner cannula only. Review of the complaint records showed: - On 06/19/2023, the patient’s spouse contacted the home health agency and reported a complaint about being unhappy with the nursing care; - On 06/20/2023, the home health agency entered the grievance into the record and began an investigation; - The home health nursing supervisor typed a summary of investigation that included the following: * On 06/09/2023, the home health office received a phone call from the patient’s (spouse) stating that the patient was having increased secretions, some bleeding around trach and would like a nurse to come out; * (Spouse) relayed the story of the trach coming completely out (during SOC visit) to the RN nursing supervisor; * On 06/09/2023, the nursing supervisor called (RN A) to discuss the decannulation (removal of the tracheostomy tube from the stoma) of the patient’s trach with him/her. (RN A) stated the trach came out when trying to remove the inner cannula. When asked if he/she had notified the MD (medical doctor), he/she stated that he/she had not. (The nursing supervisor) advised (RN A) to call the MD to notify, which she did (3 days later on 06/12/2023); * On 06/20/2023, the nursing supervisor met with (RN A) to discuss what happened in detail on his/her SOC visit; and * (RN A) reported the patient was sitting in a chair when he/she started doing the trach care. The patient had a lot of secretions and his/her trach ties were very dirty from mucus. (RN A) removed the trach ties while holding the trach in place. (RN A) stated that he/she went to turn the inner cannula while holding the trach with his/her hand and the whole trach came out in his/her hand. (RN A) cleaned the trach and placed it back in the patient without resistance or difficulty. The patient’s oxygen saturation was assessed and was 98%. At the end of the visit the (spouse) informed (RN A) that he/she did not know the whole thing could come out and (RN A) told him/her that the whole trach should never come out and he/she was only to change the inner cannula. Review of the clinical record failed to show documentation on the start of care visit about the trach coming out unexpectedly. During an interview, on 09/13/2023 at 12:10 PM, the nursing supervisor stated that: - The spouse informed him/her that the trach had fallen out at the SOC; - He/she spoke to the nurse and confirmed that the trach did fall out; - He/she did not see documentation of the trach falling out on the SOC visit; and - He/she would expect the nurse to document the trach falling out. During an interview, on 09/13/2023 at 12:45 PM, RN A stated that: - The trach fell out unexpectedly during the SOC visit; and - He/she did not document the trach falling out on the SOC visit because the visit was chaotic and he/she forgot to document it.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, job description review, record review, and interview, the home health provider failed to communicate with physician(s) involved in the plan of care, when a patient’s tracheostomy device came out unexpectedly, in one of three full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy, titled, "Home Health- Initial Assessment," showed, in part: - A comprehensive assessment will be conducted during the initial visit and documented in the medical record; - The initial assessment findings are communicated by the documentation in the medical records; and - Each discipline will assess patients within that disciplines scope of practice. After the initial assessment visit, the clinician contacts the physician to review their findings and develop the plan of care. Review of the provider’s job description, titled, “RN (registered nurse) Home Health RN," showed, in part: - Coordinate and communicate with other team members, ensuring that all members of the healthcare team are aware of any patient medical, physical or psychosocial conditions requiring change in the plan of care; and - Provide timely and accurate documentation of care provided, care communication and care coordination. RECORD/PATIENT #1: Review of the SOC (start of care) comprehensive OASIS (Outcome and Assessment Information Set) assessment, dated 06/06/2023 at 9:00 AM, showed: - The patient rated pain at a 2 out of 10 (0 being no pain and 10 being the worst pain); - In the pain comment section, “Pt (patient) has new trach (tracheostomy- a surgically created hole in the windpipe that provides an alternative airway for breathing) which is still healing and causing pain,” was noted; - Tracheostomy was marked with a yes and the size/type of tracheostomy had Shiley (tracheostomy tube that helps maintain airway patency) #6 (size 6- length of 74mm (millimeters), inner diameter of 6.4mm, and outer diameter of 10.8mm) documented; - Clinical visit summary showed: * Pt has new size 6 shiley trach; * Educated/demonstrated to (spouse) and pt who does want to be able to perform cleanings (himself/herself) to take some burden off (spouse) on how to do a sterile cleaning of the inner cannula and suctioning; * Educated (spouse) only to go into the trach twice and suction as (he/she) pulled back; * Educated how to clean around insertion site with just NS (normal saline) and gauze and how to change out trach collar (a soft plastic device that goes over and around the tracheostomy tube and helps provide humidification and supplemental oxygen if needed); * Educated spouse how to connect O2 (oxygen) tubing of nasal cannula and how to work the compressor; * (Named physician) will sign all HH (home health) orders per (named) nurse; - RN (registered nurse) taught (spouse) how to clean properly the inner cannula. (Spouse) was able to verbalize understanding. (Spouse) was able to suction via trach with verbal cues from the nurse; and - Pt/CG (patient and caregiver) educated on infection control guidelines related to handwashing, medical equipment cleaning, devices, supplies, and limiting exposure to contagious diseases per (agency) admission booklet. Review of the complaint records showed: - On 06/09/2023, the home health office received a phone call from the patient’s (spouse) stating that the patient was having increased secretions, some bleeding around trach and would like a nurse to come out; - (Spouse) relayed the story of the trach coming completely out to the RN nursing supervisor; - A PRN (as needed) visit was made and the RN reported findings which were decreased breath sounds bilaterally, increased secretions, patient got Mucinex today (06/09/2023) and was to start on that, educated to increase free water during feeding due to the Mucinex and to make sure to be using humidification; - Discussed sending patient back to the ER but family not wanting to go; - On 06/09/2023, the nursing supervisor called RN A to discuss the decannulation (removal of the tracheostomy tube from the stoma) of the patient’s trach with him/her. (RN A) stated the trach came out when trying to remove the inner cannula. When asked if he/she had notified the MD (medical doctor), he/she stated that he/she had not. (The nursing supervisor) advised (RN A) to call the MD to notify, which she did (3 days later on 06/12/2023). Review of a care coordination note, dated 06/12/2023 at 4:47 PM, showed the following: - Message left to inform PCP (primary care provider) that this nurse accidently removed the entire trach on SOC visit when attempting to clean; - RN immediately put (trach) in sterile saline, cleaned using a sterile technique, and replaced back without any issues; and - (Spouse) informed to only remove the inner cannula only. Review of the clinical record failed to show documentation of communication with the physician regarding the trach coming out unexpectedly during the start of care visit until 6 (six) days later. During an interview, on 09/13/2023 at 12:10 PM, the nursing supervisor stated that: - He/she spoke to the nurse and confirmed that the trach did fall out; - The nurse reported that he/she did not notify the physician of the trach falling out unexpectedly; - He/she would have expected the nurse to notify the physician immediately and then call him/her (nursing supervisor); and - He/she advised the nurse to notify the physician on 06/09/2023 and he/she did not know why the call was not placed to the physician until 06/12/2023. During an interview, on 09/13/2023 at 12:45 PM, RN A stated that: - He/she called the doctor after the visit; and - He/she did not know if he/she documented the call that day (06/06/2023). During an interview, on 09/13/2023 at 1:00 PM, the nursing supervisor stated that: - He/she reached out to the physician’s office to see if they had record of the nurse notifying the physician on 06/06/2023 about the trach falling out; and - He/she spoke to (named staff) at the physician’s office and was informed that the nurse did call the physician’s office on 06/06/2023 for approval of the POC (plan of care) but did not see a note about the trach falling out. On 06/12/2023 a message was left regarding the trach falling out during the start of care visit. On 06/13/2023 at 9:42 AM a staff member from the physician’s office returned the nurses (RN A) call acknowledging that the physician’s office did receive his/her message regarding the trach falling out.