Every finding on record at Nurse in the House, Inc Central Iowa

The Department of Inspections, Appeals, and Licensing conducted a complaint investigation for Complaint #107619 from 7/15/24 through 7/17/24. The allegation related to 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care, was investigated and no condition level deficiencies were identified and one standard level deficiency was identified (G580). The agency reported a current census of 235 patients.

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 observations, staff interviews, clinical record reviews and policy review, the agency failed to provide medications, treatments, or services as ordered by the physician and per the plan of care for 4 out of 5 sampled patients. (Pt #1, #2, #4 and #5) Failure to ensure staff follow physician orders for administration of medications, treatments or services, placed agency patients at risk for inconsistent care treatment and possible harm. 3. Patient #2 had a start of care date of 11/15/16. Clinical record review revealed: a. Plans of Care, dated 4/7/24 to 6/5/24 and 6/6/24 to 8/4/24, included medication order for Haldol Decanoate 100 mg (milligrams)/ml (milliliter), intramuscular solution, take 75 mg solution intramuscular. b. Skilled nursing visit notes, dated Thursday 5/9/24, Thursday 5/23/24, and Thursday 6/20/24, included documentation Haldol Decanoate injection had been administered. c. Skilled nursing visit note, dated Wednesday 6/5/24, included documentation Haldol Decanoate injection had been administered. d. Care Coordination note, dated 6/13/24, included documentation Staff B, Clinical Manager was called to Patient #2 home by Staff D, RN (registered nurse), Staff D attempting to complete a skilled nursing visit with another agency patient in the home and was approached by a family member regarding concern over the administration of the Haldol Decanoate on Wednesday 6/5/24 instead of Thursday 6/6/24 as ordered. e. Interim physician order, dated 6/17/24, identified Haldol Decanoate 100 mg/ml intramuscular solution take 75 mg (0.75 ml) solution intramuscular every 13-15 days for mental health. During an interview on 7/16/24 at 11:09 AM, primary care physician office nurse contacted regarding current prescription for Haldol Decanoate medication, nurse reported current prescription is dated 6/10/24 and reads Haldol Decanoate 75 mg every other Thursday, patient has been on this dose for quite a while, nurse is unable to locate exact date in medical record when this dose was first ordered. Prescription label on medication bottle, dated 7/8/24, reads inject 75 mg intramuscularly every 2 weeks for psychosis every other Thursday. During an interview on 7/16/24 at 11:38 AM, Staff D, RN, reported Patient #2 usually received Haldol Decanoate every 2 weeks on Thursdays, on 6/5/24 patient had a recert visit, this was one day early (Wednesday). The following week Staff D, RN was in Patient #2 home seeing another agency patient, a family member approached Staff D, RN regarding the skilled nursing visit that was completed on 6/5/24 and voiced concern regarding the Haldol Decanoate being given on Wednesday instead of Thursday. Staff D, RN contacted physician office and received order to give medication every 13-15 days. During an interview on 7/17/24 at 11:45 AM, Staff B, Clinical Manager reported agency reviewed Patient #2 plan of care, identified the missing frequency for the Haldol Decanoate medication and had Staff B, RN reach out to physician for clarification of the order. The skilled nurse failed to administer the medication as ordered. 4. Patient #2 had a start of care date of 6/11/24. Clinical record review revealed: a. Plan of Care, dated 6/11/24 to 12/8/24, included physician order for skilled nursing to perform wound cares 3 times weekly and to measure wound weekly. b. Initial skilled nursing comprehensive assessment, dated 6/11/24, lacked documentation of wounds or wound measurements. c. Skilled nursing visit notes, dated 6/12/24, 6/17/24, included documentation right heel and right ankle wound care completed as ordered but lacked documentation of wound measurements. d. Skilled nursing visit note, dated 6/14/24, included documentation right heel wound treatment completed as ordered but lacked documentation of wound measurements or right ankle wound. e. Skilled nursing visit note, dated 6/20/24, included documentation right heel wound, dressing removed with yellow/light green drainage on dressing but lacked documentation wound care was completed, wound measurements, or right ankle wound. f. Skilled nursing visit note, dated 6/21/24, included documentation right heel wound with green drainage, right ankle scabbed, wound care completed as ordered but lacked documentation of wound measurements. g. Skilled nursing visit note, dated 6/24/24, included documentation right heel and right ankle wound care completed as ordered, stage 1 wound on bottom measured 1 centimeter (cm) x 0.5 cm but lacked documentation of wound measurements for right heel and right ankle, wound care for stage 1 wound on bottom and depth measurement for wound on bottom. h. Skilled nursing visit note, dated 6/26/24, included documentation right heel wound, wound care completed as ordered, no worsening on area on bottom, Desitin to area on bottom but lacked documentation of right ankle wound and wound measurements. i. Skilled nursing visit note, dated 6/28/24, included documentation right heel wound with light green drainage, right ankle wound scab fell off, wound care completed today but lacked documentation of wound on bottom, what wound care completed and wound measurements. j. Skilled nursing visit note, dated 7/2/24, included documentation right heel wound 1.4 cm x 1.5 cm, right ankle scab fell off, stage 2 area on bottom 1.1 cm x 1.2 cm with patient using Desitin, wound cares completed as ordered but lacked documentation of wound depths for right heel and stage 2 on bottom and right ankle wound measurements. k. Skilled nursing visit note, dated 7/3/24, included documentation right heel wound treatment completed as ordered but lacked documentation of right ankle wound, wound on bottom and wound measurements. l. Skilled nursing visit note, dated 7/5/24, included documentation right heel wound treatment completed as ordered, right ankle wound healed but lacked documentation of wound on bottom and wound measurements. During an interview on 7/16/24 at 3:51 PM, Staff B, Clinical Manager reported agency expectation is for wounds to be measured weekly, measurements should include length, width and depth. The nurse failed to complete wound measurements weekly as ordered for all identified wounds. The above findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the policy, Physician Participation in the Plan of Care, dated October 2019, the physician will direct the care of every home health care patient admitted for service. The attending physician will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically necessary. The attending physician will participate in the care planning process by initiating, reviewing and revising the plan of care (therapeutic and diagnostic orders). 1. Patient #1 had a start of care date of 10/16/2019. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/22/24 to 7/20/24, included the medication Bumex,( a medication used to remove excess fluid from the body) 2 milligram tablet ordered for once a day, with a second 2 milligram tablet to be given daily as needed for a weight gain of more than 2 pounds in one day. b. The current medication profile, dated 7/15/24, included the medication Bumex,( a medication used to remove excess fluid from the body) 2 milligram tablet ordered for once a day, with a second 2 milligram tablet to be given daily as needed for a weight gain of more than 2 pounds in one day. c. During a home observation visit, with Staff E, RN on 7/15/24 at 1:00 pm, the patients routine medications were set up for the following week in the medication planner. d. The RN did weigh the patient and verbalized the patient had lost weight. e.. The RN verbalized setting up the Bumex for twice a day in the medication planner for am and pm. The nurse failed to set up the patients medications as ordered by the physician. 2. Patient #5 had a start of care date of 5/29/24. a. The POC, dated 5/29/24 to 7/27/24, included orders for the skilled nurse to draw labs, specifically to obtain a WBC w/diff (a blood test to measure the total number of all white blood cells in the blood) ordered to be drawn via peripheral venipuncture every 4 weeks by skilled nurse to begin week of 06/03/2024. b. The WBC w diff laboratory test was completed the week of 6/3/24 on nursing visit dated 6/7/24. c. The subsequent laboratory test was completed the week of 7/8/24, which was outside of the ordered 4 week interval. The agency failed to complete the ordered laboratory blood tests within the time frame ordered by the physician.