Every finding on record at One Home Health Agency, Ltd

Substantial Allegation Survey conducted for Complaint #2121277 / IL 61244. Standard level deficiency cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon, Evening SN = Skilled Nurse ns = normal saline x = times cm = centimeters

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide wound assessment and treatment orders, as per the POC. This was found in 1 of 3 Pts. (Pt. #1) reviewed for wound care. Findings include: 1. Pt. #1. SOC: 5/19/21. Diagnoses: Diabetes Type 2 with Diabetic Polyneuropathy, Pressure Ulcer of the Left Heel, Pressure Ulcer of the Coccyx, and Pressure Ulcer of the Scrotum. The clinical record of Pt. #1 was reviewed on 11/22/21 at 11:10 AM. The record contained the comprehensive initial assessment dated 5/19/21. This assessment contained documentation Pt. #1’s left heel had a Stage 3 Pressure Ulcer, measuring 2.5 cm long x 6 cm wide x 0 cm in depth. Pt. #1 also had a Stage 3 scrotum Pressure Ulcer, measuring 3.0 cm long x 0.8 cm wide x 0 cm in depth, no tunneling, and a Stage 2 Coccyx area wound, with multiple scattered areas of macerated skin, and consisted of epithelial, slough, and necrotic tissue. The POC effective 5/19/21 contained Physician orders for twice weekly Nursing visits for the first two weeks. This POC also includes the Physician’s order: “Skilled Nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled Nurse to provide skilled teaching related to altered skin integrity, including pathophysiology, nutrition, medication regimen, and frequent repositioning. Skilled Nurse to report significant changes in status to Physician for early intervention.” This POC also included the wound treatment orders: Cleanse sacrum and coccyx with ns/wound cleanser. Pat area dry gently. Apply medihoney to affected area and cover with silver alginate and secure with sacral dressing. Monitor maceration in gluteal folds and apply creams as needed. Do wound care every Monday, Wednesday, and Friday, and then do as needed if becomes soiled or falls off. If Patient showers, bandage needs to be changed to the left heel. Cleanse left heel with wound cleanser or normal saline. Pat dry. Apply medihoney then cover with silver alginate dressing, secure with foam heel dressing, if available, if not, secure with Abd pad or rolled gauze. Change every Monday, Wednesday, and Friday, or if becomes soiled or falls off. To scrotum…cleanse peri area completely, removing excess creams. Pat dry and apply moisture barrier to periwound. Apply medihoney to wound bed. Cut hydrafera blue down to size to only cover tunneling. Cover with siliver alginate and secure with border foam dressing, ensuring a good seal to protect from urine. Change every Monday, Wednesday, and Friday, or if becomes soiled or falls off.” The 5/30/21 Physician’s order changed the SN visit frequency to once weekly for 7 weeks. SN visit notes dated 6/23/21, 6/30/21, and 7/8/21 lack documentation Pt. #1’s wounds were assessed, and include: “Wound care not provided. Caregiver completed care.” SN weekly visit notes dated 6/14/21, 6/23/21, 6/30/21, and 7/8/21 lack wound measurements. 2. The Agency policy titled “Wound Care” was reviewed on 11/22/21 at 12:00 PM, and required: “…The admitting clinician will document each wound status including location and etiology, measurement of length, width, and depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing, and peri wound condition. Each wound will be numbered and documentation associated with each numbered wound will be completed on each visit…” 3. During an interview on 11/22/21 at 2:37 PM, the Vice President of Clinical Operations/Interim Agency Supervisor confirmed the above findings, and stated wounds should be assessed during each Nursing visit, unless the Pt. has an appliance, such as a wound vacuum, that is not due to be removed. The appearance, drainage, odor (if any) and condition of the skin surrounding the wound should be assessed and documented. All wounds should be measured at least weekly, noting the length, width, and depth of the wounds. If a Caregiver reports the Patient’s wound dressings were already changed by the Caregiver, the Nurse should educate the Pt./Caregiver regarding the importance of the Nurse’s direct assessment and measurement of the Patient’s wounds, so that wound healing/lack of wound healing can be monitored, and the treatment plan adjusted accordingly.