Every finding on record at Oroville Hospital

The following reflects the findings of the California Department of Public Health during a federal recertification survey conducted from 3/14/22 through 3/23/22. This federal recertification survey was a review of all federal regulations related to the operation of a home health agency, and represents a full inspection of this agency. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN) 23083, HFEN Admissions (unduplicated, for a 12-month period): 799 Current Census: 106 Sample Size: 17 Home Visits: 7 All Conditions of Participation were met.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to maintain an emergency plan that was reviewed and revised every two years when the Emergency Plan signature page was dated 2016. This failure had the potential to cause emergency mitigation strategies to be inadequate to address current situations, leading to damage of facility property and loss of life. Findings: During a concurrent interview and document review of the hospital system Emergency Plan binder on 3/14/22 at 4:30 pm, it indicated a signature page dated 5/31/2016. Registered Nurse (RN) M confirmed that the Plan had not been reviewed every two years as required. During an interview on 3/22/22 at 3:27 pm, the Chief Nursing Officer (CNO) stated that the system’s Emergency Plan had been reviewed in 2019, and confirmed that it had not been reviewed every two years as required. CNO stated that it needed to be updated and that she would send a copy of the signature page.

The following reflects the findings of the California Department of Public Health during a federal recertification survey conducted from 3/14/22 through 3/23/22. This federal recertification survey was a review of all federal regulations related to the operation of a home health agency, and represents a full inspection of this agency. Representing the Department: 40484, Health Facilities Evaluator Nurse (HFEN) 23083, HFEN Admissions (unduplicated, for a 12-month period): 799 Current Census: 106 Sample Size: 17 Home Visits: 7 All Conditions of Participation were met.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to honor Patient 3’s rights when he experienced discomfort during placement of a urinary catheter (tube inserted into the bladder connected to a drainage bag) and requested a licensed nurse to stop. This action had the potential for further injury, pain and patients’ rights not being honored. Findings: A review of a facility document titled, “Patient Rights/ Responsibilities and Resolution of Conflict,” revised 8/2019, indicated the patient has the right to request or refuse treatment. Patient 3 was admitted to the agency on 3/2/22 with diagnoses that included chronic respiratory failure and bladder incontinence. A physician’s order (plan of care) dated 3/2/22, prescribed a urinary catheter for incontinence to be replaced every month and as needed. A home visit was conducted with Registered Nurse (RN) B on 3/15/2022 at 9:30 am. At 9:40 am, RN B was observed removing Patient 3’s old urinary catheter by deflating the water filled balloon in Patient 3’s the urethra (opening of penis where urine flows from) while he laid in his bed. Patient 3 was observed yelling out during this procedure. At 10:10 am, RN B was observed inserting the new urinary catheter into Patient 3’s urethra. Patient 3 was observed yelling out three times and then stated, “Please stop.” RN B instructed Patient 3 to take a deep breath and Patient 3 then stated, “That really hurts.” Then RN B asked Patient 3 if he was ok and he replied, “Not really.” During an interview with Patient 3 at 10:44 am, after RN B had left Patient 3’s residence he stated the procedure…” really hurt and he wanted her to stop.” On 3/16/22 at 4:20 pm, RN B was interviewed. RN B stated it was common for most men to yell during this procedure and she stated she thought Patient 3 was subdued compared to most men. RN B stated she did not hear Patient 3 ask her to stop while she was inserting the catheter. RN B was asked if she would have done anything differently, and she stated she would not have done anything differently. During an interview with Registered Nurse Manager (RN M) on 3/23/22 at 12:10 pm, she stated RN B should have stopped the procedure when Patient 3 asked her to stop.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct an initial assessment within 48 hours of the referral, for one of 17 sampled patients (Patient 10). This failure had the potential to delay necessary treatment and lead to a loss of well-being for Patient 10. Findings: A review of a facility document titled, “Comprehensive Assessments and OASIS [Outcome and Assessment Information Set, the comprehensive assessment tool for Home Health] and Submission,” reviewed October 2019, indicated that the facility must complete the initial assessment visit within 48 hours of the referral, or on the date specified by the ordering physician. A review of the clinical record indicated that Patient 10 received an initial visit on 11/8/21, and had received wound care, diabetes management, physical and occupational therapy. The referral date was 11/5/21. A review of an unsigned physician order dated 11/7/21 indicated that Patient 10 requested an initial visit on 11/8/21. During an interview on 3/22/22 at 2:04 pm, Registered Nurse (RN) M stated that a physician’s order was required for a late initial assessment visit, and confirmed that the order dated 11/7/21 for Patient 10’s late initial visit was not signed by the physician.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to maintain accurate clinical records when one of 17 sampled patients (Patient 9) had a wound that was not completely assessed upon discovery. This failure had the potential to cause incorrect treatment to be prescribed, leading to delayed wound healing and reduced patient well-being. Findings: A review of a facility document titled, “Clinical Visit Note and Assessment,” reviewed October 2019, indicated that clinical notes must directly reflect the patient’s condition and the treatment provided. A review of the clinical record indicated that Patient 9 received an initial assessment on 3/10/21, and had been receiving a nursing visit monthly to change the urinary catheter (tube inserted into the bladder connected to a drainage bag). A review of a nursing visit note dated 2/2/22 at 1:30 pm indicated that Patient 9 had a new skin tear on the right forearm. No measurements were included in the wound description. During an interview on 3/22/22 at 2:04 pm, Registered Nurse (RN) M confirmed that Patient 9’s wound was not measured per agency practice when it was discovered on 2/2/22.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that a comprehensive assessment was updated and revised within 48 hours of Patient 1’s return home from a hospital admission. This failure had the potential to contribute to a delay of necessary care and services, and a loss of well-being for Patient 1. Findings: A review of a facility document titled, “Comprehensive Assessments and OASIS [Outcome and Assessment Information Set, the comprehensive assessment tool for Home Health] and Submission” reviewed October 2019, indicated that a resumption of care must be done within 48 hours of the patient’s return home from an inpatient stay of over 24 hours for any reason other than testing. Patient 1 was admitted to the agency on 2/4/22 with diagnoses that included weakness, recent falls, and diabetes (high sugars in the blood stream). A physician’s order (plan of care) dated 2/4/22, prescribed Nursing frequency once a week for 4 weeks, and 2 prn (as needed) for impaired skin integrity or medication management. Physical Therapy (PT) frequency was also ordered once a week for 1 week, then once or twice a week for 3 weeks, to begin on 2/6/22. A review of Patient 1’s record indicated she had fallen and was admitted to a local hospital on 2/20/22 and was then discharged on 2/24/22 (4 days later). A hospital referral for home health services was obtained on 2/25/22 to continue services. The resumption of care visit was not conducted until 3/7/22 (11 days later), greater than 48 hours after Patient 1 returned home from the hospital. During an interview with the Registered Nurse (RN) Manager on 3/22/22 at 3:40 pm, she acknowledged Patient 1 was discharged from the hospital on 2/25/22 and that her resumption of care was more than 48 hours late (11 days late).

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure that services provided conform with physician’s orders when orders for four of 17 sampled patients (Patients 8, 9, 10, and 13) were not carried out as specified by the physician. These failures had the potential to contribute to a loss of patient well-being by delaying or omitting essential care. Findings: A review of a facility document titled, “Physician Plan of Care/Change Orders,” revised October 2019, indicated that the facility must comply with Medicare requirements, and that physician’s orders are to be considered necessary for treatment. 1.Patient 8 was admitted to the agency on 2/18/22 with diagnoses that included bilateral venous stasis ulcers to his legs, diabetes, and heart failure. A physician’s order (plan of care) dated 2/18/22, prescribed skilled nursing frequency once a week for one week, then twice a week for three weeks, and then re-evaluate. A review of Patient 8’s record indicated he had only received one skilled nursing visits on week 2 (2/20 to 2/26/22) and week 3 (2/27 to 3/5/22). During an interview with Registered Nurse (RN) M on 3/23/22 at 11 am, she acknowledged Patient 8 had the above missed visits, and the physician was not notified or an order obtained. RN M stated the usual practice was to receive a communication note from the nursing staff so she could follow up on missed visits, and obtain a physician’s order. 2. A review of the clinical record indicated that Patient 9 received an initial assessment on 3/10/21, and had been receiving a nursing visit monthly to change the urinary catheter (tube inserted into the bladder connected to a drainage bag) for urinary incontinence (inability to control urine flow). A review of a nursing visit note dated 2/2/22 at 1:30 pm, indicated that Patient 9 had a new wound requiring care. An order dated 2/3/22 indicated that the nurse was to make home visits weekly for three weeks to provide wound care. A review of a nursing note dated 2/7/22 at 3:09 pm, indicated that Patient 9’s wound had improved, the caregiver in the home was providing appropriate wound care, and no further scheduled wound care nursing visits were necessary. No physician’s order or communication note was located in the record indicating the physician had been consulted or an order obtained for the alteration in patient care. During a concurrent interview and record review on 3/22/22 at 2:04 PM, Registered Nurse (RN) M confirmed that there was no order in the record for a changed visit frequency for Patient 9, or to consult with the physician regarding altered wound status. A review of an unsigned physician’s order dated 2/23/22 at 5:20 pm, indicated that Patient 9 had experienced symptoms of a urinary tract infection, including urinary catheter leakage, a red and irritated perineum (the area between the legs), and odorous urine with sediment; and the nurse had requested a urinalysis (UA, a lab test of urine for the presence of infection). During a concurrent interview and record review on 3/22/22 at 2:04 PM, RN M confirmed that the UA order dated 2/23/22 was never signed by the physician, and no UA was done for Patient 9. 3. A review of the clinical record indicated that Patient 10 received an initial visit on 11/8/21 to receive care for diabetes, history of a stroke, and inability to walk. A review of a physician order without electronic signature dated 11/7/21 indicated that Patient 10 requested an initial visit on 11/8/21. During an interview on 3/22/22 at 2:04 pm, RN M stated that a physician’s order with an electronic or faxed signature was required for a late initial assessment visit. RN M confirmed that the order dated 11/7/21 for Patient 10’s late initial visit was not electronically signed by the physician. 4. A review of the clinical record indicated that Patient 13 received an initial assessment on 1/28/22. Patient 13 required care for diabetes and wounds. A signed physician’s order dated 2/19/22 indicated that the nurse was to visit Patient 13 once for one week, then three to four times a week for three weeks. A review of the clinical record indicated that during the week of 3/6/22, week 7, Patient 13 refused a visit on 3/10/22, and one nursing visit was made on 3/12/22. Patient 13 was to have had three visits during week 7, and only one was made. No order for the missed visits was located in the clinical record. During a concurrent interview and record review on 3/22/22 at 2:04 pm, RN M stated that the missed visit during the week of 3/6/22 was due to Patient 13 making a wound clinic visit. RN M confirmed that no physician’s order had been obtained for the changed visit frequency, or any note made in the record reflecting this.

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 facility failed to ensure that the physician was notified of patient changes of condition or the need to alter the plan of care for four of 17 sampled patients (Patients 1, 8, 9, and 13) when: 1. Patient 1, 8 and 13's missed visits. 2. a. Patient 9 had a new order obtained and wound no longer required skilled care. b. Patient 9 had an order to perform a urinalysis (UA, laboratory test used to analyze urine for abnormalities) was not obtained from Patient 9’s physician. These failures had the potential to lead to the physician being unaware of the patient’s current condition, and delaying or omitting essential care, contributing to a loss of patient well-being. Findings: A review of a facility document titled, “Physician Plan of Care/Change Orders,” revised October 2019, indicated that the physician must be consulted to approve any changes to the Plan of Care (POC), and that the consultation must be documented in the clinical record. 1. Patient 1 was admitted to the agency on 2/4/22 with diagnoses that included weakness, recent falls, and diabetes (high sugars in the blood stream). A physician’s order (plan of care) dated 2/4/22, prescribed Nursing frequency once a week for four weeks, and 2 visits prn (as needed) for impaired skin integrity or medication management. Physical Therapy (PT) frequency was also ordered once a week for one week, then 1-2 times a week for three weeks to begin on 2/6/22. A review of Patient 1’s record indicated she had fallen and was admitted to a local hospital on 2/20/22 and was then discharged on 2/24/22. A hospital referral for home health services was obtained on 2/25/22 to continue services. The resumption of care visit was not conducted until 3/7/22, greater than 48 hours after she returned home from the hospital. The physician was not notified of the delay. During an interview with the Registered Nurse (RN) Manager on 3/22/22 at 3:40 pm, she acknowledged Patient 1 was discharged from the hospital on 2/25/22 and that her resumption of care was late, and the physician was not notified. Patient 8 was admitted to the agency on 2/18/22 with diagnoses that included bilateral venous stasis ulcers to his legs, diabetes, and heart failure. A physician’s order dated 2/18/22, prescribed skilled nursing frequency once a week for one week, then twice a week for three weeks, and then re- evaluate. A review of Patient 8’s record indicated he had only received one skilled nursing visit on week 2 (2/20 to 2/26/22) and week 3 (2/27 to 3/5/22). During an interview with RN M on 3/23/22 at 11 am, she acknowledged Patient 8 had missed the above missed visits, and the physician was not notified. Patient 13 received an initial assessment on 1/28/22. Patient 13 required care for diabetes and wounds. A signed physician’s order dated 2/19/22 indicated that the nurse was to visit Patient 13 once for one week, then three to four times a week for three weeks. A review of the clinical record indicated that during the week of 3/6/22, week 7, Patient 13 refused a visit on 3/10/22, and one nursing visit was made on 3/12/22. Three visits should have been made during week 7, and only one was made. No order for the missed visits was located in the clinical record. During a concurrent interview and record review on 3/22/22 at 2:04 pm, RN M stated that the missed visit during the week of 3/6/22 was due to Patient 13 making a wound clinic visit. RN M confirmed that no physician’s order had been obtained or any note made in the record reflecting this. 2. a. A review of the clinical record indicated that Patient 9 received an initial assessment on 3/10/21, and had been receiving a nursing visit monthly to change the urinary catheter for urinary incontinence (inability to control urine flow). A review of a nursing visit note dated 2/2/22 at 1:30 pm, indicated that Patient 9 had a new wound requiring care. An order dated 2/3/22 indicated that the nurse was to make home visits weekly for three weeks to provide wound care. A review of a nursing note dated 2/7/22 at 3:09 pm, indicated that Patient 9’s wound had improved, the caregiver in the home was providing appropriate wound care, and no further scheduled wound care nursing visits were necessary. No physician’s order or communication note was located in the record indicating the physician had been consulted or an order obtained for the alteration in patient care. During a concurrent interview and record review on 3/22/22 at 2:04 PM, Registered Nurse (RN) M confirmed that there was no order in the record for a changed visit frequency for Patient 9, or to consult with the physician regarding altered wound status. 2.b. A review of an unsigned physician’s order dated 2/23/22 at 5:20 pm, indicated that Patient 9 had experienced symptoms of a urinary tract infection, including urinary catheter leakage, a red and irritated perineum (the area between the legs), and odorous urine with sediment (particles); and the nurse had requested a UA. During an interview and record review on 3/22/22 at 2:04 PM, RN M confirmed that the UA order dated 2/23/22 was never signed by the physician, and no UA was done for Patient 9.

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, interview and record review, the facility failed to ensure that standard infection control precautions were followed during home visits when: 1. A barrier was not consistently used to protect supplies and reusable equipment. 2. A nurse was unaware a patient had Methicillin Resistant Staphylococcus (MRSA, a serious bacterial resistant to many antibiotics) prior to a home visit (Patient 8). 3. Hand hygiene was not performed consistently during home visits with Patients 2 and 3. These failures had the potential to promote the spread of infection in the home, and among multiple patients being visited. Findings: 1. A review of a facility policy and procedure titled, “Infection Control Practices,” reviewed October 2019, indicated that all staff will use a barrier during a home visit to ensure that infection control is maintained. Patient 1 was admitted to the agency on 2/4/22 with diagnoses that included weakness, recent falls, and diabetes (high sugars in the blood stream). A physician’s order (plan of care) dated 2/4/22, prescribed nursing frequency once a week for four weeks, and 2 visits prn (as needed) for impaired skin integrity or medication management. A home visit was conducted on 3/14/22 at 2 pm, with Registered Nurse (RN) A. During the visit RN A did not have a barrier placed on Patient 1’s table where she had placed Patient 1’s field file throughout the visit. During an interview with RN A on 3/17/22 at 9:15 am, she stated she had placed the field file on Patient 1’s table without using a barrier. On 3/17 /22 at 9:30 am, RN M stated RN A should have used a barrier to place Patient 1’s field file on during the home visit. During an observation of a home visit on 3/15/22 at 11:10 am, RN D placed a barrier on a table, then placed some wound care supplies on it, and other supplies directly on the table. RN D then opened the supply packets, and placed all of them on the barrier, including those packets that had been resting directly on the table. During an interview at 12:55 pm, RN D confirmed that the barrier had not been used for all the supplies used during the visit. 2. A review of the policy titled, "Management of Patients with MRSA," reviewed 11/21, under isolation orders indicated that it was the responsibility of the health care team to assess and determine the need to isolate the patient. Patient 8 was admitted to the agency on 2/18/22 with diagnoses that included bilateral venous stasis ulcers to his legs, diabetes, and heart failure. A physician’s order (plan of care) dated 2/18/22, prescribed skilled nursing visits once a week for one week, then twice a week for three weeks, and then re- evaluate. A review of a faxed note from the local wound clinic dated 3/11/22 indicated an alert that Patient 8 had MRSA. On 3/23/22 at 9:10 am, RN Manager stated Patient 8's MRSA alert was missed. She stated the nurses on an average would have seen three to four patients a day. A review of Patient 8's nursing visits indicated there was a nursing visit conducted on 3/14/22 at 11:20 am, four days after the agency received the faxed alert on 3/11/22. A review of Patient 8's nursing visits indicated there was a nursing visit conducted on 3/14/22 at 11:20 am, four days after the agency received the faxed alert on 3/11/22. On 3/16/22 at 1:15 pm prior to a home visit with RN C, she stated she was not aware Patient 8 had MRSA. RN C was shown the faxed paperwork dated 3/11/22 from a local wound clinic with the diagnosis. RN C was then observed obtaining an isolation box with supplies (gown, gloves masks, shoe covers, thermometer, statoscope and blood pressure cuff) to take to the home visit. During an interview with a Family Member on 3/22/22 at 1:30 pm, she stated she was not informed Patient 8 had MRSA and she had been transferring him to all his wound clinic appointments. She stated she was only told that his wound culture showed two types of bacteria. 3. A review of a facility policy titled, “Hand Hygiene,” revised May 2021, indicated that staff must wash or decontaminate their hands before and after patient contact, and after removing gloves. It indicated its purpose was to identify a baseline of adherence to accepted professional standards to improve patient outcome and reduce the transmission of pathogenic microorganisms (organism capable of causing disease). The indications for hand hygiene (alcohol-based hand rub or the use of antimicrobial soap) directed to decontaminate hands before donning (applying) sterile gloves and before inserting an indwelling urinary catheter. a. During an observation of a home visit on 3/15/22 at 11:10 am, RN D obtained vital signs for Patient 2, then donned gloves without sanitizing hands. During an interview at 12:55 pm, RN D confirmed that an opportunity for performing hand hygiene had been missed. b. Patient 3 was admitted to the agency on 3/2/22 with diagnoses that included chronic respiratory failure and bladder incontinence. A physician’s order (plan of care) dated 3/2/22, prescribed a urinary catheter (tube inserted into the bladder connected to a drainage bag) for incontinence to be replaced every month and as needed. A home visit was conducted with RN B on 3/15/2022 at 9:30 am. At 9:40 am, RN B was observed removing Patient 3’s old urinary catheter by deflating the water filled balloon in Patient 3’s the urethra (opening of penis which urine flows from) while he laid in his bed. At 10 am, RN B was then observed preparing to insert the new catheter while wearing gloves. She opened the catheter tray, removed her gloves, and then applied sterile gloves from the container without washing her hands or using alcohol hand sanitizer. At 10:10 am, RN B inserted the catheter. On 3/16/22 at 4:20 pm, RN B was interviewed. RN B acknowledged she did not wash her hands or use alcohol hand sanitizer after removing soiled gloves and applying sterile gloves before placing the urinary catheter in Patient 3. During an interview with Registered Nurse Manager (RN M) on 3/23/22 at 12:10 pm, she stated RN B should have performed hand hygiene when she removed her dirty gloves prior to applying sterile gloves.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure skilled professional services were delivered according to the agencies policy and procedures when: 1. Patient 1’s pain was not assessed during a nursing home visit. . 2. Patient 3’s pain was not assessed during a nursing home visit when he had yelled out three times exhibiting pain during a urinary catheter (tube inserted into the bladder connected to a drainage bag) change. These actions had the potential for un-recognized pain, delay in treatment, and negative side effects to occur to patients. Findings: 1. Patient 1 was admitted to the agency on 2/4/22 with diagnoses that included weakness, recent falls, and diabetes (high sugars in the blood stream). A physician’s order (plan of care) dated 2/4/22, prescribed nursing frequency 1 time a week for 4 weeks, and 2 prn (as needed) for impaired skin integrity or medication management. The physicians order dated 2/4/22, under skilled nursing instructed to assess Patient 1’s pain management. A home visit was conducted on 3/14/22 at 2 pm, with Registered Nurse (RN) A. During the visit RN A did not assess Patient 1’s pain. Patient 1 was currently prescribed: Cymbalta delayed release (DR) 60 milligrams (mg) orally twice daily for chronic (long term) musculoskeletal pain. Gabapentin 600 mg, two tablets orally for neuropathic (nerve) pain, and Hydromorphone (trade name Dilaudid) 4 mg, one tab every 6 hours as needed for pain. During an interview with RN A on 3/17/22 at 9:15 am, she stated she did not assess Patient 1’s pain level during the home visit. On 3/17/22 at 9:30 am, the Registered Nurse Manager (RN) M stated RN A should have assessed Patient 1’s pain level during the home visit. 2. Patient 3 was admitted to the agency on 3/2/22 with diagnoses that included chronic respiratory failure and bladder incontinence. A physician’s order dated 3/2/22, prescribed a urinary catheter for incontinence to be replaced every month and as needed. Patient 3 did not have anything for pain prescribed by his physician. A home visit was conducted with RN B on 3/15/22 at 9:30 am. At 9:40 am, RN B was observed removing Patient 3’s old urinary catheter by deflating the water filled balloon in Patient 3’s urethra (opening of penis which urine flows from) while he laid in his bed. Patient 3 was observed yelling out during this procedure. At 10 am, RN B told Patient 3 she would come back later to bring him catheter leg bags (smaller bags that are strapped to the leg) as she had only brought a larger type of overnight bags. RN B was then observed preparing to insert the new catheter. At 10:10 am, RN B inserted the catheter. Patient 3 yelled out three times and then stated, “Please stop.” RN B instructed Patient 3 to take a deep breath and Patient 3 stated, “That really hurts.” Then RN B asked Patient 3 if he was ok and he replied, “Not really.” During an interview with Patient 3 at 10:44 am, after RN B had left Patient 3’s residence, he stated the procedure really hurt. On 3/16/22 at 4:20 pm, RN B was interviewed. She stated it was common for most men to yell during this procedure and stated she thought Patient 3 was subdued compared to most men. RN B was asked if she would have done anything differently, as she had planned to return to see Patient 3 to bring him his leg bags. RN B was questioned as to why she did not assess his pain during the procedure when he yelled out or call his physician for an order to insert lidocaine (numbing lubricant) prior to inserting the catheter. RN B stated she would not have done anything differently. She stated if she had left Patient 3’s catheter out and came back later he might have swelled, and then she might have not been able to insert the catheter. RN B failed to assess Patient 3’s pain level while he was yelling out during the catheter change. A review of the policy titled, "Pain Management," reviewed 9/2021, directed the pain intensity scale of zero to 10 would be used with ten being the worst pain, and zero being no pain. Additionally, the policy instructed that the below ABCDE approach would be used: Asses pain systemically and reassess. Believe the Patient reports of pain. Choose pain control options appropriate for the patient. Deliver interventions timely, logically, and in a coordinated fashion, and Empower patients. During an interview with RN M on 3/23/22 at 12:10 pm, she stated RN B should have assessed Patient 3’s pain level when he was calling out during the catheter change. She stated RN B could have waited until she returned with the catheter bags and called the physician for an order for lidocaine. RN M stated RN B could have done things differently.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to make annual onsite supervisory visits to patients receiving Home Health Aide services. This failure had the potential to prevent patients from receiving safe, appropriate care from Home Health Aides, and lead to a decline in patient well-being. Findings: A review of a facility document titled, “Employee Performance Evaluation,” reviewed November 2021, indicated that employees must receive an annual performance evaluation in order to gauge on the job performance of their duties. During an interview on 3/17/22 at 11:41 am, the Home Health Aide (HHA) stated she had worked since June 2021, and denied having received any supervisory visits. HHA stated nurses have come out to visit the patient after she had done her visit, but did not remember being supervised. During an interview on 3/17/22 at 4 pm, Registered Nurse (RN) A stated that Home Health Aides are not supervised using concurrent visits. During an interview on 3/22/22 at 2:04 pm. RN M confirmed that the facility had no concurrent supervisory visits with HHAs, only visits every two weeks with the patients receiving HHA service. RN M also confirmed that the facility did not do annual competency checks for HHAs.