Every finding on record at Primecare Network, L.L.C.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: ER- Extended Release mcg-microgram mg-milligram MEQ- milliequivalents mEq/L- milliequivalents per liter ml- milliliter

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations during home visits, interviews, and record reviews, the agency failed to ensure the patient’s comprehensive assessment included a review of all medications the patient was currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications during subsequent home visits for 4 of 4 (#4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” revealed the following, in part: Purpose: To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications. Key Words/Definitions: Medications: includes all over the counter, prescription, regularly taken PRN medications, herbals, and nutraceuticals that the client takes in all places of residence. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/04/2023 and had a current Certification Period of 10/31/2023 to 12/29/2023. Patient #4 had diagnoses, which included Chronic Combined Systolic and Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Unspecified Cardiomyopathy. Further review revealed Patient #4 received Skilled Nursing Visits once weekly for nine weeks for Certification period of 10/31/2023 to 12/29/2023. A home visit was conducted with Patient #4 on 12/18/2023 at 1:00 p.m. with S7PT present in the home. Patient #4’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #4’s Current Medication Profile provided by the Home Health Agency: Fish Oil 1000 mg soft gel take one soft gel by mouth daily– present in the home and not on the Medication Profile Buspirone 5 mg tablet take one tablet by mouth three times daily – on the Medication Profile, but not present in the home Hydrocodone 7.5 mg-Acetaminophen 325 mg tablet take one tablet by mouth every 12 hours as needed for Pain – on the Medication Profile, but not present in the home An interview was conducted with Patient #4 during the home visit. She stated she managed her own medications. She stated she had been taking Fish Oil for at least 6 months and she stopped taking Hydrocodone about 5 months ago. She further stated it had been months since she had taken Buspirone. An interview was conducted with S7PT during the home visit on 12/18/2023 at 1:35 p.m. He stated the nurses should reconcile the patient’s medications every visit. S7PT said he only asked Patient #4 if she had any medication changes each visit and if she reported she did, he notified the agency’s office nurses with the changes to update the medication profile. S7PT verified the medications on Patient #4’s Medication Profile and what the patient was taking did not match and should have. Patient #5 Review of Patient #5’s Clinical Record revealed she began receiving services from the Home Health Agency on 10/07/2023 and had a current Certification Period of 12/06/2023 to 02/03/2024. Patient #5 had diagnoses, which included Pressure Ulcer of Other Site Stage 2, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Chronic Diastolic Congestive Heart Failure, Mixed Hyperlipidemia, and Primary Generalized Osteoarthritis. Further review revealed Patient #5 received Skilled Nursing Visits once weekly for one week and twice weekly for eight weeks for Certification period of 12/06/2023 to 02/03/2024. A home visit was conducted with Patient #5 on 12/18/2023 at 2:00 p.m. with S4LPN present in the home. Patient #5’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #5’s Current Medication Profile provided by the Home Health Agency: Albuterol Sulfate 2.5 mg/3 ml vial nebulizer take every 6 hours as needed, filled on 12/02/2023- present the in home and not on the Medication Profile Trelegy Ellipta 100 mcg/62.5 mcg/25 mcg inhaler take one inhalation daily, filled on 12/02/2023 with 16 doses remaining – present in the home and not on the Medication Profile Atenolol 25 mg tablet take one tablet by mouth daily, filled on 12/11/2023 – present in the home and not on the Medication Profile Calcium 500 plus D 500 mg-5 mcg tablet take one tablet by mouth daily- on the Medication Profile and not present in the home Calcium 600 mg plus Vitamin D3 20 mcg tablet take one tablet by mouth daily- present in the home and not on the Medication Profile Metoprolol Succinate ER 25 mg tablet, Extended Release 24 hour – on the Medication Profile and not present in the home Pantoprazole 40 mg tablet take one tablet 30 minutes before breakfast, filled 12/11/2023 – present in the home and not on the Medication Profile Rosuvastatin 5 mg tablet take one tablet by mouth daily – on the Medication Profile and not present in the home Melatonin 10 mg tablet take one tablet by mouth at night – present in the home and not on the Medication Profile An interview was conducted with Patient #5 during the home visit. She stated her daughter filled her pill box weekly, but she knew what medications she was on. She stated she took Albuterol nebulizer treatments daily at 10:30 a.m. She stated she had been taking the Trelegy Ellipta inhaler for at least two weeks. She stated she took Atenolol daily but did not know where the Metoprolol bottle was or if she was still taking it. She stated she had been on taking Pantoprazole daily for months. She stated she had been out of her Rosuvastatin for a while. She stated she had been taking Melatonin almost every night for a while. A telephone interview was conducted with Patient #5’s daughter on 12/19/2023 at 4:48 p.m. She stated she assisted Patient #5 with her medications by filling her pill box weekly. She stated Patient #5 took Albuterol nebulizer treatments daily. She stated Patient #5 had been taking the Trelegy Ellipta inhaler for over a month as she had completed one 30 day inhaler and was now on a second inhaler. She stated Patient #5 began taking Atenolol on 12/11/2023. She stated Patient #5 was taking Pantoprazole daily. An interview was conducted with S4LPN during the home visit on 12/18/2023 at 2:10 p.m. She stated she had been seeing Patient #5 since 12/12/2023. S4LPN also reviewed Patient #5’s medications and confirmed the above discrepancies. S4LPN stated Patient #5’s medications should have been reconciled every skilled nursing visit. S4LPN confirmed Patient #5’s current Medication Profile should have been up to date and it was not. Patient #6 Review of Patient #6’s Clinical Record revealed he began receiving services from the Home Health Agency on 09/26/2022 and had a current Certification Period of 11/20/2023 to 01/18/2024. Patient #6 had diagnoses, which included Hypertensive Heart Disease with Heart Failure, Unspecified Systolic Congestive Heart Failure, and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Further review revealed Patient #6 received Skilled Nursing Visits once weekly for three weeks and twice weekly for six weeks. A home visit was conducted with Patient #6 and his spouse on 12/19/2023 at 9:00 a.m. with S5RN present in the home. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #6’s Current Medication Profile provided by the Home Health Agency: Pepcid 20 mg tablet take one tablet by mouth daily – on the Medication Profile and spouse stated Patient #6 was not taking Vitamin D3 50 mcg soft gel take one soft gel daily – present in the home and not on the Medication Profile Zinc 50 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile Magnesium Extra Strength 400 mg soft gel take one soft gel by mouth daily – present in the home and not on the Medication Profile Vitamin B12 5000 mcg take one quick dissolve tablet by mouth daily – present in the home and not on the Medication Profile An interview was conducted with Patient #6’s spouse during the home visit. She stated she managed Patient #6’s medications. She stated Patient #6 had not taken Pepcid for four to five months. She stated Patient #6 had been taking the above supplements for a long time. An interview was conducted with S5RN on 12/19/2023 at 9:45 a.m. She stated Patient #6’s medications should have been reconciled every visit. She reviewed Patient #6’s medications and Medication Profile and confirmed the above discrepancies. She confirmed the Medication Profile and the medications Patient #6 was taking should match and did not. Patient #7 Review of Patient #7’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/02/2023 and had a current Certification Period of 11/28/2023 to 01/26/2024. Patient #7 had diagnoses, which included Lymphedema, Major Depressive Disorder, Personal History of Pulmonary Embolism, and Peripheral Vascular Disease. Further review revealed Patient #7 received Skilled Nursing Visits twice weekly for eight weeks and once weekly for one week for Certification period of 11/28/2023 to 01/26/2024. A home visit was conducted with Patient #7 on 12/19/2023 at 11:00 a.m. with S6RN present in the home. Patient #7’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #7’s Current Medication Profile provided by the Home Health Agency: Escitalopram 10 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile Aspirin 81 mg tablet take one tablet by mouth daily – present in the home and not on the Medication Profile An interview was conducted with Patient #7 during the home visit. She stated she had been taking Escitalopram daily for about one year. She stated she had been taking Aspirin daily for a couple months. An interview was conducted with S6RN on 12/19/2023 at 11:20 a.m. She stated medications were reconciled by looking at the medication bottles on admit and recertification. She reviewed Patient #7’s medications and confirmed the above discrepancies. She confirmed the Medication Profile and the medications the patient was taking should match and did not. An interview was conducted with S1ADM on 12/19/2023 at 11:50 a.m. She was notified of the medication discrepancies found during the home visits for Patient #4, #5, #6 and #7. She stated each patients’ medications should have been reconciled every nursing visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.

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 interviews and record review, the agency failed to communicate an elevated Potassium level with the Physician for 1 (#4) of 4 (#4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s Policy titled, “Medication Management” revealed the following, in part: Purpose: To reduce errors and improve quality of care and promote safety throughout the home care program. Monitoring Effects of Medications 4. Laboratory values will be evaluated as ordered and other clinical responses noted in the record and reported to the physician or allowed practitioner as indicated. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 01/04/2023 and had a current Certification Period of 10/31/2023 to 12/29/2023. Patient #4 had diagnoses, which included Chronic Combined Systolic and Diastolic Heart Failure, Stage 3 Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, and Unspecified Cardiomyopathy. Further review revealed Patient #4 received Skilled Nursing Visits once weekly for nine weeks for Certification period of 10/31/2023 to 12/29/2023. Review of Patient #4’s current Medication Profile provided by the Home Health Agency revealed the following, in part: Start date: 07/11/2022 – Potassium Chloride ER 20 MEQ Tablet, Extended Release- take one tablet by mouth daily as needed on days she takes Lasix Start date: 05/18/2023 – Furosemide 40 mg tablet take one tablet as needed for weight gain greater than 2 pounds Review of Patient #4’s Physician Orders dated 12/01/2023 revealed the following, in part: Obtain labs at next Skilled Nurse Visit Comprehensive Metabolic Panel Review of Patient #4's Laboratory Results dated 12/11/2023 revealed the following, in part: Potassium 5.5 mEq/L High, Reference Range (3.5-5.1) Review of Patient #4's Nurses’ Notes dated December 2023 revealed no documented evidence the physician was notified or the agency followed up regarding Patient #4's elevated potassium results on 12/11/2023. A home visit was conducted with Patient #4 on 12/18/2023 at 1:00 p.m. She stated the home health nurse drew her labs last week, but she had not heard back from the agency or the doctor with the results. She stated she had a history of abnormal electrolytes. She stated she was mildly short of breath and had gained 2.5 pounds on 12/17/2023 and took a dose of Furosemide and Potassium. A telephone interview was conducted with S3LPN on 12/20/2023 at 8:40 a.m. She stated on 12/11/2023, she reviewed and faxed Patient #4’s laboratory results to the patient’s physician. She confirmed the laboratory results revealed an elevated Potassium level of 5.5. She stated she was aware Patient #4 was prescribed Potassium Chloride as needed. She confirmed she did not follow up with Patient #4 or the physician regarding the elevated Potassium level. She stated at this point she would have expected a response and new orders from the physician. She stated she did not communicate Patient #4’s Potassium level of 5.5 to S2RN. An interview was conducted with S2RN on 12/20/2023 at 9:22 a.m. She stated she was aware S3LPN faxed laboratory results for Patient #4 on 12/11/2023 to the physician. She stated S3LPN did not notify her of Patient #4’s elevated Potassium level of 5.5. She stated at this point she would have expected a response or new orders from the physician. She confirmed there was no documentation of the agency staff having communicated or followed up with Patient #4's physician regarding the Potassium level of 5.5. She confirmed Patient #4 had not had a skilled nurse visit since the labs were drawn on 12/11/2023. She confirmed a Potassium level outside of therapeutic range could be life threatening. An interview was conducted with S1ADM on 12/20/2023 at 8:30 a.m. She stated S3LPN reviewed and faxed Patient #4’s laboratory results to the physician on 12/11/2023. She confirmed there was no documentation the agency staff communicated or followed up with Patient #4's physician regarding the Potassium level of 5.5. She stated a patient with an elevated Potassium level would warrant a follow up phone call from the agency to the physician. She confirmed a Potassium level outside of therapeutic range could be life threatening.

Recertification and Relicensing A COVID-19 Focused Infection Control Survey was conducted on 04/28/2021 per QSO-20-20-ALL. No deficiencies were cited as a result of this survey. Abbreviations: mcg microgram mg milligram ml milliliter PEG Percutaneous Endoscopic Gastrostomy RN Registered Nurse SN Skilled Nurse WOC(ET)/CWCN Wound, Ostomy, and Continence (Enterostomal Therapy)/Certified Wound Care Nurse

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using and/or did not reflect medications the patients were no longer using, for 2 (#4 and #5) of 5 (#1-#5) sampled patients reviewed who received home visits. Findings: Review of an agency policy titled Medication Reconciliation, which was provided by S1ADM, revealed, in part, the following: POLICY: (Agency) will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient facility stays, and at the time of discharge. Medication reconciliation will also occur at the time of each client's comprehensive assessment, a thorough review of all currently prescribed and over-the-counter medications, herbal and nutritional supplements will be performed. PURPOSE: To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications. PROCEDURES: 6. Any prescriptions that have not been filled at the time of the reconciliation should be reported to the physician or allowed practitioner with a collaborative plan for obtaining the medication or decision that it is acceptable to await client action on obtaining the medication. Patient #4 Review of the clinical record revealed a start of care date of 12/17/2020. The patient's current primary diagnosis was Hypertensive Heart and Chronic Kidney Disease. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 04/16/2021 to 06/14/2021 revealed orders for Frequency/Duration of Visits which included: SN effective 04/18/2021 1WK8. On 04/28/2021 at 9:00 a.m., a home visit was conducted in the home of Patient #4 with S2RN. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medication with discrepancies noted: Lantus Solostar U-100 insulin 100 units/ml (3 ml) subcutaneous pen 30 units 2 times daily. An injectable pen of Lantus insulin was observed in the home with a prescription fill date of 03/17/2021; instructions stated 40 units every AM and 30 units every PM. Patient #4 verified he was currently taking 40 units in the morning and 30 units in the evening. A review of SN visit documentation revealed SN visits were conducted with Patient #4 on the following date during the current Certification Period of 04/16/2021 to present: 04/23/2021. A review of SN visit documentation revealed SN visits were conducted on the following dates during the previous Certification Period of 02/15/2021 to 04/15/2021 following the change in the dose of Lantus insulin: 03/24/2021, 03/30/2021, 04/07/2021, and 04/14/2021 (recertification visit). There was no documentation of the Lantus insulin dose updated during any of those visits. On 04/28/2021 at 9:00 a.m., an interview was conducted with S2RN during the home visit. She verified the patient was currently receiving SN visits once a week. Patient #5 Review of the clinical record revealed a start of care date of 04/02/2021. The patient's primary diagnosis was Other Sequelae of Cerebral Infarction. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 04/02/2021 to 05/31/2021 revealed orders for Frequency/Duration of Visits which included: SN 1WK9. On 04/28/2021 at 3:00 p.m., a home visit was conducted with Patient #5. Review of the patient's medications listed on the current medication list provided by the agency revealed orders for the following medications with discrepancies noted: 1. Atorvastatin 40 mg tablet 1 tablet daily. There was none of this medication observed in the home. 2. Levothyroxine 50 mcg tablet 1 tablet daily. There was none of this medication observed in the home. During the home visit, Patient #5 stated her daughter managed her medications and filled her pill box for her a couple of times a week. On 04/29/2021 at 9:10 a.m., a telephone interview was conducted with the patient's daughter. She stated she was familiar with all the medications the patient was taking and verified she prepared the patient's medications in a pill planner each week. When asked about Atorvastatin and Levothyroxine, she stated, "If the medicine is not in the plastic bag in her house, then she is not taking it." She verified the patient had not been taking Atorvastatin or Levothyroxine since she was discharged from the hospital on 04/01/2021. A review of SN visit documentation revealed SN visits were conducted with Patient #5 on the following dates during the current Certification Period of 04/02/2021 to present: 04/02/2021 (start of care visit), 04/06/2021, 04/13/2021, 04/22/2021, and 04/27/2021. There was no documentation of any updates to the medication profile regarding the clarified use of Atorvastatin or Levothyroxine during any of those visits. Further review of the clinical record revealed no communication between the agency's nurse and the patient's physician regarding the use of these 2 medications. On 04/29/2021 at 11:40 a.m., an interview was conducted with S1ADM. She was notified of the medication discrepancies found during the home visits for Patients #4 and #5. She verified the medication profiles were not up to date. S1ADM verified nurses should reconcile medications during each SN visit and update the medication profile accordingly. She further verified nurses would be expected to clarify any questions about medications with the patient's physician in a timely manner.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the plan of care was signed and dated by the patient's physician in a timely manner for 5 (#3, #7, #9, #11, #13) of 13 (#1-#13) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #3 Review of the clinical record for Patient # 3 revealed a start of care date of 01/12/2021. Review of the plan of care for the certification period 03/13/2021 - 05/11/2021 for the patient revealed a principal diagnosis of Pressure Ulcer of Left Buttock, Stage 2. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #7 Review of the clinical record for Patient # 7 revealed a start of care date of 02/18/2021. Review of the plan of care for the certification period 02/18/2021 - 04/18/2021 for the patient revealed a principal diagnosis of Acute Chronic Diastolic Heart Failure. Further review of the plan of care for this certification period revealed the plan of care was not signed until 04/27/2021. Resident #9 Review of the clinical record for Patient #9 revealed a start of care date of 09/26/2020. Review of the plan of care for the certification period dated 09/25/2020 to 11/24/2020 revealed it was signed by the physician on 10/29/2020, which was not within 30 days. Review of the plan of care for the certification period dated 11/25/2020 to 01/23/2021 revealed it was signed by the physician on 12/29/2020, which was not within 30 days. Review of the plan of care for the certification period dated 01/24/2021 to 03/24/2021 revealed it was signed by the physician on 04/14/2021, which was not within 30 days. Review of the plan of care for the current certification period 03/25/2021 to 05/23/2021 revealed the patient had a primary diagnosis of Pressure Ulcer of Sacral Region, Stage 3. Further review of the plan of care for this certification period revealed it was not signed by the physician, which was not within 30 days. Patient #11 Review of the clinical record for Patient #11 revealed a start of care date of 01/20/2021. Review of the plan of care for the certification period 01/20/2021 - 03/20/2021 revealed the patient had a principal diagnosis of Unspecified Fall, Subsequent Encounter. Further review of the plan of care for this certification period revealed it was not signed until 04/06/2021. Patient #13 Review of the clinical record for Patient #13 revealed a start of care date of 12/09/2021. Review of the plan of care for the certification period 12/09/2020 - 01/07/2021 revealed the patient had a principal diagnosis of Pressure Ulcer of Sacral Region, Stage 2. Further review of the plan of care for this certification period revealed it was not signed until 04/28/2021. An interview was conducted on 04/29/2021 at 12:00 p.m. with S1Adm. After reviewing the Plan of Care for Patients #3, #7, #9, #11, and #13, she verified the Physician's Orders were not signed for Patient #3 and #9, and the orders for Patient #7, #11 and #13 were not signed in a timely manner. She confirmed previous certification periods for Patient #9 were also late. She verified it was the agency's policy to have all physician's orders signed within 30 days.

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 record review and interview, the agency failed to comply with accepted professional standards and principles by failing to have a Registered Nurse assess a patient's wounds, including the size and stage, weekly for 2 (#3, #9) of 3 (#3, #9, #13) patients reviewed with pressure ulcers out of a total of 13 sampled patients. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through January 2019) Chapter 37. Nursing Practice revealed, in part: The registered nurse is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. i. Any situation where tasks are delegated should meet the following criteria. (a). The person has been adequately trained for the task. (b). The person has demonstrated that the task has been learned. (c). The person can perform the task safely in the given nursing situation. (d). The patient's status is safe for the person to carry out the task. (e). Appropriate supervision is available during the task implementation. (f). The task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. iv. Contingent upon the registered nurse's evaluation of each patient's condition and also upon the registered nurse's evaluation of the competency of each unlicensed nursing personnel, registered nurses may delegate non-complex tasks to unlicensed nursing personnel. Chapter 39. Legal Standards of Nursing Practice revealed the following in part: §3901. Legal Standards A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The standards of nursing practice provide a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a registered nurse or by a registered nurse in conjunction with other licensed or unlicensed personnel as provided in LAC 46: XLVII.3703. B. The standards are based on the premise that the registered nurse is responsible for and accountable to the individual for the quality of nursing care he or she receives. Documentation must reflect the quality of care. C. The standards of practice shall: 1. be considered as base line for quality nursing care; 2. be developed in relation to the law governing nursing; 3. apply to the registered nurse practicing in any setting; 4. govern the practice of the licensee at all levels of practice. §3915. Standard Number 7: Professional Performance A. The registered nurse demonstrates the following professional nursing practice behaviors. 1. Evaluates own nursing practice in relation to professional practice standards, relevant state and federal statutes, and relevant administrative rules. 2. Acquires and maintains current knowledge in nursing practice. 3. Considers factors related to safety, effectiveness, and cost in planning and delivering nursing care. 4. Nursing decisions and actions are determined in an ethical manner. 5. Clarifies any order or treatment regimen believed to be inaccurate, or contraindicated by consulting with the appropriate licensed practitioner and by notifying the ordering practitioner when the registered nurse makes the decisions not to administer the medication or treatment. Review of the Louisiana State Board of Nursing Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management adapted 02/1999 revealed the following in part: Registered nurses render care that is directed towards the prevention and treatment of wounds. Wounds are a common health care challenge that often occur with or result from chronic disorders such as impaired circulation and malnutrition. Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity, that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers, and conditions resulting from incontinence, surgical procedures, and/or trauma. Professional organizations, such as the National Pressure Ulcer Advisory Panel Consensus Development Conference, the Wound Ostomy and Continence Nurses Society (formerly International Association of Enterostomal Therapy), and the Agency for Health Care Policy and Research (AHCPR) agree upon the following definitions and clinical presentations of the four stages of pressure ulcers: Stage I: Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts may be associated with Stage IV pressure ulcers. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. Recognizing that the physician must always prescribe wound care, the following roles are defined to delineate the scope of practice for each member of the nursing team members. The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Contingent upon the RN's evaluation of each patient's condition and also upon the RN's evaluation of competency of each unlicensed assistive personnel (UAP), an RN may delegate non-complex tasks to a UAP. A non-complex task is one that can safely be performed according to exact directions, with no need to alter the standard procedure, and the results are predictable. When the above criteria has been met, the following wound care interventions may be delegated when non-complex: topical application of anti-infective medications, protective ointments, wound cleansers, skin sealants, gauze, transparent films, hydrocolloids, and hydrogels and the cleansing of the skin of a mature, healed PEG tube site with soap and water or 3% hydrogen peroxide. The Board recognizes the responsible of the employing agency to have written policies and procedures to allow for such delegable interventions, and a written system in place to document competency for each caregiver. Wound care management requires the registered nurse to collaborate with other members of the interdisciplinary team to ensure that the individual's nutritional and psychosocial needs are being met and to provide for preventive and therapeutic measures. The registered nurse should consult with the physician and/or WOC(ET)/CWCN to assure safe, quality nursing measures that facilitate appropriate skin and wound management. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Resident #3 Review of the clinical record for Patient #3 revealed a start of care date of 01/12/2021. Review of the plan of care for the current certification period 03/13/2021 - 05/11/2021 revealed a primary diagnosis of Pressure Ulcer of Left Buttock, Stage 2. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN effective 03/14/2021. Orders of Discipline and Treatment included the following: Need for skilled teaching and intervention related to Stage 2 to buttocks. Skilled nurse or trained patient/caregiver to perform wound care using aseptic technique, cleanse with soap and water as needed, pat dry, and apply barrier cream to wound bed. Wound care to be performed 2-3 times daily and as needed if soiled or dislodged. Review of the SN visit documentation revealed visits were conducted on the following dates during this current certification period: 03/16/2021, 03/22/2021, 04/06/2021, 04/13/2021, 04/20/2021, and 04/27/2021. All SN visits were conducted by S4LPN. There was no documentation a Registered Nurse had assessed the wound weekly. Resident #9 Review of the clinical record for Patient #9 revealed a start of care date of 09/26/2020. Review of the plan of care for the current certification period 03/25/2021 to 05/23/2021 revealed a primary diagnosis of Pressure Ulcer of Sacral Region Stage 3. Further review of the plan of care revealed orders for the following Frequency/Duration of Visits: SN 1WK1, 2WK8. Orders of Discipline and Treatment included the following: SN to perform decubitus care to Stage 3 decubitus ulcer left sacrum using clean technique two times a week - cleanse with Dakins and gauze, pat dry with gauze, apply Duoderm Hydrocolloid to wound bed. Review of the SN visit documentation revealed SN visits were conducted on the following dates during this current certification period: 03/26/2021, 03/29/2021, 04/02/2021, 04/05/2021, 04/08/2021, 04/13/2021, 04/16/2021, 04/19/2021, and 04/22/2021. All SN visits were conducted by S3RN. There was no documentation of pressure ulcer wound measurements for the weeks 04/05/2021 and no documentation provided of wound measurements for the week of 04/19/2021. On 04/29/2021 at 11:50 a.m., an interview was conducted with S1ADM. She stated the agency's goal was to have an RN make a SN visit once a week to stage and assess any pressure ulcers. After reviewing the clinical records for Patients #3 and #9, she verified a visit was not conducted by an RN each week to assess Patient #3's pressure ulcers. S1ADM further verified the RN failed to properly assess Patient #9's pressure ulcer by not measuring the wound each week.