Every finding on record at Sta Rita Health Systems, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 25046, Health Facilities Evaluator Nurse Surveyor # 45783, Health Facilities Evaluator Nurse Unduplicated Admissions - 408 Active Patients - 119 Sample Size - 10 Patients Home Visits – 4

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 observation, interview, and record review, the home health agency (HHA) staff failed to review all the medications and update the medication profile with currently used medications for three of 10 sample patients (Patients 1, 2, 6). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. c. A review of Patient 6's plan of care (POC) for the certification period from 7/26/22 to 9/23/22, indicated start of care (SOC) dated 9/29/21, with diagnoses that included change or removal of nonsurgical wound dressing, diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) with skin ulcer, dependence on renal dialysis, long term use of insulin, acquired absence of left and acquired absence of right foot. The skilled nurse (SN) was to visit twice a week for one week, three times a week for 7 weeks, and twice a week for one week to perform/demonstrate/instruct daily wound care. The SN was to provide teaching/instructions to patient/primary caregiver the medication regimen (Purpose, dosage, frequency, effects/side effects). On 8/10/2022, at 10:50 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 6 was observed sitting in a wheelchair, alert and oriented, and communicable. Family member 1 was next to the patient. At 12 p.m., during a review of Patient 6's current medications compared with the medication profile provided by the agency, it was noticed the patient had following medications: 1. There was an unlabeled medication container filled with half-cut tablets. During an interview with Family member 1 (with translation by RN 1 who spoke the same language with Family member 1), she stated the tablet was Atorvastatin 40 milligram (mg) and she cut the tablet in half because if the patient takes one tablet, he gets a headache. She stated she had transferred the half tablets from the original container to that unlabeled container. Family member 1 stated the patient had been taking a half-tablet since past one week and the other visiting nurse knew that. The medication profile indicated Patient 6 was to take one tablet of Atorvastatin 40 mg one tablet daily. 2. There was a medication container labeled Carvedilol 12.5 milligram half tablet to take everyday (dated 5/25/2022) while the medication profile which indicated Carvedilol 6.25 mg one tablet two times daily. During an interview with RN 1 at the same time, he stated the medication profile should have been updated whenever there were changes of the medications and instruction/education should have been provided to the patient after notification/clarification to the physician. A review of the agency's undated policy of the "Medication Profile/ Drug Regimen Review" indicated the nurse/therapist shall review all medications with the patient and/or caregiver to ensure he/she understands how the drugs are to be stored, administered, and is aware of side effects which could be experienced following administration. Information is also given to the patient regarding prescription refills, actions when doses are missed, disposal of unused and expired medication, and avoidance of contamination. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 10/27/21, with primary diagnoses of encounter for fitting and adjustment of urinary device (a tube placed in the body to drain and collect urine from the bladder). A review of Patient 1's Plan of Care (POC) review dated 6/21/22, included orders for the skilled nurse (SN) to visit twice a week for one week, and once a week for seven weeks. The skilled nurse was to review the medication regimen and educate patient and/or family/caregiver on purpose, dosage, frequency, effects/side effects, and compliance to dietary regimen. On 8/11/22 at 10 a.m., during a joint home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 1 was observed sitting in a wheelchair, awake and alert. LVN 1 and Family Member 2 (FM 2) then transferred Patient 1 to bed prior to LVN 1 assessment of Patient 1. During a review of Patient 1's current medications with LVN 1 during the joint home visit, it was noted that Patient 1 was taking Vitamin D 50,000 Unit, 1 tablet once a week for nutritional supplement and Vitamin B12 2.5 Mcg 1 tablet under the tongue daily for nutritional supplement. Patient 1’s medication profile indicated that Patient 1 was taking Vitamin D 500 Mg 1 tablet once a week, and Vitamin B12 500 Mg 1 tablet under the tongue daily. During an interview with LVN 1 on 8/11/22 at 10:55 a.m., LVN 1 acknowledged there are discrepancies on the doses of Vitamin D and Vitamin B12. LVN 1 stated it was her responsibilities as the field nurse to update and reconcile patient’s medication profile on every visit. LVN 1 further stated not having an updated medication profile could result in patient receiving incorrect dose of medications. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 5/12/22, with primary diagnoses of unspecified open wound and Diabetes Mellitus 2 (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2's Plan of Care (POC) review dated 7/11/22, included orders for the skilled nurse (SN) to visit twice a week for one week, and once a week for eight weeks. The skilled nurse was to review the medication regimen and educate patient and/or family/caregiver on purpose, dosage, frequency, effects/side effects, and compliance to dietary regimen. On 8/11/22 at 11:30 a.m., during a joint home visit with LVN 1 Patient 2 was observed lying in bed, awake and alert. LVN 1 proceeded with assessment and dressing change on Patient 2’s bilateral lower extremities. Observed LVN 1 doing dressing change on Patient 2 at 11:35 a.m. LVN 1 sanitized her hands with hand sanitizer, put on gloves, and removed the old dressing on patient’s left leg. LVN 1 then cleansed Patient 2’s wound with Normal Saline (a mixture of sodium chloride and water that has a number of uses, including cleaning wounds). LVN 1 then patted dry the cleansed wound, applied Medihoney on the wound, covered it with dry gauze, applied Unna boot on top, and covered with multi-layer of compression dressing. LVN 1 repeated the same procedure with Patient 2’s right leg. During a review of Patient 2's current medications with LVN 1 during the joint home visit, Medihoney and Unna boot were not found on the medication profile. It was also noted that Patient 2 was taking Potassium Chloride 20 MEQ, 1 tablet twice a day as electrolyte replenishers, Magnesium 250 Mg, 1 tablet daily as nutritional supplement, and Atorvastatin Calcium 20 Mg 1 tablet at bedtime for high cholesterol. Patient 2’s medication profile indicated that Patient 2 was taking Potassium Chloride 10 MEQ 1 tablet twice a day, and Magnesium 200 Mg 1 tablet daily. Atorvastatin Calcium 20 Mg was not found on the medication profile. During an interview with the Director of Patient Care Services (DPCS) on 8/12/22 at 12:06 p.m., DPCS stated it was the responsibility of the visiting nurse to check patient's medications on every visit and update the medication profile in the patient’s medical records. DPCS also stated that the visiting nurse had to call the physician to let them know that patient doesn’t need a certain medication so it could be discontinued. DPCS stated that it was very important to have medication profile updated as soon as there was a change in a patient’s medications, so that all interdisciplinary team members are aware of the changes, and patient can be monitored appropriately. A review of the undated home health agency policy and procedure titled “Medication Profile/Drug Regimen Review”, indicated the medication profile should be reviewed by a Registered Nurse every 60 days and updated whenever there is a change or discontinuation in medication.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the HHA skilled nurse (SN) failed to calibrate a glucometer periodically as indicated in plan of care (POC) for one of 10 sample patients (6). This deficient practice has the potential to result in an incorrect blood sugar reading that could impact the patient's blood sugar level status such as hyperglycemia (an excess of glucose in the bloodstream)/hypoglycemia (deficiency of glucose in the bloodstream). A review of Patient 6's plan of care (POC) for the certification period from 7/26/22 to 9/23/22, indicated start of care (SOC) dated 9/29/21, with diagnoses that included change or removal of nonsurgical wound dressing, diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) with skin ulcer, dependence on renal dialysis, long term use of insulin, acquired absence of left and acquired absence of right foot. The skilled nurse (SN) was to visit twice a week for one week, three times a week for 7 weeks, and twice a week for one week to perform/demonstrate/instruct daily wound care. The SN was to assess the patient/Primary Caregiver (PCG)’s knowledge and competence and teach/instruct regarding blood sugar level check via fingerstick, proper use/maintaining/calibrating the blood glucometer machine. The POC included the physician’s order to administer Lantus insulin (100 unit/milliliter) daily as needed for high blood sugar as follows: 160 milligram (mg)/deciliter (dl) to 270 mg/dl = 10 unitsgreater than 270 mg/dl = 18 units On 8/10/2022, at 10:50 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 6 was observed sitting in a wheelchair, alert and oriented, and communicable. Family member 1 was next to the patient. At 12:20 p.m., Family member 1 brought Glucometer 1. During an interview with Family member 1 (with translation by RN 1 who spoke the same language as Family member 1), she stated the patient had been using Glucometer 1 for approximately two years. But Patient 6 and Family member 1 did not remember when Glucometer 1 was calibrated. During an interview with RN 1 at the same time, he stated he did not know either, and he could not find the documented evidence when Glucometer 1 was calibrated. On 8/11/2022, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated the control solution test should have been performed per manufacture guideline of Glucometer 1. A review of Glucometer 1’s manufacture’s “Comprehensive Resource Guide for Healthcare Professionals” indicated the Control test should be performed when opening a new vial of test strips. It indicated there are 50 test strips in a vial of test strip. Based on observation, interview, and record review, the Home Health Agency (HHA) staff failed to ensure 1 of 10 sampled patients (Patient 2) had his blood sugar level checked and his glucometer calibrated. This deficient practice has the potential to subject patient to ineffective blood sugar monitoring and inaccurate reading of blood sugar. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 5/12/22, with primary diagnoses of unspecified open wound and Diabetes Mellitus 2 (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2's Plan of Care (POC) review dated 7/11/22, included orders for the skilled nurse (SN) to visit twice a week for one week, and once a week for eight weeks. SN to check patient’s blood sugar level every visit. SN to assess patient/caregiver’s knowledge and competence and teach/instruct regarding blood sugar level check via fingerstick, proper use/maintaining/calibrating blood glucometer, infection control measures, sharps precaution, and proper disposal of sharps. On 8/10/22 at 11:30 a.m., during a joint home visit with LVN 1 Patient 2 was observed lying in bed, awake and alert. LVN 1 proceeded with assessment and dressing change on Patient 2’s bilateral lower extremities. LVN 1 asked patient if he checked his blood sugar that morning. Patient 2 replied, “Yes. I checked it before breakfast.” He reported his fasting blood sugar was 316. LVN 1 asked him what he ate last night. Patient 2 stated that he had cake from Costco. Patient 2 mentioned that he injected himself with insulin as usual. LVN 1 proceeded with checking patient’s colostomy site after she did the dressing change. LVN 1 did not check Patient 2’s blood glucose during her visit, nor did she check with patient when the glucometer was last calibrated. During an interview with LVN 1 on 8/10/22 at 12:20 p.m., LVN 1 stated she did not check patient’s blood sugar because he always checked his blood sugar in the morning. She added that patient had been doing it for a long time, so he knew what he was doing. LVN stated that patient was familiar with blood sugar management and glucometer management. During an interview with Patient 2 on 8/11/22 at 09:17 a.m., he said that he checked his blood sugar once daily, before breakfast. He self-injected himself with 45 units of Lantus. Patient said he didn’t check his blood sugar again after taking Lantus. Patient did not remember when he calibrated his glucometer. During an interview with the Director of Patient Care Services (DPCS) on 8/11/22 at 12:18 p.m., DPCS stated LVN 1 should have checked Patient 2’s blood sugar, especially when the fasting blood sugar was as high as 316. He stated by checking the blood sugar, HHA staff could monitor if the insulin dose was effective. DPCS also stated HHA staff needed to instruct and educate patient regarding glucometer calibration using the control solution test should have been performed per manufacturer’s recommendation.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the plan of care (POC) covered all pertinent diagnoses for 2 of 10 sampled patients (Patients 1, 6). Patients 6 receives dialysis (procedure that performs the functions of the kidneys in people whose kidneys failed) treatment via permacath (a long, flexible catheter that requires adherence to strict technique and optimal catheter management). There was no care outlined in the POC for management of receiving dialysis. Patient 6 also had a pacemaker (a medical device that generates electrical impulses delivered by electrodes to contract the heart muscles and regulate the electrical conduction system of the heart) implanted. There was no information of pacemaker included in the POC to provide instruction/education to the patient/primary caregiver (PCG). This deficient practice had the potential to put the patient at risk for complications like bleeding, infection or unmanaged fluid restriction, delay in detecting malfunction of the pacemaker, and delay in responding if an emergency situation occurs. b. A review of Patient 6's plan of care (POC) for the certification period from 7/26/22 to 9/23/22, indicated start of care (SOC) dated 9/29/21, with diagnoses that included change or removal of nonsurgical wound dressing, diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) with skin ulcer, dependence on renal dialysis, long term use of insulin, acquired absence of left and acquired absence of right foot, systolic heart failure, and presence of cardiac pacemaker. The skilled nurse (SN) was to visit twice a week for one week, three times a week for 7 weeks, and twice a week for one week to perform/demonstrate/instruct daily wound care. The POC indicated Patient 6 receives hemodialysis on Monday, Wednesday, and Friday. However, the POC did not include regarding hemodialysis management such as monitoring the access site for bleeding, infection, and fluid restriction instruction. Also, the POC did not indicate the management of cardiac pacemaker including the information of the patient’s pacemaker such as the type, model number, serial number, set rate, the date for the battery was to be changed, and the cardiologist’s name and phone number. On 8/10/2022, at 10:50 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 6 was observed sitting in a wheelchair, alert and oriented, and communicable. Family member I was next to the patient. Patient 6 had a permacatheter (covered by partly yellowish colored dressing) and pacemaker on the right upper chest. At 11:10 a.m., during an interview with Family member 1 (with translation by RN 1 who spoke the same language as Patient 6 and Family member 1), stated Patient 6 was on fluid restriction of 1200 cubic centimeter per day. When asked whether the patient had measured the amount of fluid intake, Family member 1 stated she had not measured the fluid intake, and Patient 6 did not have a measuring cup. Also, when asked about the information about pacemaker such as the model number, serial number, set rate, or battery change, both Patient 6 and Family member 1 was not able to answer. During an interview with RN 1, he was not able to answer either. During an interview with the Director of Patient Care Services (DPCS) on 8/11/2022, at 11:50 a.m., he was not able to find the documented evidence the SN had provided education /instruction regarding hemodialysis and pacemaker. The DPCS stated the POC should have included the management of hemodialysis and the information of pacemaker, and the SN should have provided instruction/education accordingly. A review of the agency’s undated policy titled “Plan of treatment/care (485) indicated the agency will develop an individualized plan of care for each patient with all pertinent diagnoses, mental/psychosocial/cognitive status, services/supplies/equipment needed. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 10/27/21, with primary diagnoses of encounter for fitting and adjustment of urinary device (a tube placed in the body to drain and collect urine from the bladder). On 8/11/22 at 10 a.m., during a joint home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 1 was observed sitting in a wheelchair, awake and alert. LVN 1 and Family Member 2 (FM 2) then transferred Patient 1 to bed prior to LVN 1 assessment of Patient 1. A review of Patient 1's Plan of Care (POC) review dated 6/21/22, included orders for the skilled nurse (SN) to visit twice a week for one week, and once a week for seven weeks. The POC did not indicate Patient 1 had a pacemaker as one of the diagnoses, thus no management and monitoring of pacemaker was included in patient’s POC. However, a review of Patient 1's skilled assessment/skilled nurse visit note dated 7/21/22, 7/28/22, and 8/4/22 indicated that patient had a pacemaker on left upper chest wall. During an interview with the Director of Patient Care Services (DPCS) on 8/12/22 at 12:18 p.m., DPCS stated that Patient 1 had a pacemaker. He previously also mentioned about Patient 1’s pacemaker when arranging for a home visit. DPCS acknowledged that pacemaker management needed to be included in Patient 1’s POC, so that the visiting nurse would be aware and could provide necessary management, monitoring, and education for patient’s family or caregiver. A review of the home health agency’s undated policy titled “Plan of Treatment/Care (485)” indicated each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals. The policy also indicated the individualized POC for patients requiring medical orders shall include, but not limited to, the following information: a. all pertinent diagnosis; n. patient-specific intervention and education, measurable outcomes, and goals identified by the agency and the patient.

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 SN (skilled nurse) failed to notify the physician regarding the out-of-range blood pressure readings for one of 10 sample patients (Patient 6). This deficient practice can place the patient at risk for negative outcome by not receiving adequate care timely. Findings: A review of Patient 6's plan of care (POC) for the certification period from 7/26/22 to 9/23/22, indicated start of care (SOC) dated 9/29/21, with diagnoses that included change or removal of nonsurgical wound dressing, diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) with skin ulcer, hypertensive heart disease and systolic heart failure. The skilled nurse (SN) was to visit twice a week for one week, three times a week for 7 weeks, and twice a week for one week to perform/demonstrate/instruct daily wound care and for comprehensive skilled nursing assessment/skilled observation of vital signs and all body system. The SN was to report the physician when the blood pressure is more than 160/90 millimeter mercury (mmHg). A review of “Skilled Assessment/SN visit note” indicated the patient’s blood pressure was as follows: 6/11/2022- 174/91 mmHg6/17/2022 – 164/87 mmHg7/23/2022 – 170/64 mmHg8/2/2022 – 167/75 mmHg A review of Patient 6’s record indicated there was no documented evidence the physician was notified regarding the out-of-range blood pressure readings on above days. During an interview with the Director of Patient Care Services (DPCS), on 8/11/2022, at 11:30 a.m., he was not able to provide the documented evidence the physician was notified regarding these out of range blood pressure readings on above days. A review of the agency’s undated policy titled “Plan of treatment/care” indicated the professional person responsible for any specific treatment shall notify the attending physician, dentist, podiatrist, or other licensed and legal authorized practitioner within his/her scope of practice of significant changes of patient’s condition.