Every finding on record at Sumner Regional Medical Center, LLC

An Emergency Preparedness survey was conducted along with a recertification survey beginning on 2/21/2023. This facility was found to be in compliance with the regulations reviewed related to Emergency Preparedness.

A recertification survey was conducted beginning 2/21/2023 through 2/23/2023. The facility was notified of survey findings during an exit conference on 2/23/2023.

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 policy review, medical record review, observation, and interview, the facility failed to ensure all medications were reconciled for 1 of 5 (Patient #5) patients observed during home visits. The findings included: 1. Review of the facility’s “Monitoring Medications,” policy (revised 5/1/2019), revealed “…Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home…A drug review regimen review will be performed on all patients in conjunction with all comprehensive assessments…For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout this episode…The physician is contacted immediately if any discrepancies between agency information and patient medications are found…” 2. Medical record review revealed Patient #5 with a Start of Care (SOC) date of 1/15/2023 with diagnoses that included Left Lower Leg Open Wound, Chronic Obstructive Pulmonary Disease, Rheumatoid Arthritis, Bipolar Disorder, Anxiety, and History of Falling. Review of the Client Medication Report revealed on 12/20/2022, Diclofenac Sodium (Anti-inflammatory) 75 milligram (mg) tablet to be taken orally daily. Observations in the patient's home on 2/23/2023 beginning at 11:20 AM, revealed Diclofenac Sodium was not in Patient #5’s box of medications. Also found in Patient #5’s box of medications were the following medications, that were not documented on the Client Medication Report: -1 bottle of Rheumate (dietary supplement) 1 capsule orally every day. -1 bottle of Sulfasalazin (treats Rheumatoid Arthritis) 500 mg orally 2 tablets every morning and 1 tablet every night dated 11/28/22. -1 bottle of Valacyclovir (anti-viral) 500 mg orally every day dated 11/29/2022. -2 bottle of Prevastatin (anti-cholesterol) 20 mg orally every day dated 9/22/2022. -2 boxes of Domperidone (anti-nausea) Tabs 1 tab taken every day with meals. -1 bottle of Prevastatin 10 mg orally every day dated 6/24/2020. -2 bottles of Protonix (proton pump inhibitor) 40 mg orally twice daily dated 4/6/2022. -4 bottles of Depakote (mood stabilizer) orally as needed for migraines. During an interview on 2/23/2023 at 11:35 AM, Patient #5 confirmed these were medications she was currently taking. During an interview with Registered Nurse (RN) #1 on 2/23/2023 at 11:50 AM, RN #1 stated “…I picked this patient up 3 weeks ago and have been concentrating on her leg wound. No, I have not reviewed her medications…” During an interview on 2/23/2023 at 12:30 PM, the Executive Director stated, “…Our Physician Orders are incorrect…Her [Patient #5] medications are on auto refill through her insurance company…It’s the clinician’s responsibility who completes the patient’s recertification for services to perform a medication reconciliation…”

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 policy review, record review and interview, the facility failed to ensure coordination of care related to changes in patients conditions for 2 of 9 (Patient # 5 and 6) current patients reviewed. The findings included: 1. Review of the facility's "COORDINATION OF CARE, FROM ADMIT THROUGH DISCHARGE" policy (revised 8/1/19) revealed, "...The agency provides care and services within an integrated continuum of care system. This is accomplished by...Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge...4. Coordination of care with physician...a. When changes occur in the patient's condition or response to treatment...5. Coordination of care among disciplines...c. Appropriate, timely communication with the patient, caregivers, and staff involved in the patient's care regarding patient needs, goals, and care as well as changes in these..." 2. Medical record review for Patient #5 revealed a Start of Care (SOC) date of 1/16/2023 with diagnoses that included open wound to left lower leg. Review of a 1/23/2023 communication note revealed Patient #5 called the agency and reported she had head lice, and the shampoo she was using wasn't getting rid of the lice. There was no documentation the facility notified the physician of Patient #5's difficulty with head lice, and no documentation the facility followed up with Patient #5 about the head lice until a skilled nurse visit on 1/30/2023, one week later. In an interview on 2/22/2023 at 2:45 PM, the Executive Director (ED) verified there was no documentation of follow up after receiving the communication from Patient #5 about head lice. 3. Medical record review for Patient #6 revealed a Plan of Care (POC) date of 1/14/2023 through 3/14/2023 with diagnoses that included Pressure Ulcer of right heel. Review of a 2/7/2023 Skilled Nurse note revealed Licensed Practical Nurse (LPN) #1 documented a new open area to the left buttock. LPN #1 cleansed the wound, and applied a dressing. There was no documentation LPN #1 notified a Registered Nurse (RN) or the patient's physician of the new wound. Review of a 2/9/2023 Skilled Nurse note revealed RN #1 documented Patient #6's indwelling catheter tubing was disconnected and laying on the floor. Patient #6's caregiver stated he disconnected the tubing for a doctor's appointment. There was no documentation RN #1 followed up with Patient #6's physician about catheter management. There was no documentation RN #1 provided teaching to Patient #6 or caregiver related to catheter care and management. In an interview on 2/22/2023 at 2:45 PM, the ED verified there was no documentation of follow up regarding Patient #6's new wound after the visit on 2/7/23, and no follow up related to concerns of catheter management on 2/9/2023.