Every finding on record at Team Select Home Care of Colorado LLC

A complaint survey, prompted by #CO62838 was completed on 5/4/22. One deficiency was cited.

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 agency failed to ensure services and treatments were provided in conformance with physician orders for 1 of 4 patient records reviewed (Patient #3). Findings include: AGENCY POLICY According to the agency guidelines, "Wounds" dated 2019, in pertinent part "All wounds will be measured/documented by location, size in centimeters (cm), and a picture taken weekly by the clinician." 1. The clinical record for Patient #3 was reviewed on 5/2/22. The plan of care for certification period dated 3/19/22 to 5/17/22, revealed a start of care date of 3/19/22; diagnoses included pressure ulcer of left heel stage three, hypertensive chronic kidney disease, and peripheral vascular disease. Plan of care orders included skilled nursing (SN) visits once a week for one week then twice weekly for four weeks. a) The agency failed to provide wound care measurements weekly as ordered by the physician. Review of the plan of care dated 3/19/22 revealed Patient #3 was to receive wound care twice weekly for a wound on the left heel. The wound care orders were as follows; SN to perform pressure ulcer injury care to the left heel twice a week; Cleanse with wound cleanser, apply silver gel, cover with foam dressing using clean technique. The SN was ordered to measure the wound weekly. Review of the clinical record for Patient #3 revealed that the agency obtained wound measurements on 3/19/22 and 3/22/22. Further record review revealed that the no wound measurements were taken on the following SN visits; 3/29/22, 4/1/22, 4/4/22, and 4/8/22. There was no evidence the agency had measured Patient #3's wound weekly as ordered for two weeks. During interview on 5/3/22 at 12:47 p.m., the LPN #4 stated she had not taken any wound measurements during the visits she made to Patient #3. The LPN went on to state the electronic medical record (EMR) system usually alerted her when to take wound measurements but it was not happening for this patient. The LPN stated she had realized she had not taken any wound measurements and meant to measure the wound on the visit 4/8/22, however she did not.