Every finding on record at Thibodaux Regional Health System, Inc

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

Recertification Survey.

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, interviews, and record reviews, the agency failed to ensure patient medications were reconciled for 2 (Patient #7, Patient #12) of 7 (Patient #1, Patient #2, Patient #4, Patient #5, Patient #6, Patient #7, Patient #12) sampled patients reviewed for medication reconciliation. Findings: Patient #7 Review of Patient #7’s Home Health Certification and Plan of Care for the certification period of 11/24/2024 through 01/22/2025 revealed Patient #7 was to receive skilled nursing services twice a week for eight weeks. Review of Patient #7’s Medication Profile dated 01/28/2025 revealed, in part, an order for Tramadol (medication used to treat pain) 50 milligrams (mg) one tablet every six hours as needed for pain. Observation on 01/29/2025 at 10:06AM revealed Patient #7’s Tramadol 50mg one tablet twice a day as needed for pain with a prescription fill date of 12/23/2024. In an interview on 01/29/2025 at 10:06AM, Patient #7 confirmed the prescription label was the current order for Tramadol twice a day, which was different from Patient #7’s medication profile. In an interview on 02/03/2025 at 1:52PM, S1Administrator/Director of Nursing (DON) indicated the nursing staff should have identified the change in order for Patient #7’s Tramadol order and reconciled the medication list. Patient #12 Review of Patient #12’s Home Health Certification and Plan of Care for the certification period of 12/31/2024 through 02/28/2025 revealed Patient #12 was to receive skilled nursing services twice a week for three weeks, then once a week for six weeks. Review of Patient #12’s Physician Progress Note dated 01/09/2025 revealed Patient #12’s medication list included, in part, Ropinirole (generic name for Requip) (medication used to treat parkinson’s disease) 0.25 mg administer one tablet at bedtime. Review of Patient #12’s Medication Profile dated 01/28/2025 revealed no documented evidence Requip was documented as a current medication. Observation on 01/29/2025 at 11:50AM revealed Patient #12 had Requip 0.25 mg one tablet by mouth every night with a prescription date fill date of 01/16/2025. In an interview on 01/29/2025 at 11:50AM, Patient #12’s caregiver confirmed Patient #12 was currently receiving Requip and had been on the Requip for quite some time. In an interview on 02/03/2025 at 2:04PM, S1Administrator/DON indicated the agency did not capture the Requip on Patient #12’s medication profile and should have.

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 interviews and record reviews, the agency failed to: 1. Ensure the skilled nurse assessed daily weights per the patient’s plan of care (Patient #7); 2. Ensure the skilled nurse provided care and services per the frequency and specifications of the plan of care (Patient #9); and, 3. Ensure the skilled nurse obtained vital signs during the skilled nurse visit per the plan of care (Patient #13). This deficient practice was identified for 3 (Patient #7, Patient #9, Patient #13) of 17 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17) sampled patients reviewed for care and services per the plan of care. Findings: Patient #7 Review of Patient #7’s Home Health Certification and Plan of Care for the certification period of 11/24/2024 through 01/22/2025 revealed Patient #7 had a diagnosis of, in part, Chronic Diastolic Heart Failure (condition in which the patient’s heart does not pump effectively). Further review revealed, in part, Patient #7 was to receive skilled nurse services twice a week for eight weeks and the skilled nurse was to notify the physician of a weight gain of 2-3 pounds in one day or 5 pounds in a week and was symptomatic. Review further revealed if Patient #7 was unable to weigh, notify the physician of other symptoms of fluid retention. Review of Patient #7’s record revealed the following, in part: 11/29/2024 Patient #7 was able to ambulate with a walker, and the skilled nurse documented Patient #7 was able to ambulate, and the skilled nurse documented Patient #7 was not weighed daily; 12/11/2024 Patient #7 was able to ambulate with a walker, and the skilled nurse documented Patient #7 was not weighed today; 12/13/2024 Patient #7 was not weighed daily; 12/18/2024 Patient #7 was not weighed daily; 12/20/2024 no documentation of Patient #7’s weight; 12/25/2024 Patient #7 ambulated on the skilled nurse’s arrival, and no documentation of Patient #7’s weight; 01/01/2025 Patient #7 was not weighed daily; and, 01/08/2025 Patient #7 able to ambulate, and the skilled nurse documented Patient #7 was not weighed today. In an interview on 02/03/2025 at 1:52PM, S1Administrator/Director of Nursing (DON) indicated per Patient #7’s plan of care, daily weights should be obtained daily unless unable to stand. The skilled nurse should review the daily weights and notify the physician per the plan of care for weight gains. S1Administrator/DON further indicated if Patient #7 had not weighed himself, the skilled nurse should have weighed Patient #7 or documented if Patient #7 was refused to get weighed. Patient #9 Review of Patient #9’s Home Health Certification and Plan of Care for the certification period of 12/31/2024 through 02/28/2025 revealed, in part, Patient #9 was to receive skilled nursing services twice a week for three weeks. Review of Patient #9’s record revealed the week of 01/05/2025 through 01/11/2025 Patient #9 had a completed skilled nurse visit on 01/08/2025; however, the skilled nurse visit on 01/09/2025 was a non-billable visit because the skilled nurse only provided care to read a skin test for tuberculosis, and did not perform a skilled nursing visit per the plan of care. There was no documented evidence, and the agency presented no documented evidence, Patient #9 had a complete skilled nurse visit per the plan of care for the week of 01/05/2025 through 01/11/2025. In an interview on 02/03/2025 at 4:02PM, S1Administrator/DON indicated the agency did not have any documented evidence Patient #9 received a second complete skilled nurse visit the week of 01/05/2025 through 01/11/2025. Patient #13 Review of Patient #13’s Home Health Certification and Plan of Care for the certification period of 11/01/2023 through 12/30/2023 revealed, in part, the skilled nurse was to obtain and notify the physician of vital signs outside of the following parameters: systolic blood pressure (top number of a blood pressure) of greater than 150 millimeters of mercury (mmHg) or less than 90 mmHg and symptomatic; diastolic blood pressure (bottom number of a blood pressure) of greater than 90 mmHg or less than 40 mmHg and symptomatic; heart rate of greater than 100 beats per minute or less than 50 beats per minute; and temperature of greater than 101 degree Fahrenheit. Review of Patient #13’s record revealed no documented evidence, and the agency presented no documented evidence, Patient #13’s blood pressure, heart rate, and temperature had been obtained and documented on Patient #13’s skilled nurse visit dated 11/14/2023. In an interview on 02/03/2025 at 3:55PM, S2Registered Nurse (RN)/Patient Care Coordinator (PCC) indicated she had performed the visit on 11/14/2023 and did not have any documentation of Patient #13’s blood pressure, heart rate, nor temperature documented as required by the plan of care. In an interview on 02/03/2025 at 3:56PM, S1Administrator/DON indicated the above vital signs should have been obtained and documented on the 11/14/2023 visit and were not.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure weekly wound measurements were obtained for 2 (Patient #7 and Patient #16) of 7 (Patient #7, Patient #9, Patient #10, Patient #13, Patient #14, Patient #15, Patient #16) sampled patients reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Patient #7 Review of Patient #7’s Home Health Certification and Plan of Care for the certification period of 11/24/2024 through 01/22/2025 revealed Patient #7 was to receive skilled nursing services for, in part, wound care to the right heel stage III pressure ulcer (wound caused by pressure which extends through the subcutaneous [fat] tissue). Review of Patient #7’s record revealed no documented evidence, and the agency presented no documented evidence, Patient #7’s right heel wound was measured the week of 12/22/2024 through 12/28/2024. In an interview on 02/03/2025 at 1:52PM, S1Administrator/Director of Nursing (DON) indicated the agency did not have evidence of Patient #7’s wound had been measured the week of 12/22/2024 through 12/28/2024. S1Administrator/DON further indicated the nurses should measure wounds weekly. Patient #16 Review of Patient #16’s Home Health Certification and Plan of Care for the certification period of 08/03/2024 through 10/01/2024 revealed Patient #16 was to receive skilled nursing services for, in part, wound care to the right buttock stage II pressure ulcer (wound caused by pressure which extends through the first level of skin). Review of Patient #16’s record revealed no documented evidence, and the agency presented no documented evidence, Patient #16’s right buttock wound was measured the weeks of 09/01/2024 through 09/07/2024, and 09/15/2024 through 09/21/2024. In an interview on 02/03/2025 at 4:00PM, S1Administrator/DON indicated the agency did not have wound care measurements for the above mentioned weeks. S1Administrator/DON further indicated all wounds should be measured weekly.

Complaint Survey #61537

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient received written instructions for a physical therapy home exercise program for 1 (Patient #1) of 5 patients reviewed for therapy services in a total investigation sample of 5. Findings: Review of Patient #1’s Home Health Certification and Plan of Care for certification period of 11/03/2021 to 01/01/2022 revealed physical therapy once a week for one week, then twice a week for four weeks. Further review revealed to teach on transfer techniques, and therapeutic exercise home program. Review of Patient #1’s Record revealed no documented evidence of Patient #1 or Patient #1’s caregivers having received written instructions for a home exercise program. In an interview on 01/26/2022 at 11:07am, S2Physical Therapist (PT) stated she did not provide written instructions for Patient #1’s home exercise program. S2Physical Therapist stated Patient #1 was blind and therefore she did not give written instructions, S2PT stated she educated Patient #1’s family on the home exercise program, however the family could have used the written instructions. In an interview on 01/26/2022 at 1:49pm, S1Director of Professional Services stated per regulations S2PT should have given written instructions to Patient #1 and Patient #1’s caregivers for Patient #1’s home exercise program.