Every finding on record at Total Care of North Carolina - Shelby

An onsite complaint investigation survey was conducted on February 8-9, 2021. The complaint was substantiated and a standard level deficiency was identified. NC00173400

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, staff interviews, hospital case manager interview, and physician office interview, the agency failed to follow the plan of care regarding visit frequency and changing an indwelling catheter in 1 of 1 patients with a catheter (#2). Findings include: A policy, "Care Planning" revised 3/11/20, was provided on 2/9/21 at 2:45 p.m. by the agency director. The policy stated, "Care will be planned to ensure effective utilization of services/resources. The total number of visits/hours provided will be appropriate to the care required/ordered." Patient #2 was admitted on 1/3/19 with diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and bladder neck obstruction. The Plan of Care (POC) of 10/22/20-12/20/20 contained orders for skilled nursing 1 time per week for 2 weeks, and once every 3 weeks for 6 weeks. The POC for 12/21/20-2/18/21 contained orders for skilled nursing 1 time for 1 week, 1 time every 3 weeks for 6 weeks, then 1 time every 2 weeks for 2. The POCs also included orders for the catheter to be changed every 21 days and as needed for "dislodgment or stoppage, and obtain a urine specimen as indicated." A skilled nurse visit was made on 12/16/20. RN #1 changed the indwelling catheter without difficulty noted. A Coordination Note on 1/6/21 revealed a skilled nurse missed visit due to "COVID exposure." The physician's office was notified and orders were obtained for "[skilled nurse] to change catheter on Thursday or Friday of next week due to COVID exposure" (1/14/21 pr 1/15/21). On 1/10/21, a Coordination Note stated, "Patient called the on-call answering service reporting that his catheter was leaking. Called and spoke with patient and his wife, patient states that the leakage is coming from the bottom of the foley bag ...Patient requesting an appointment with his nurse tomorrow. Patient also verbalized that he has had recent contact with someone who has COVID. On 1/14/21, a Coordination Note stated, "Received call from _______ in Dr. _______ office-stating pt has not [seen home health] ...Main problem is catheter pain-needs to be seen asap-spoke with ____RN-she will call [patient] to eval situation." The nurse did not visit on 1/14/21 or 1/15/21 as ordered by the physician. No skilled nursing visit until 2/1/21. RN #1 conducted the visit but did not change the catheter. On 2/8/21, hospital records show the patient was "brought in by EMS with fever and abdominal pain with chronic indwelling Foley. Patient with large amount of blood in his Foley bag." An interview with RN #1 was conducted on 2/8/21 at 4:55 p.m. RN #1 stated the patient was to have catheter changes every 21 days. The patient was non-compliant with leg bags for the catheter and often carried the catheter drainage bag hung on his pocket. The RN stated the visit on 1/6/21 was moved because the patient's family member had COVID. Interview revealed LPN #2 on 2/9/21 at 8:45 a.m. she had talked with the family on 1/11/21 and the patient was having pain and blood in the urine. RN #1 stated, "I dropped the ball on documenting." The RN confirmed she did not change the catheter on 2/1/21 because the patient told her "it was changed the week before." She did not ask the patient where it was changed or who changed it. There was no follow-up with the physician to notify the agency did not change the catheter per the POC. An interview with LPN #2 was conducted on 2/9/21 at 8:45 a.m. The LPN stated she was supposed to see the patient for a catheter change on 1/6/21. She called on 1/5/21 to schedule the visit. On 1/6/21, the family called and canceled the visit due to COVID. The LPN notified the physician office and obtained an order to change the catheter on 1/14/21 or 1/15/21. She entered the order and put the visit on the schedule. She stated she received a call on Sunday (1/10/21). The family called back on 1/11/21 stating the patient had gone the emergency department. On 2/9/21, an interview was conducted with nurse from the physician office. The nurse stated the office had called the patient on 1/14/21 to follow-up on COVID positive status and was told the home health nurse had not been out and the patient had been to the hospital 3 prior to have his bag changed. The nurse was unclear if the bag was changed or if the catheter had been changed. An interview with the family caregiver was conducted on 2/9/21 at 9:15 a.m. The caregiver confirmed the patient had been to the emergency department on January 11. 2021 but was unsure if the catheter was changed or if just the bag was changed. The family stated the patient would go to short term rehab after the hospitalization. An interview with the Hospital Case Manager was conducted on 2/9/21 at 9:25 a.m. The Case Manager stated the patient was hospitalized with a urinary tract infection. She confirmed that only the catheter drainage bag was changed during the 1/11/21 emergency department visit.