Every finding on record at Vital Point Corporation

Purpose of visit: Recertification/Relicensure and Follow up survey (05/19/2018) Entrance Date: 03/16/2021 at 10:52 AM with the Administrator/RN, Identifier A, the Alternate Administrator/RN, Identifier B, and the Director of Nursing/RN, Identifier C. Agency Census: 185 Licensed and Certified clients - 39 Licensed Home Health - 0 Personal Assistance Services - 146 Exit Date: 03/18/2021 at 2:57 PM with the Administrator, Identifier A, the Alternate Administrator, Identifier B, the Director of Nursing/Registered Nurse, Identifier C, the Secretary, Identifier D, and the Office Manager, Identifier E. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies." The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of visit: Recertification/Relicensure and Follow up survey (05/19/2018) Entrance Date: 03/16/2021 at 10:52 AM with the Administrator/RN, Identifier A, the Alternate Administrator/RN, Identifier B, and the Director of Nursing/RN, Identifier C. Agency Census: 185 Licensed and Certified clients - 39 Licensed Home Health - 0 Personal Assistance Services - 146 Exit Date: 03/18/2021 at 2:57 PM with the Administrator, Identifier A, the Alternate Administrator, Identifier B, the Director of Nursing/Registered Nurse, Identifier C, the Secretary, Identifier D, and the Office Manager, Identifier E. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies." The agency was in compliance with the Conditions of Participation for Home Health Agencies with a standard level deficiency cited. Abbreviations: SN - Skilled Nurse POC - Plan of Care SOC-Start of Care # - number RN - Registered Nurse OASIS - Outcome Assessment Information Set lbs - pounds LVN - Licensed Vocational Nurse DON - Director of Nurses TULIP - Texas Unified Licensure Information Portal PRN- as needed PRS-pressure CHR-chronic MIDFT-midfoot W-with MD-Medical Doctor >-greater than HYP-Hypertensive HRT-Heart &-and KDNY-Kidney DIS-Disease FAIL-Failure STG-Stage UNSP-Unspecified OTH-Other PRT-Part R-Right BRKDWN-Breakdown ABD-Abdominal BLE-Bilateral Lower Extremities X-Times WK-Week

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 record review, observation and interview, the agency failed to furnish skilled nursing services in conformance with physician orders, in that: 1. In two (Patient # 1 and 5) of two patients with an order for wound care, the SN failed to provide wound care only as ordered by the physician. 2. In two (Patients #2 and 5) two patients with a weight gain/loss that was not within the physician ordered parameters, the SN failed to report to the physician as ordered. The failures placed Patients # 1, 2, and 3 at risk to have a decline in their health condition, an exacerbation of their disease processes and/or a lack of physician oversight for their skilled nursing care. FINDINGS INCLUDED: Clinical Record Review # 1: The clinical record for Patient # 1 contained a Plan of Care (POC) with a start of care (SOC) date of 06/17/2020. The POC had a certification period 12/14/2020 to 02/11/2021 and a diagnosis of Non-prs chronic ulcer oth prt r foot limited to brkdwn skin and Pressure ulcer of other site, stage 2. The POC contained an order for skilled nurse (SN) frequency, "2wk9" (2 times a week for 9 weeks). The POC was electronically signed and dated 01/19/2021 by Physician (Identifier P3). The POC contained orders for the following: 1. "SN to perform wound care separately as follows. Wound #1 Right posterior lower leg SN to cleanse and protect the wound as follows: Cleanse wound with Dakin's solution, apply collagen, apply Mupirocin ointment to wound bed only-apply first. Apply hydrofera, cover wound with ABD, secure dressing with Kling, followed by cloth tape." HH skilled nurse to change dressing 2x (2 times) weekly. Compression: BLE starts above toes to just below knees apply amlactin lotion first change two times per week ...SN to assess skin Q(every) visit for breakdown ...notify MD immediately ..." "Skilled Nurse Visit" note dated 12/14/2020 electronically signed by LVN A contained an area titled "Visit Narrative " LVN A documented "patient with new wounds wound #3 pressure stage 2, right index finger, wound #4 pressure ulcer stage 2 to left index finger, wound #5 left pressure ulcer stage 2 to palm hand. The visit note contained an area titled "Wound Care Flowsheet" LVN A documented "cleansed each wound with wound cleanser pat dried applied collagen, covered with a dry dressing and secured with tape." Patient #1 had 3 new wounds. The 12/14/2020 visit note had an area titled "Care Coordination" there was not any notation in the area that LVN A had notified the patient's physician. The clinical record did not include a communication note that documented any communication with Patient #1's physician. LVN A did not apply Mupirocin ointment, hydrofera, or perform compression to BLE. LVN A failed to follow wound care orders. New Order dated 12/15/2020 read in part as follows: 1. Wound #1 Right posterior lower leg SN to cleanse and protect the wound as follows: Cleanse wound with Dakin's solution, apply collagen, apply Mupirocin ointment to wound bed only-apply first. Apply hydrofera, cover wound with ABD, secure dressing with Kling, followed by cloth tape." HH skilled nurse to change dressing 2x (2 times) weekly. Compression: Tubigrip-BLE starts above toes to just below knees apply amlactin lotion first change two times per week. 2. Wound #4 Right Plantar Foot cleanse with wound cleanser, pat dry with gauze. Apply Collagen. Apply Mupirocin ointment to wound bed only apply first. Apply alginate. Cover wound with Bordered Foam .... change dressing 2 x weekly. "Skilled Nurse Visit" notes dated 12/17/2020, 12/24/2020, 12/26/2020, 01/02/02021, 01/07/2021, 01/09/2021, 01/14/2021, 01/16/2021, 01/21/2021, 01/23/2021, and 01/28/2021 electronically signed by LVN A contained an area titled "Wound Care Flowsheet" LVN A documented "cleansed each wound with wound cleanser pat dried applied collagen, covered with a dry dressing and secured with tape." LVN A did not apply Mupirocin ointment or hydrofera to wound #1. LVN A did not Mupirocin ointment and alginate or cover with Bordered Foam to wound #4. LVN A did not perform compression to BLE. LVN A failed to follow wound care orders. New Order dated 01/26/2021 read in part as follows: 1. Wound #1 Right posterior lower leg SN to cleanse and protect the wound as follows: Cleanse wound with wound cleanser, pat dry with gauze, apply collagen, apply Gentamicin ointment to wound bed only. Apply hydrofera, cover wound with ABD, secure dressing with Kling, secure dressing with cloth tape." HH skilled nurse to change dressing 2x (2 times) weekly. Compression: Tubigrip-BLE start above toes to just below knees apply amlactin lotion first. 2. Wound #6 Right Third Toe cleanse with wound cleanser, pat dry with gauze. Apply hydrofera. Cover with gauze. Secure dressing with Kling. .... change dressing 2 x weekly. "Skilled Nurse Visit" note dated 01/30/2021, electronically signed by LVN A contained an area titled "Wound Care Flowsheet" LVN A documented "cleansed each wound with wound cleanser pat dried applied collagen, covered with a dry dressing and secured with tape." LVN A did not apply Gentamicin ointment or hydrofera to wound #1. LVN A did not apply hydrofera wound #6. LVN A did not perform compression to BLE. LVN A failed to follow wound care orders. New Order dated 02/02/2021 read in part as follows: 1. Wound #1 Right posterior lower leg SN to cleanse and protect the wound as follows: Cleanse wound with wound cleanser, pat dry with gauze, apply collagen, apply Gentamicin ointment to wound bed only. Apply hydrofera, cover wound with ABD, secure dressing with Kling, secure dressing with cloth tape." HH skilled nurse to change dressing 2x (2 times) weekly. Compression: Tubigrip-BLE start above toes to just below knees apply amlactin lotion first. 2. Wound #6 Right Third Toe cleanse with wound cleanser, pat dry with gauze. Apply Gentamicin ointment to wound bed only-collagen. Apply hydrofera. Cover with gauze. Secure dressing with Kling. .... change dressing 2 x weekly. "Skilled Nurse Visit" notes dated 02/04/2021 and 02/06/2021 electronically signed by LVN A contained an area titled "Wound Care Flowsheet" LVN A documented "cleansed each wound with wound cleanser pat dried applied collagen, covered with a dry dressing and secured with tape." LVN A did not apply Gentamicin ointment or hydrofera to wound #1. LVN A did not apply Gentamicin ointment or hydrofera wound #6. LVN A did not perform compression to BLE. LVN A failed to follow wound care orders. New Order dated 02/10/2021 read in part as follows: 1. Wound #1 Right posterior lower leg SN to cleanse and protect the wound as follows: Cleanse wound with Dakin's Solution. Apply collagen, apply Gentamicin ointment to wound bed only. Apply hydrofera, cover wound with Bordered Gauze. HH skilled nurse to change dressing Monday, Wednesday, and Friday. Compression: Tubigrip-BLE start above toes to just below knees apply amlactin lotion first. 2. Wound #6 Right Third Toe cleanse with Dakin's Solution. Apply Gentamicin ointment to wound bed only-collagen. Apply hydrofera. Cover with gauze. Secure dressing with Kling. .... change dressing Monday, Wednesday, and Friday. 3. Wound #7 Left Lower Leg cleanse wound with Dakin's Solution. Apply Gentamicin ointment to wound bed only. Cover with Bordered Foam. SN to change dressing Monday, Wednesday, and Friday. "Skilled Nurse Visit" notes dated 02/11/2021 electronically signed by LVN A contained an area titled "Wound Care Flowsheet" LVN A documented "cleansed each wound with wound cleanser pat dried applied collagen, covered with a dry dressing and secured with tape." LVN A did not apply Gentamicin ointment or hydrofera and did not use Bordered Gauze to wound #1. LVN A did not apply Gentamicin ointment or hydrofera wound #6. LVN A did not perform compression to BLE. LVN A failed to follow wound care orders. LVN A did not apply Gentamicin ointment or use Bordered Foam on Wound #7 Clinical Record Review # 2: The clinical record for Patient # 2 contained: A Plan of Care (POC) with a start of care (SOC) date of 01/07/2021. The POC had a certification period 01/07/2021 to 03/07/2021 and a diagnosis of Hyp hrt & chr kdny dis w hrt fail and stg 1-4/unsp chr kdny. The POC contained an order for skilled nurse (SN) frequency, "1wk9" (1 time a week for 9 weeks). The POC was electronically signed and dated 01/19/2021 by Physician (Identifier P2). The POC contained orders for the following: 1. "SN to notify MD ... ...report Wt. >3/b weekly." The "Skilled Nurse Visit" note dated 02/22/2021 and electronically signed by LVN A contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN A recorded the weight as 280 pounds. The "Oasis-D1 Recertification" note dated 03/05/2021 and electronically signed by Administrator/RN, Identifier A contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. Administrator/RN, Identifier A recorded the weight as 308 pounds. Patient #2 had a weight gain of 28 pounds in one week. The 03/05/2021 visit note had an area titled "Care Coordination" there was not any notation in the area that Administrator/RN, Identifier A notified the patient's physician. The clinical record did not include a communication note that documented any communication with Patient #2's physician. Clinical Record Review # 5: The clinical record for Patient # 5 contained: A Plan of Care (POC) with a start of care (SOC) date of 08/29/2020. The POC had a certification period 12/27/2020 to 02/24/2021 and a diagnosis of Non-prs chr ulcer of right heel and midft w fat layer expos. The POC contained an order for skilled nurse (SN) frequency, "1wk1,2wk3,1wk5 " (1 time a week for 1 week, 2 times a week for 3 weeks then 1 time a week for 5 weeks). The POC was electronically signed and dated 01/07/2021 by Physician (Identifier P2). The POC contained orders for the following: 1. "SN to notify MD Wt. >3/b weekly." 2. " SN to perform foot assessment and foot care q visit .....to include wound size." "Skilled Nurse Visit" note dated 01/07/2021 and electronically signed by LVN B contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN B recorded the weight as 288 pounds. The "Skilled Nurse Visit" note dated 01/14/2021 and electronically signed by LVN B contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN B recorded the weight as 386 pounds. Patient #5 had a weight gain of 102 pounds in one week. The 01/14/2021 visit note had an area titled "Care Coordination" there was not any notation in the area that LVN B notified the patient's physician. The clinical record did not include a communication note that documented any communication with Patient #5's physician. "Skilled Nurse Visit" note dated 01/21/2021 and electronically signed by LVN B contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN B recorded the weight as 387 pounds. The "Skilled Nurse Visit" note dated 01/28/2021 and electronically signed by LVN B contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN B recorded the weight as 390 pounds. Patient #5 had a weight gain of 3 pounds in one week. The 01/28/2021 visit note had an area titled "Care Coordination" there was not any notation in the area that LVN B notified the patient's physician. The clinical record did not include a communication note that documented any communication with Patient #5's physician. "Skilled Nurse Visit" note dated 02/18/2021 and electronically signed by LVN B contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. LVN B recorded the weight as 390 pounds. The "Oasis-D1 Recertification" note dated 02/23/2021 and electronically signed by DON/RN, Identifier C contained an area titled "Vital Signs" which contained a space for the skilled nurse to record the weekly weight. DON/RN, Identifier C recorded the weight as 395 pounds. Patient #5 had a weight gain of 3 pounds in one week. The 02/23/2021 visit note had an area titled "Care Coordination" there was not any notation in the area that DON/RN, Identifier C notified the patient's physician. The clinical record did not include a communication note that documented any communication with Patient #5's physician regarding the weight gain. The surveyor reviewed Patient 5's "Skilled Nurse Visit" notes signed by LVN B. The notes were dated 12/28/20, 1/7/21, 1/14/21, 1/21/21, 1/28/21, 2/4/21, 2/11/21, and 2/18/21. Reviewed "Oasis-D1 Recertification" note electronically signed by Alternate Administrator/RN, Identifier B dated 2/23/21. Patient 5's "Skilled Nurse Visit" and "Oasis-D1 Recertification" notes did not include foot care or wound size as ordered on the POC. During an interview with the DON/RN, Identifier C, Alternate Administrator/RN, Identifier and Administrator/RN, Identifier A on 03/18/2021 at approximately 2:15 p.m., the surveyor discussed the above findings and asked: 1. Why LVN A did not follow wound care orders for Patient #1. Identifier C replied, "The nurse seems to be copying previous notes each visit and we will make sure to in-service the nurses. 2. Did LVN A notify the physician regarding the new wounds on 12/14/2020? Identifier C replied, "No, because the Nurse Practitioner sees the patient once a week. The nurse probably thought the Nurse Practitioner was aware of the new wounds." 3. Did Administrator/RN, Identifier A report the weight gain greater than 3 pounds in a week on 03/05/2021 for Patient #2? Identifier C, asked Identifier A was the weight gain reported? Identifier A replied, "The weight documented was an error." Identifier C told the surveyor "The weight documented was an error." 4. Did LVN B measure the wounds weekly for Patient #5? Identifier C replied, "It was an oversight." 5. Did LVN B report weight gain of 102 pounds in one week on 01/14/2021 and the weight gain of 3 pounds in one week on 01/28/2021 for Patient #5? Identifier C replied, "The nurse documented the wrong weights." 6. Did Identifier C report the weight gain greater than 3 pounds in a week on 02/23/2021 for Patient #5? Identifier C replied, "The nurse documented the wrong weights." Agency policy titled "Orders for Care PC.7" revised 110120 read in part: "The Agency will obtain orders and provide care in accordance with physician's and/or non-physician practitioners orders which are established prior to initiating patient/client care ...All orders are kept current and renewed or updated as appropriate when: Changes in patient's/client's condition occur; The ordered care is ineffective; Changes in diagnosis, treatment (including procedures and medications), and equipment occur; Desired goals are not being achieved; Required by applicable law and regulation ....."