Every finding on record at VNA Home Health & Hospice

Federal Complaint # 108084 Onsite survey date: 08/26/2024 Glossary/Definitions: AVP = Assistant Vice President RLQ = Right Lower Abdominal Quadrant RN = Registered Nurse SN = Skilled Nursing A complaint survey was conducted at Northern Light Home Care & Hospice, a Home Health Agency, to evaluate compliance with 42 Code of Federal Regulations ("CFR"), Part 484, Condition of Participation ("CoP"): Skilled Professional Services (§484.75). This survey determined the hospital was in substantial compliance with 42 CFR, Part 484, CoP: Skilled Professional Services. However, the following standard level deficiencies were identified.

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 document reviews, interviews, and observations, the home health agency failed to ensure wound packing material was removed from a patient’s wound when indicated for one (1) out of ten (10) patients reviewed (Patient #1). This failure led to the wound packing material becoming retained inside of the wound as it healed, which ultimately led to Patient #1 requiring surgery to remove the retained wound packing material. Findings: Northern Light Home Care & Hospice’s procedure for wound packing “Evidence Tag G710 Skills_Wound Packing (Home Health Care),” (no date), states in part, “…Gently remove the tape and old dressing…” “…Assess for the presence of drainage on the old material. Place soiled materials in a plastic bag…” “…Remove gloves, clean hands, and don clean gloves…” “…Clean the wound with a sterile 0.9% sodium chloride solution or another solution ordered by the practitioner…” “…Assess the characteristics of the wound, including drainage, color, size, presence of odor, and signs and symptoms of infection. Use a sterile cotton-tipped applicator and ruler to measure the width, depth, and length of the wound, including any areas of tunneling and undermining…” “Dispose of all soiled dressings, supplies, or single-use equipment in a waterproof bag…” “…Document the procedure in the patient’s record…” Northern Light Home Care & Hospice’s Wound Assessment policy, last revised 03/27/2024 states in part, “…Wound Care: document wound care provided as indicated by the plan of care…” “…Instructions given: document teaching done with patient/caregiver and subject of teaching…” A review of Patient #1’s medical record revealed the patient had a gunshot wound in his/her right lower quadrant of his/her abdomen and was referred to Northern Light Home Care & Hospice following hospitalization for his/her injuries. Patient #1’s medical record revealed that he/she began receiving home health care services from Northern Light Home Care & Hospice on 02/05/2024. The review of Patient #1’s medical record revealed an order for wound care dated 02/05/2024 and signed by PA #1. The order stated in part, “…Traumatic Wound: RLQ Abdominal wound – gun shot – to clean with normal saline and or vashe, lightly pack with ¼ inch iodoform packing strips, covering with gauze and secure with tape. To change daily – Patients [family member] to complete when SN [Skilled Nursing] not in home…” “…Assess wound location, size, stage, drainage, wound bed, and peri-wound area…” The review of Patient #1’s medical record revealed the patient had Skilled Nursing home health visits on the following dates: 02/05/2024, 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/19/2024, 02/22/2024, 02/26/2024, 02/29/2024, 03/04/2024, 03/11/2024, 03/18/2024, 03/25/2024, 04/03/2024, 04/10/2024, 04/17,2024, 04/23/2024, & 04/30/2024. The review of Patient #1’s medical record did not reveal documentation indicating how many individual pieces of wound packing material were packed into Patient #1’s right lower quadrant abdominal wound during each episode of wound care, nor did the medical record reveal documentation indicating how many individual pieces of old wound packing material were removed from the patient’s wound during each episode of wound care. Patient #1’s medical record did not reveal documentation indicating what specific education was provided to the patient and family regarding the procedure for packing wounds, nor the importance or removing old wound packing material during wound care, nor the risks associated with failure to ensure old packing material was removed from wounds. Patient #1’s medical record contained an entry by RN #2 on 03/18/2024 which stated in part, “…patients [family member] is managing dressing changes when sn not in home, no issues noted…” Patient #1’s medical record revealed the patient was discharged from home health services on 04/30/2024. The review of Patient #1’s medical record revealed an Operative Note written by Surgeon #1 on 06/28/2024 which stated in part, “…Attention was now directed towards the right lower quadrant gunshot wound site. Initial attempts at aspirating fluid were unsuccessful. A cruciate incision was therefore made at this point using an 11 blade. Through this some purulent appearing fluid was seen…” “…I was able to digitize the cavity using my pinky. At this point in time I identified what felt like a foreign substance. This was grasped using a DeBakey and when extracted appeared to be 1 ft of previously placed packing gauze from the time of [his/her] wound care several months prior…” During an interview with the Assistant Vice President for Home Health (AVP-Home Health) on 08/26/2024 at 11:26 AM, the AVP-Home Health stated the home health agency was seeing Patient #1 for services after [he/she] was seen at the hospital for a gunshot wound to the abdomen. The AVP-Home Health stated the patient’s [family member] was involved in the patient’s care, and was completing wound care on the days the home health nurses weren’t seeing the patient. The AVP-Home Health indicated that the agency admitted Patient #1 on 02/05/2024 and discharged Patient #1 on 04/30/2024. The AVP-Home Health stated after being discharged, Patient #1 had gone back into the hospital for a [procedure] and stated that during the procedure the packing was discovered. The AVP-Home Health stated since the home health agency was providing wound care and the patient’s [family member] was also providing wound care, they were not able to determine who had left the packing in the patient’s wound. During an interview with RN #1 on 08/26/2024 at 11:43 AM, they stated the home health agency’s charting system did not show a specific number indicating how many dressings or materials were packed into Patient #1’s wounds during wound care visits. During an interview with RN #1 on 08/26/2024 at 11:46 AM, they indicated that no actions have been taken as of 08/26/2024 (the date of the initiation of the survey) to ensure wound packing materials will not be inappropriately left in another patient’s wound in the future. RN #1 confirmed on 08/26/2024 at 11:47 AM that counting the number or lengths of dressings or materials packed into a wound has not yet been addressed with agency staff since the incident involving Patient #1. RN #1 indicated that the plan was to address this incident with agency staff after 09/30/2024. During an interview with Wound Care Nurse #1 on 08/26/2024 at 3:22 PM they stated that staff did not document how many pieces of packing material were packed into wounds. Wound Care Nurse #1 stated that the nurse would just document that, “the wound care was provided as ordered.” They stated sometimes the packing material would be documented as removed, but stated it hadn’t been something that was required. On 08/26/2024 at 3:30 PM Wound Care Nurse #1 stated caregivers and patients did not receive education regarding the risk of retained packing materials in wounds. Wound Care Nurse #1 stated the risks associated with failing to remove wound packing materials and leaving the packing materials inside of the wound would include, “infection,” and “necrosis of tissues.” Wound Care Nurse #1 stated that patients and family members were not educated regarding these risks because the intention was to never leave packing materials inside of a wound.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on document reviews, interviews, and observations, the home health agency failed to provide discharge instructions for two (2) out of seven (7) records reviewed for patients who were discharged from home health services (Patient #1 & Patient #6). Findings: Northern Light Home Care & Hospice’s policy titled, “Discharge Instructions,” last revised 11/21/2023 states in part, “…The clinician will complete the form prior to or upon the last visit made to the patient whenever possible and will provide a copy of the discharge instructions to the patient…” A review of Patient #1’s medical record revealed the patient was discharged from home health services on 04/30/2024. The review of Patient #1’s medical record revealed there were no discharge instructions in the medical record for Patient #1’s 04/30/2024 discharge. RN #1 confirmed on 08/26/2024 at 12:16 PM that they reviewed Patient #1’s medical record and confirmed that there were no discharge instructions in the medical record for Patient #1’s 04/30/2024 discharge from home health services. A review of Patient #6’s medical record revealed the patient was discharged from home health services on 08/19/2024. The review of Patient #6’s medical record revealed there were no discharge instructions in the medical record for Patient #6’s 08/19/2024 discharge. RN #1 confirmed on 08/26/2024 at 1:49 PM that there were no discharge instructions in the medical record for Patient #6’s 08/19/2024 discharge.