Every finding on record at Wake Forest Baptist Health Care at Home, LLC

An onsite complaint investigation was conducted. The allegations were unsubstantiated but deficiencies to the Medicare Conditions of Participation were identified.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to follow up with the physician for 1 of 1 patient that had a decline in condition (#1); to notify the physician of patient’s non-compliance with medication for 1 of 3 patients reviewed (#3); and to notify the physician of the inability to obtain blood as ordered from an implanted port for 1 of 1 patient with an implanted port (#3). Findings included: A policy, Coordination of Care—Case Conference (revised 11/22), was provided by the Area Director of Operations on 1/17/23 at 1:06 p.m. The policy stated, “Communicate with the patient’s physician/allowed practitioner must occur regarding the patient’s progress or lack of progress toward established goals, significant changes in condition, identification of new problems and coordination of orders from any consulting physician/allowed practitioner.” A policy, Care Planning (revised 9/22), was provided by the Area Director of Operations on 1/17/23 at 1:06 p.m. The policy stated, “The home health agency will notify the physician/allowed practitioner, patient, patient representative (if any) and caregiver if changes are identified in the patient’s condition and obtain physician orders to add or change the current patient POC [plan of care].” 1. Patient #1 was admitted on 9/9/22 with a diagnosis of hypertensive heart and chronic kidney disease. The Plan of Care for 11/8/22-1/6/23 included orders for physical therapy twice weekly for three weeks and weekly for six weeks. The physical therapist conducted a recertification visit on 11/3/22. The note revealed patient #1 was walking with standby assistance using a front wheeled rolling walking for approximately 20 feet. On 12/8/22, PTA #1 conducted a visit. The caregiver reported the patient hallucinated and had “other odd behaviors.” The caregiver also reported the patient had a fall on 12/7/22. The patient reported pain level of 10 on a pain scale of 0 to 10. The pain was on the entire left side of the body. The note stated, “…[patient] refused to perform any task that require moving…PTA contacted [physical therapist] and informed of current situation. The caregiver reported the patient had a urinary tract infection [UTI]. However, the patient had not seen a physician or nurse for symptoms of UTI. The patient’s daughter informed the PTA that she had been administering antibiotics to the patient. [Physical therapist] spoke with caregiver on the phone. [Physical therapist] will contact PCP [primary care provider] to inform of fall and request orders for a urine sample.” The PTA visited the patient on 12/12/22. The patient reported left foot pain. The note stated, “[Patient] was confused and talking out of her head/hallucinating…” The patient performed a stand and pivot transfer during the visit, but did not walk. On 12/20/22, PT #2 conducted a reassessment visit. The patient expressed concern that she may have pneumonia. The visit note also stated, “The patient did have a fall 12/7 with AMS [altered mental status]. Family suspected UTI [urinary tract infection] and administered Bactrim [antibiotic] medication left over from previous UTI. [Physical therapist] contacted PCP office about this on 12/9/22. The patient’s caregiver reports the patient has had improved mobility and cognition, [sic] however she has not returned to baseline. The patient has required increased encouragement to participate with [physical therapy], and has declined walking activity. [Physical therapist] contacted PCP office again today to give report…].” The note also stated that the patient/caregiver “had not heard back from PCP” related to the initial report of a change in condition reported on 12/9/22. An interview with PTA #1 on 1/17/23 at 1:35 p.m. confirmed the patient had declined walking since the fall on 12/7/22. The PTA also stated that she was unaware if the urinalysis was ordered or obtained. She confirmed that she did not contact the physician’s office regarding the patient status. She confirmed that the physical therapist planned to contact the physician on 12/8/22 regarding the fall and possible urinary tract infection. PCP notes for 12/9/22 revealed that “…physical therapist with [name of agency] is requesting an order for a urine analysis. Daughter gave patient Bactrim and patient seem to be doing better (urine seems clearer), however patient fell yesterday. In addition, patient seems fatigued. [Physical therapist] reports that the daughter cannot get the patient out of the house.” There was no evidence of coordination with the physician between 12/10/22 and 12/20/22 related to hallucinations, self-treatment for UTI, or patient’s refusal to walk. PTA #1 visited patient on 12/28/22. The caregiver reported the patient did not go to PCP visit the prior week “due to [patient] refusing to get out of bed.” On 1/5/23, the agency completed a transfer assessment. Hospital records revealed the patient was taken to the emergency department via EMS on 12/31/22. The patient was diagnosed with acute fractures of the second through fifth metatarsal (foot) bones. The report noted swelling of soft tissue. The patient was admitted to the hospital from 12/31/22-1/7/23. Then discharged to a skilled nursing facility. 2A. Patient #3 was admitted on 10/7/22 with a diagnosis of infection/inflammation of left knee prosthesis. The Plan of Care (POC) for 10/7/22-12/5/22 included orders for skilled nursing one time for one week, three times per week for one week, then weekly for eight weeks. The POC also included orders for enoxaparin (Lovenox—used to prevent blood clots) 40 mg subcutaneously daily. On 10/24/22, the visit note from RN #2 stated, “Patient said she does not take her Lovenox shots every day. States that it makes her very light-headed, and does not want to fall [sic].” On 11/7/22, RN #2 stated, “Patient reports try is trying to lean [sic] off narcotics, and having stopped taking her sub q [subcutaneous] blood thinner due to Tylenol not helping and needing to take Advil instead. Patient’s doctor is aware.” There was no evidence that the RN notified the physician regarding the non-compliance with the enoxaparin on 10/24/22 or 11/7/22 visits. An interview with the agency director on 1/7/23 at 4:08 p.m. confirmed there was no evidence the physician was notified of the non-compliance with the medication used to prevent blood clots. 2B. Patient #3 was admitted on 10/7/22 with a diagnosis of infection/inflammation of left knee prosthesis. The Plan of Care (POC) for 10/7/22-12/5/22 included orders for skilled nursing one time for one week, three times per week for one week, then weekly for eight weeks. The POC also included orders for “Skilled nurse to collect blood specimen for [labs] via port a cath on Mondays…” On 10/10/22, RN #2 documented, “Performed venipuncture in right ac [antecubital space—area in the bend of the elbow]…” Venipuncture for labs was also performed on 10/17/22, 10/24/22, 10/31/22, 11/1/22, and 11/7/22. The nurse documented there were problems with blood return from the implanted port. There was no evidence the nurse notified the physician of the inability to obtain blood from the port as ordered. An interview with the agency director on 1/7/23 at 4:08 p.m. confirmed there was no evidence the physician was notified of the inability to obtain blood from the implanted port.