Every finding on record at Western Health Resources

The following reflects the findings of the California Department of Public Health during the investigation of complaint #CA0071246. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 43247 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide continuity of care when one of five patients (Patient 1) was discharged from HH services without follow up arranged for suprapubic catheter (a tube inserted through the abdomen directly into the bladder to drain urine) changes. This failure caused Patient 1 to miss a scheduled suprapubic catheter change which had the potential to cause infection. Findings: A review of Patient 1's "Patient Information Record" indicated she was last referred to the HHA in January 2020 with multiple diagnoses including mitochondrial myopathy (a neuromuscular disease that causes muscle fatigue and weakness), VAD (Ventricular Assist Device -pumps blood from the heart to rest of the body), neuromuscular dysfunction of the bladder (lack of bladder control caused by nervous system disorder), ileostomy (an opening in the skin surface for the small bowel to eliminate waste) and gastrostomy (an opening from the abdominal wall to the stomach). A review of Patient 1's "Home Health Certification and Plan of Care," for certification period 1/17/22 to 3/17/22, indicated: "Frequency/Duration of Visits: SN [Skilled Nurse] 1WK9 [1 times a week for 9 weeks] PLUS 2 PRN [as needed} VISITS MAY BE MADE FOR IV [Intravenous-a tube or needle inserted into a vein], LABS, CATHETER [tube placed into the bladder to drain urine]/OSTOMY [an opening from the inside of the body to the outside] NEEDS/ TROUBLESHOOTING, INTEGUMENT [skin] CHANGES, PAIN, FALLS, OR MEDICATION MANAGEMENT. Orders of Discipline and Treatments: ...SKILLED NURSE TO PERFORM INFUSION ACCESS [IV] SITE CARE FOR INFUSION ASSESS DEVICE...WITH DRESSING CHANGES ONCE A WEEK AND PRN... SKILLED NURSE FOR INSERTION OF SUPRAPUBIC CATHETER MAINTENANCE...CHANGE EVERY 6 WEEKS AND PRN FOR DISLODGMENT OR STOPPAGE, AND OBTAIN URINE SPECIMEN AS INDICATED.... SKILLED NURSE TO COLLECT URINE SPECIMEN FOR UA [urinalysis-evaluation of the urine] AND CULTURE [identify an urinary tract infection with an urine sample] VIA SUPRAPUBIC CATHETER ON EVERY CATHETER CHANGE AND PRN S/S [signs or symptoms] OF INFECTION... Goals/Rehabilitation Potential/Discharge Plans: ...PATIENT/ CAREGIVER WILL VERBALIZE/DEMONSTRATE REQUIRED KNOWLEDGE TO MANAGE URINARY CATHETER CARE AS EVIDENCED CONSISTENT RETURN DEMONSTRATIONS USING PROPER TECHNIQUE AND WILL BE ABLE TO VERBALIZE SIGNS AND SYMPTOMS OF URINARY TRACT INFECTION BY WEEK 8... DC [discharge] Plans: DC TO CARE OF FAMILY UNDER SUPERVISION OF MD [medical doctor] WHEN GOALS ARE MET..." A review of Patient 1's "Client Coordination Note Report," dated 3/15/22, indicated "Reason visit missed: Patient did not want this nurse for visit today. Unable to staff visit with another nurse. Will likely be discharging patient from home health once arrangements have been made..." A review of Patient 1's "Client Coordination Note Report," dated 3/16/22, indicated "...Patient will be closed at the end of her certification period 3/17/22. Patient's parents were aware of this decision and were also aware of the plans for her future service...[PCP-Primary Care Provider] is aware of this closure per conversation with RN [Registered Nurse]...supra pubic catherer needs to be changed this week and [PCP] and home health staff have advised to go to ED [emergency department] for change. Patient needs urologist [a doctor who specializes in treatment of the urinary tract] that takes [patient's insurance]. Suggested [cities outside of local area]. Father says this is too far away at this time..." A review of Patient 1's "Client Occurrence Report," dated 3/16/22, indicated "Father was notified on 3/16/22 via telephone call of discharge...Advised to go to ED for catheter change and attempt to find a urologist that takes her insurance..." A review of Patient 1's "Discharge- Transfer Summary Report," dated 3/16/22, indicated "...Patient no longer wishes to have this nurse for home health, no other nursing staff available. Upon discussion with supervisors and patient's parents, it was decided that all of the care needed for the patient can be completed as outpatient care. Patient will continue with [central line-an IV line in the chest wall], catheter care and labs weekly at the infusion center and per patient's PCP...patient will need to go to ED for catheter changes as they are unable to do them in their office. Patient encouraged to find urologist... Goal Description...Patient tolerated catheter insertion with return of urine...Not Met- Additional time required to meet intervention/goal..." During a telephone interview on 4/29/22 at 8:33 a.m. with Patient 1's family member (FM 1), FM 1 stated Patient 1 had received services from the HHA for seven years. The FM stated that on 3/15/22, the HHA dropped Patient 1 from their service. The FM stated the agency told him they did not have a nurse available to send to the home. FM 1 stated that Patient 1 accidentally sent a text to the HH nurse stating "I'm done with her." FM 1 stated this text was meant to be sent to him. The HHA notified FM 1 the next day that they no longer had a nurse available. The HHA was not able to transfer her care to another HHA, because there were no other HHAs serving the area. Patient 1 is wheelchair bound (unable to walk) and uses oxygen. Patient 1 is now going to an infusion clinic for weekly dressing changes and labs. Patient 1's suprapubic catheter was to be changed every 6 weeks and was supposed to have been changed on 3/15/22. FM 1 stated that there are not any outpatient services, including urology, in the local area to provide that service due to Patient 1's insurance coverage. Patient 1's PCP is unable to provide suprapubic catheter changes in the office. FM 1 took Patient 1 to the ED on 4/14/22 to have the suprapubic catheter changed. During an interview on 4/29/22 at 12:30 p.m. with the Clinical Supervisor (CS), the CS stated Patient 1 sent a text message to the nurse stating that she did not want the nurse to come any more. The CS stated the central line care and lab draws had been set up for outpatient services. The CS stated FM 2 had been trained to change the suprapubic catheter in the last five years, but was not sure who had trained her. During a telephone interview on 4/29/22 at 1:19 p.m. with LN (Licensed Nurse) 1, LN 1 stated Patient 1 was seen weekly for central line care, labs, and every six weeks suprapubic catheter changes every six weeks. LN 1 stated that Patient 1 preferred visits at 1:00 p.m. LN 1 stated she notified Patient 1 via text message the day before the next visit, prior to 5:00 p.m., that she needed to schedule the visit between 11:00 a.m. and 12:00 p.m. LN 1 received a text message back from Patient 1, that stated "So want to be done with her." Thirty minutes later Patient 1 acknowledged, via text message, that she had mistakenly sent the text message to LN 1. LN 1 stated that she did not feel comfortable going into the home after the text messages from Patient 1. During a telephone interview on 4/29/22 at 1:52 p.m. with the Administrator (ADM), the ADM stated Patient 1's needs could be provided as an outpatient. THe ADM stated FM 1 was notified of the need for an urologist to follow up with patient for suprapubic catheter changes. The ADM stated that there was not an urologist locally to provide care and advised FM 1 to obtain one outside of the local area. The ADM stated that Patient 1 did not want LN 1 in the home, but no other nurse was willing to go to the home. ADM stated FM 2 was able to do suprapubic catheter changes, but the ADM acknowledged he did not know when training had taken place. The ADM stated It should have been documented in the record if training had occurred. ADM acknowledged that there was no documentation of training in the past six months in Patient 1's clinical record. During a telephone interview on 5/6/22 at 12:34 p.m. with Director of Patient Care (DPCS), the DPCS stated that patient 1 was not happy with the time that LN 1 had scheduled to see Patient 1. LN 1 had received a text message from Patient 1 that indicated this, but was meant for someone else. LN 1 was uncomfortable going to the home after receiving the text message. The DPCS stated that other nurses available declined, because they did not feel comfortable going to the home. The DPCS notified Patient 1's FM 1 on 3/16/22 that they no longer had a nurse to go to the home. THe DPCS advised FM 1 to take Patient 1 to the ED for suprapubic catheter changes and to find an urologist outside the local area. FM 2 notified the DPCS that she had been taught 2 to 3 years ago to change Patient 1's suprapubic catheter. The DPCS stated that FM 2 had not been evaluated by the HHA to provide suprapubic catheter changes. The DPCS stated, "Not something I thought about at the time. That would have been something we could have done in hindsight." The DPCS stated they did not contact local urologists to see if any would accept Patient 1 as an exception, because of past experience with the local urologists not willing to accept patients. The DPCS stated the PCP had agreed to make referrals to urologists outside of local area. The DPCS acknowledged that there had been problems arranging timely follow up with urologists outside of local area. The DPCS acknowledged it would have been a taxing effort (homebound- requires a considerable and taxing effort to leave the home) for Patient 1 to leave the home due to weakness and need for oxygen. During a telephone interview on 5/12/22 at 11:37 a.m. with Patient 1's FM 1, FM 1 stated he had been unable to find an accepting urologist to see Patient 1. He stated that he or FM 2 had not been trained to change the suprapubic catheter. During a telephone interview on 7/19/22 at 3:29 p.m. with FM 1, FM 1 stated he still has not been able to find an urologist, locally or out of the local area, to follow patient for suprapubic catheter changes. He stated the the ED was not a good option due to concerns about COVID-19 exposure for Patient 1. He stated he is not sure when the catheter will be changed. A review of the HHA "Patient Orientation for Home Health Care" Section "Discharge, Transfer and Referral Policy," not dated, indicated "We may only discharge or transfer you from this agency if:...Our agency determines, based on our policy, that your behavior or the behavior of other persons in your home is disruptive, abusive, or uncooperative to the extent that delivery of your care...is seriously impaired. Prior to discharging for cause, our agency must...Make efforts to resolve the problem(s) presented by your behavior or the behavior of other persons in your home or situation...Document in your medical record the problem(s) and efforts made to resolve the problem(s)..." A review of the HHA policy titled "Discharge and Transfer," revised 6/5/19, indicated "...The Agency may transfer or discharge the patient if:...The patient or other persons in the patient's home exhibit disruptive, abusive or uncooperative behavior...The Agency arranges a safe and appropriate transfer to other care entities..." A review of the HHA policy titled "Expectations and Responsibilities for Field Staff," revised 1/8/22, indicated "...Field staff will:..Schedule their home visits in compliance with physician ordered frequency/duration...Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner...Provide care, treatment and services to each patient according to their established plan of care..." A review of a document provided by the HHA on 4/29/22, not dated, indicated "Suprapubic catheterization involves inserting a urinary catheter directly into the bladder through the lower abdominal wall...Long- term suprapubic catheters should be changed per practitioner's order..."

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to demonstrate efforts to resolve concerns for one of five sampled patients (Patient 1), when Patient 1 was discharged from home health services without follow up care for suprapubic catheter (a tube inserted through the abdomen directly into the bladder to drain urine) changes. This failure caused Patient 1's suprapubic catheter to not be changed every six weeks and this had the potential to cause infection. A review of Patient 1's "Patient Information Record" indicated she was last referred to the HHA in January 2020 with multiple diagnoses including mitochondrial myopathy (a neuromuscular disease that causes muscle fatigue and weakness), VAD (Ventricular Assist Device -pumps blood from the heart to rest of the body), neuromuscular dysfunction of the bladder (lack of bladder control caused by nervous system disorder), ileostomy (an opening in the skin surface for the small bowel to eliminate waste) and gastrostomy (an opening from the abdominal wall to the stomach). A review of Patient 1's "Home Health Certification and Plan of Care," for certification period 1/17/22 to 3/17/22, indicated: "Frequency/Duration of Visits: SN [Skilled Nurse] 1WK9 [1 times a week for 9 weeks] PLUS 2 PRN [as needed} VISITS MAY BE MADE FOR IV [Intravenous-a tube or needle inserted into a vein], LABS, CATHETER [tube placed into the bladder to drain urine]/OSTOMY [an opening from the inside of the body to the outside] NEEDS/ TROUBLESHOOTING, INTEGUMENT [skin] CHANGES, PAIN, FALLS, OR MEDICATION MANAGEMENT. Orders of Discipline and Treatments: ...SKILLED NURSE TO PERFORM INFUSION ACCESS [IV] SITE CARE FOR INFUSION ASSESS DEVICE...WITH DRESSING CHANGES ONCE A WEEK AND PRN... SKILLED NURSE FOR INSERTION OF SUPRAPUBIC CATHETER MAINTENANCE...CHANGE EVERY 6 WEEKS AND PRN FOR DISLODGMENT OR STOPPAGE, AND OBTAIN URINE SPECIMEN AS INDICATED.... SKILLED NURSE TO COLLECT URINE SPECIMEN FOR UA [urinalysis-evaluation of the urine] AND CULTURE [identify an urinary tract infection with an urine sample] VIA SUPRAPUBIC CATHETER ON EVERY CATHETER CHANGE AND PRN S/S [signs or symptoms] OF INFECTION... Goals/Rehabilitation Potential/Discharge Plans: ...PATIENT/ CAREGIVER WILL VERBALIZE/DEMONSTRATE REQUIRED KNOWLEDGE TO MANAGE URINARY CATHETER CARE AS EVIDENCED CONSISTENT RETURN DEMONSTRATIONS USING PROPER TECHNIQUE AND WILL BE ABLE TO VERBALIZE SIGNS AND SYMPTOMS OF URINARY TRACT INFECTION BY WEEK 8... DC [discharge] Plans: DC TO CARE OF FAMILY UNDER SUPERVISION OF MD [medical doctor] WHEN GOALS ARE MET..." A review of Patient 1's "Client Coordination Note Report," dated 3/16/22, indicated "...Patient will be closed at the end of her certification period 3/17/22. Patient's parents were aware of this decision and were also aware of the plans for her future service...[PCP- Primary Care Provider] is aware of this closure per conversation with RN [Registered Nurse]...supra pubic catheter needs to be changed this week and [PCP] and home health staff have advised to go to ED for change. Patient needs urologist that takes [patient's insurance]. Suggested [cities outside of local area]. Father says this is too far away at this time.." A review of Patient 1's "Client Occurrence Report," dated 3/16/22, indicated "...Father was notified on 3/16/22 via telephone call of discharge...Advised to go to the ED for catheter change and attempt to find a urologist that takes her insurance..." A review of Patient 1's "Discharge- Transfer Summary Report," dated 3/16/22, indicated "...Patient no longer wishes to have this nurse for home health, no other nursing staff available. Upon discussion with supervisors and patient's parents, it was decided that all of the care needed for the patient can be completed as outpatient care. Patient will continue with [central line -an IV line in the chest wall], catheter care and labs weekly at the infusion center and per patient's PCP [primary care physician]...patient will need to go to ED [emergency department] for catheter changes as they are unable to do them in their office. Patient encouraged to find urologist [a doctor who specializes in treatment of the urinary tract]... Goal Description...Patient tolerated catheter insertion with return of urine...Not Met- Additional time required to meet intervention/goal..." During a telephone interview on 4/29/22 at 8:33 a.m. with Patient 1's Family Member (FM) 1, FM 1 stated Patient 1 had received services from the HHA for seven years. Patient 1 was wheelchair bound (unable to walk) and used oxygen. The FM 1 stated that on 3/15/22, the HHA dropped Patient 1 from their service. FM 1 requested the HHA send another nurse. The FM 1 stated the agency told him they did not have a nurse available to send to the home. The Licensed Nurse (LN) 1 had notified Patient 1 of a change in schedule and needed to come earlier. FM 1 stated that Patient 1 accidentally sent a text message to LN 1 stating "I'm done with her." Patient 1 was frustrated with the change in schedule and timing of the visit. FM 1 stated this text message was meant to be sent to him. FM 1 stated that Patient 1 apologized to LN 1 via text message, but LN 1 did not respond. The HHA notified FM 1 the next day that they no longer had a nurse available. FM 1 requested the Administrator (ADM) and Director of Patient Care Services (DPCS) reevaluate and was told Patient 1 was not homebound (confined to the home). The HHA was not able to transfer her care to another HHA, because there were no other HHAs serving the area. FM 1 took Patient 1 to the ED on 4/14/22 to have the suprapubic catheter changed. Patient 1's suprapubic catheter was to be changed every 6 weeks and was supposed to have been changed on 3/15/22. He stated that there were not any outpatient services, including urology, in the local area to provide that service due to Patient 1's insurance coverage. Patient 1's PCP was unable to provide suprapubic catheter changes in the office. During an interview on 4/29/22 at 12:30 p.m. with the Clinical Supervisor (CS), the CS stated Patient 1 sent a text message to the nurse stating that she did not want that nurse to come any more. The CS stated the reasons for the HHA to discharge from services include the patient no longer has skilled needs, is no longer homebound, or can get care from the Primary Care Provider (PCP). The CS stated Patient 1 kept refusing nurses. The CS stated Patient 1 was not homebound. The CS stated FM 2 had been trained to change the suprapubic catheter in the last five years, but was not sure who had trained her. During a telephone interview on 4/29/22 at 1:19 p.m. with LN (Licensed Nurse) 1, she stated Patient 1 was seen weekly for central line care, labs, and every six weeks for suprapubic catheter changes. LN 1 stated that Patient 1 preferred visits at 1:00 p.m. LN 1 stated she notified Patient 1 via text message the day before the visit, prior to 5:00 p.m., that she needed to schedule the next day visit between 11:00 a.m. and 12:00 p.m. LN 1 received a text message back from Patient 1, that stated "So want to be done with her." Thirty minutes later Patient 1 acknowledged via text message, that the text message was mistakenly sent to LN 1. LN 1 did not respond to Patient's 1 text messages and notified her supervisors of Patient 1's text messages. LN 1 stated that she did not feel comfortable going into the home after receiving the text messages. During a telephone interview on 4/29/22 at 1:52 p.m. with the ADM, the ADM stated Patient 1's needs could be provided as an outpatient. The ADM stated that Patient 1 did not want LN 1 in the home and no other nurse was willing to go to the home. Patient 1 had other nurses in the past. The ADM stated FM 2 progressively complained about the nurses over time. The ADM stated Patient 1 was not homebound and was going out by car. ADM stated FM 1 was notified of the need for an urologist to follow up with Patient 1 for suprapubic catheter changes. The ADM that there was not an urologist locally to provide care and advised FM 1 to obtain one outside of the local area. ADM stated FM 2 was able to do suprapubic catheter changes, but he did not know when training had taken place. The ADM stated It should have been documented in the record if training had occurred. ADM acknowledged that there was no documentation of suprapubic catheter training in the past six months in Patient 1's clinical record During a telephone interview on 5/6/22 at 12:34 p.m. with DPCS, the DPCS stated that Patient 1 was unhappy with the time that LN 1 had scheduled to see Patient 1 on 3/16/22. LN 1 received a text message from Patient 1 that indicated this, but was meant for someone else. LN 1 was uncomfortable going to the home after receiving the text message. The DPCS stated that other nurses available declined because they did not feel comfortable going to the home. The FM 1 advised the DPCS that the text message was not about LN 1 but was referring to something else. The DPCS notified Patient 1's FM 1 on 3/16/22 that they no longer had a nurse to go to the home. THe DPCS advised FM 1 to take Patient 1 to the ED for suprapubic catheter changes and to find an urologist outside the local area. FM 2 notified the DPCS that she had been taught 2 to 3 years ago to change Patient 1's suprapubic catheter. The DPCS stated that FM 2 had not been evaluated by the HHA to provide suprapubic catheter changes. The DPCS stated, "Not something I thought about at the time. That would have been something we could have done in hindsight." The DPCS stated they did not contact local urologists to see if any would accept patient as an exception, because of past experience with the local urologists not willing to accept the patients. The DPCS stated the PCP had agreed to make referrals to urologists outside of local area. The DPCS acknowledged that there had been problems arranging timely follow up with urologists outside of local area. DPCS stated that the HHA was not planning to discharge Patient 1 from services prior to this incident. The DPCS acknowledged it would have been a taxing effort (homebound- a considerable and taxing effort to leave home) for Patient 1 to leave the home due to weakness and need for oxygen. During a telephone interview on 5/12/22 at 11:37 a.m. with Patient 1's FM 1, FM 1 stated he had been unable to find an accepting urologist to see Patient 1. He stated that he or FM 2 had not been trained to change the suprapubic catheter. During a telephone interview on 7/19/22 at 3:29 p.m. with FM 1, FM 1 stated he still has not been able to find an urologist, locally or outside the local area, to follow patient for suprapubic catheter changes. He stated the the ED was not a good option due to concerns about COVID-19 exposure for Patient 1. He stated he is not sure when the catheter will be changed. A review of the HHA "Patient Orientation for Home Health Care" Section "Discharge, Transfer and Referral Policy," not dated, indicated "We may only discharge discharge or transfer you from this agency if:...Our agency determines, based on our policy, that your behavior or the behavior of other persons in your home is disruptive, abusive, or uncooperative to the extent that delivery of your care...is seriously impaired. Prior to discharging for cause, our agency must...Make efforts to resolve the problem(s) presented by your behavior or the behavior of other persons in your home or situation...Document in your medical record the problem(s) and efforts made to resolve the problem(s)..." A review of the HHA policy titled "Expectations and Responsibilities for Field Staff." revised 1/8/22, indicated "...Field staff will:..Schedule their home visits in compliance with physician ordered frequency/duration...Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner...Provide care, treatment and services to each patient according to their established plan of care..."