Every finding on record at Wilson County Memorial Hospital District

A Recertification survey entrance conference was conducted on 04/29/25 with the Administrator and the Alternate Administrator. Census: Licensed and Certified (L&C)-99 Licensed Home Health (LHH)-0 Personal Assistance Services (PAS)-30 Acronyms: SOC-Start of Care POC-Plan of Care SN-Skilled Nurse LVN-Licensed Vocational Nurse Rt-right RBS-Random Blood Sugar mg/dl-milligrams per deciliter HH-Home Health

A Recertification survey entrance conference was conducted on 04/29/25 with the Administrator and Alternate Administrator. Census: Licensed and Certified (L&C)-99 Licensed Home Health (LHH)-0 Personal Assistance Services (PAS)-30 Acronyms: SOC-Start of Care POC-Plan of Care SN-Skilled Nurse LVN-Licensed Vocational Nurse Rt-right RBS-Random Blood Sugar mg/dl-milligrams per deciliter HH-Home Health Violations were cited.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that drugs, services and treatments were administered only as ordered by the physician such as performing blood glucose testing (the process of testing blood sugar levels by using a glucose meter and test strips to analyze a small blood sample which is usually obtained from a finger prick to manage and treat conditions like Diabetes) for one of seven active patients (Patient #2) whose records were reviewed in that: There was no documentation of the need for the blood glucose testing according to the physician’s orders. This failure had the potential to place the active patients at risk of receiving improper care that was not ordered by the physician. The findings included: Record Review of Client #2’s clinical record revealed a Start of Care (SOC) date of 03/14/25 and a Plan of Care (POC) certification from 03/14/25 through 05/12/25 with a diagnosis of “Encounter for Other Orthopedic aftercare.” Further review revealed Skilled Nursing Visits (SN) once every two weeks starting the week of 04/27/25 and no documented evidence of a physician order for blood glucose testing. During a home visit with Patient #2 on 04/30/25, LVN L (LVN), performed blood glucose testing on Client. Review of LVN L’s nursing note, titled “HH LVN Visit”, dated 04/30/25, revealed the following notation “using aseptic technique (procedure to prevent contamination and reduce risk of infection) and sterile supplies, SN performed fingerstick to rt. Index finger. RBS 120mg/dl. Patient applied pressure to fingerstick site. No bleeding or bruising noted at this time.” During an interview and record review on 05/02/25 at 10:49 a.m., the findings above were reviewed and discussed with the Administrator. The Administrator confirmed that there was no documented evidence of a physician’s order to perform blood glucose testing on Client #2 and stated that she would have to “follow-up on that.” She further stated nurses are to always follow physicians’ orders. Review of the agency's policy titled "Orders for Care" with a revision date of 011318, revealed in part, "...The Agency will obtain orders and provide care in accordance with physician’s orders..."