Every finding on record at Goldstar Home Health System Inc

Based on record review and interview the agency failed to include clinical notes in the patient records for 4 (#6, #7, #9, #10) of 10 active patient records reviewed. The failure placed the patients at risk that non-current information would be shared resulting in exacerbations (worsening) of symptoms, wounds, and other negative outcomes. --- Patient #6:Record review of Patient #6's clinical record revealed a Plan of Care dated 7/24/2024 to 10/21/2024. The Plan of Care listed Heart Failure (condition when the heart doesn't pump enough blood for the body's needs) as the primary diagnosis. Registered Nurse E was scheduled to conduct a skilled nurse visit on 8/6/2024, 8/8/2024, 8/13/2024, and 8/15/2024. Registered Nurse E's clinical notes had not been written and had not been included in the clinical record when the surveyor reviewed Patient #6's record on 9/4/2024 (greater than 14 working days). Patient #7: Record review of Patient #7's clinical record revealed a Plan of Care dated 6/26/2024 to 8/24/2024. The Plan of Care listed Paroxysmal Atrial Fibrillation (irregular heartbeat) as the primary diagnosis. Registered Nurse E was scheduled to conduct a skilled nurse visit on 8/8/2024 and 8/13/2024. Registered Nurse E's clinical notes had not been written and had not been included in the clinical record when the surveyor reviewed Patient #7's clinical record on 9/4/2024 (greater than 14 working days). Patient #9:Record review of Patient #9's clinical record revealed a Plan of Care dated 6/15/2024 to 8/13/2024. The Plan of Care listed Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (inflammatory disease that cause plaque build-up in the arteries) as the primary diagnosis. Registered Nurse E was scheduled to conduct a skilled nurse visit on 8/6/2024 and 8/13/2024. Registered Nurse E's clinical notes had not been written and were not included in the clinical record when the surveyor reviewed Patient #9's record on 9/4/2024 (greater than 14 working days). Patient #10: Record review of Patient #10's clinical record revealed a Plan of Care dated 7/16/2024 to 10/13/2024. The Plan of Care listed Parkinson's Disease with Dyskinesia (disorder of the nervous cause by damaged nerve cells in the brain that worsens over time and with involuntary muscle movements) as the primary diagnosis. Review of the agency's on-call log indicated that a call had been made to the hospice on 8/3/2024, time of call was not specified. The on-call log documentation, by Registered Nurse H, indicated that the call was to report Patient #10 had a fall. Registered Nurse H documented in the on-call log that a visit was conducted and Patient #10 was assessed. Registered Nurse H's clinical note had not been written and had not been included in the clinical record when the surveyor reviewed the record on 9/4/2024 (greater than 14 working days). During an interview on 9/5/2024 at 3:10 pm with the Supervising Nurse/Registered Nurse E, and the Director of Operations, the surveyor discussed the clinical records. The surveyor discussed that the clinical records did not include some of the clinical notes. The Supervising Nurse/Registered Nurse E did not dispute the finding that the clinical notes were not in the clinical records. The surveyor asked why the Supervising Nurse/Registered Nurse E did not write the clinical notes so the notes could be included in the clinical record. The Supervising Nurse/Registered Nurse E stated, "It escaped my mind." The surveyor asked if the staff made the visits to the patients. The Supervising Nurse/Registered Nurse E stated, "Yes." The surveyor asked how the agency would know that staff documented their clinical notes. The Director of Operations stated, "Every note is quality assessed by [Supervising Nurse].' The Director of Operations informed the surveyor that all skilled nursing notes are quality assessed, and the initial and recertification notes are quality assessed when the nurse submitted the note. During an interview on 9/6/2024 at approximately 9:00 a.m. with Registered Nurse F, which was conducted at a home visit with Client #8. The surveyor asked what was the agency's policy on documenting the clinical notes. Registered Nurse F stated, "Up to 3 days, not over a week. But I'm not really sure." During an interview on 9/6/2024 at 1:32 p.m. with the Alternate Administrator, Supervising Nurse, and Director of Operations, the surveyor asked what the agencys policy regarding when clinical notes were to be written and included in the clinical record. The Alternate Administrator stated, "The policy was to be documented within 7 days." The Alternate Administrator informed the surveyor that the policy was that information would be in the clinical record in a timely manner. The Alternate Administrator informed the surveyor that the agency received policy updates automatically but doesn't automatically receive Texas Addendums. The Alternate Administrator did not dispute the finding. Review of the agency's policy titled "Timelines," labeled IM.40, and dated 10/1/2021. The policy read in part; "Purpose To establish timely parameters for all medical record information. Policy The Hospice will ensure timely provision of care to meet patient's needs in compliance with all federal and state laws and regulations....Procedure...III. All medical record information will be incorporated into the patient's medical record in a timely manner...Timelines-Addendum, IM.40-TX Procedures I...A. All clinical and progress notes will be written the day services is rendered and incorporated into the patient's medical record within 14 working days..."

Based on record review and interview, the agency failed to include physician orders regarding wound care in the clinical records for 3 (#2, #5, #6) of 4 active patient records reviewed where wound care was provided. The failure placed the patients at risk of omission of care or inappropriate care and at risk that their wounds would worsen or become infected. --- Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 5/22/2024 to 8/19/2024. The Plan of Care listed Alzheimer's Disease (brain disorder that destroys memory, thinking skills, and the inability to carry out simple tasks) as the primary diagnosis. Licensed Vocational Nurse C conducted a skilled nurse visit on 8/3/2024. Licensed Vocational Nurse C documented a skin tear, with onset date of 8/3/2024, to Patient #2's right elbow. Licensed Vocational Nurse C documented wound care was performed by cleaning the skin tear with normal saline, patted dry, applied xeroform (sterile, non-adherent gauze dressing that is used to treat wounds), and covered with a gauze roll. Registered Nurse D conducted a Recertification skilled nurse visit on 8/13/2024. Registered Nurse D documented that Patient #2 had an open wound. Registered Nurse D documented that Patient #2 had a skin tear on right lower forearm, wound was healing and had minimal drainage. Registered Nurse D conducted a skilled nurse visit on 8/20/2024. Registered Nurse D documented that Patient #2 had a wound to the right elbow. Licensed Vocational Nurse C conducted a skilled nurse visit on 8/31/2024. Licensed Vocational Nurse C documented that Patient #2 had a wound to the right elbow. Patient #2's clinical record did not include a physician order for wound care. Patient #5: Record review of Patient #5's record revealed a Plan of Care dated 8/15/2024 to 11/12/2024. The Plan of Care listed Degenerative Disease of Nervous System Unspecified (incurable conditions that damage and destroy parts of the nervous system) as the primary diagnosis. Registered Nurse D conducted a skilled nurse visit on 8/15/2024. Registered Nurse D documented providing wound care to Patient #5's right ankle and right foot. Registered Nurse D documented cleaning the wounds with wound cleanser, patting dry, coving wounds with calcium alginate (wound product used to absorb excess moisture and promote healing), gauze and wrapped with gauze. Registered Nurse D documented to add routine antibiotics (medication used to treat infection) due to recurring signs and symptoms of infection. Registered Nurse D conducted an as needed skilled nurse visit on 8/16/2024 due to reports of pain. Registered Nurse D documented a conversation with Patient #5's family member. Patient #5's family member wanted a wound care specialist to see Patient #5. Registered Nurse D documented performing wound care to Patient #5's wounds. Registered Nurse D conducted a skilled nurse visit on 8/19/2024. Registered Nurse D documented performing wound care to Patient #5's wounds. Registered Nurse D documented that an air mattress was ordered due to development of new pressure sores. Registered Nurse D conducted a skilled nurse visit on 8/21/2024. Registered Nurse D documented that Patient #5 had a wound on the lateral side of the right foot. Registered Nurse D did not document that wound care had been performed. Registered Nurse D conducted a skilled nurse visit on 8/23/2024. Registered Nurse D documented that Patient #5 had a wound on the lateral side of the right foot. Registered Nurse D did not document that wound care had been performed. Patient #5's clinical record did not include a physician order for wound care. Patient #6: Record review of Patient #6's clinical record revealed a Plan of Care dated 7/24/2024 to 10/21/2024. The Plan of Care listed Heart Failure (condition when the heart doesn't pump enough blood for the body's needs) as the primary diagnosis. Registered Nurse E conducted an Initial Assessment on 7/24/2024. Registered Nurse E documented that Patient #6 had a skin tear present on admission to Patient #6's left lower calf. Registered Nurse E performed wound care by cleaning the wound with wound wash and covering with a Mepilex dressing (absorbent foam dressing used for treating low to medium draining wounds). Licensed Vocational Nurse C conducted a skilled nurse visit on 7/27/2024. Licensed Vocational Nurse C documented that Patient #6 refused wound care. Registered Nurse D conducted a skilled nurse visit on 7/29/2024. Registered Nurse D documented that Patient #6 refused wound care. Licensed Vocational Nurse C conducted a skilled nurse visit on 8/3/2024. Licensed Vocational Nurse C documented that Patient #6 refused wound care. Registered Nurse E conducted a skilled nurse visit on 8/6/2024. Registered Nurse E documented that Patient #6's wound to the left lower calf was cleaned with wound wash, patted dry, covered with a Mepilex dressing. Registered Nurse E documented the wound measured 1.75 centimeters x 1 centimeter x 0.1 centimeters. Registered Nurse E conducted a skilled nurse visit on 8/13/2024. Registered Nurse E documented that Patient #6's wound was healed. Patient #6's clinical record did not include physician orders for wound care. During an interview on 9/5/2024 at 3:10 pm with the Supervising Nurse and the Director of Operations, the surveyor discussed the clinical records and that physician orders for wound care were not included in the clinical records. The Supervising Nurse informed the surveyor that Physician X and unnamed nurse practitioners do not coordinate with the hospice regarding changes. The Supervising Nurse informed the surveyor that orders for the wound care were at the facilities. The Nurse Practitioners would see the nurses at the facilities and would tell the nurses about the wound care orders. The surveyor asked why the wound care orders were not included in the clinical records, the Supervising Nurse stated, "No known reason." The Supervising Nurse stated, "The Case managers would be responsible for inputting the wound care orders in the clinical records. The Director of Operations stated, "We need to have a meeting regarding wound care orders." The Supervising Nurse and the Director of Operations were unable to show the surveyor that wound care orders were included in the clinical records. During an interview on 9/6/2024 at approximately 9:00 a.m. with Registered Nurse F, conducted at a home visit with Patient #8. The surveyor asked about the band aids on Patient #8's left hand. Registered Nurse F informed the surveyor that this was new today and caused by Patient #8's hand hitting a wall. The surveyor asked what the agency's policy was regarding wound care orders. Registered Nurse F informed the surveyor that they would be written within 24 hours. During an interview on 9/6/2024 at 1:32 p.m. with the Alternate Administrator, Supervising Nurse, and Director of Operations, the surveyor asked what was the agency's policy regarding physician orders being written and included in the clinical records. The Alternate Administrator stated, "Have to be written within 24 hours." The Alternate Administrator informed the surveyor that each individual registered nurse would be responsible and that the Supervising Nurse would check for compliance. The Alternate Administrator informed the surveyor that the issue could cause a delay in implementation of care. Review of the agency's policy titled "Timelines," labeled IM.40, and dated 10/1/2021. The policy read in part; Purpose To establish timely parameters for all medical record information. Policy The Hospice will ensure timely provision of care to meet patient's needs in compliance with all federal and state laws and regulations. Procedure...I...G. Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders...III. All medical record information will be incorporated into the patient's medical record..."