Bay Nursing, Inc

The Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 3 (P#'s 7, 12, and 13) records in which Home Health Aide services were ordered, from a total of 17…

The agency failed to ensure that 2 (P's #10, 11) patients observed during home visits and 2 (P's #3, 5) records reviewed were included in the overall planning of their care including informing the patient/caregiver in advance of the days in which services would be provided, from a total of 17…

The agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 13…

The agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 2 of 17 (P-14, and 16) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by…

The agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 11 of 17 records reviewed (P’s #1, 2, 3, 5, 6, 7, 8, 9, 15, 16, and 17), resulting in a potential for failure to measure progress toward achievement of desired outcomes.

The Agency failed to ensure the Home Health Aide provided care and services as ordered in the plan of care for 1 (P-12) patient who required assistance with grooming, from a total of 17 sampled records reviewed, resulting in the potential for poor hygiene and unmet needs.

The agency failed to ensure clinical notes were accurate for 1 of 17 (P# 1) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure the discharge/transfer summary was complete, provided the patient's current health status at the time of discharge/transfer, and forwarded to the physician/receiving facility within the required time frame as per this requirement in 4 (P's #3, 12, 13, and 15) records…

The agency failed to ensure the skilled nurse obtained labs as ordered by the physician for 1 of 1 (MR# 6) records reviewed in which labs were ordered, resulting in delayed lab work and the potential for poor patient outcomes for this 1 patient.

The agency failed to ensure the registered nurse included safety measures in the patient care instructions for the home health aide in 1 of 9 (MR#2) records reviewed in which the patient received home health aide services, resulting in the potential for the provision of unsafe care for this one…

The registered nurse failed to identify all medications that the patient was taking at the time of the comprehensive assessment for 1 of 17 records reviewed (MR# 7), resulting in the potential for the patient to have a reoccurrence of a pulmonary embolism.

The agency failed to ensure the Home Health Aide provided services only as ordered by the physician in 1 of 8 records (MR's #16) out of a total sample of 17 records, which resulted in the Home Health Aide providing services not ordered by the physician.

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 1 of 5 (MR# 2) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at the…