Cape Fear Valley Home Health

The agency failed to notify the physician of a patient’s discharge and a delay in the resumption of care for 1 of 1 patient with a discharge and a resumption of care (start of care after discharge) (patient #1).

The agency failed to identify high risk medications when answering OASIS [The Outcome and Assessment Information Set] question N0415 for 2 of 16 records [2 and 8]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 10/16/24 with admitting diagnoses of non-pressure chronic ulcer…

The agency failed to remove gloves and perform hand hygiene and failed to disinfect reuseable equipment for 1 of 4 patients with skilled nurse home visits conducted.

The SN [skilled nurse] failed to obtain weekly wound measurements for 2 of 6 patients with a wound [2 and 14]; and failed to obtain weekly PICC [peripherally inserted central catheter- form of intravenous access that can be used for a prolonged period of time] line measurements for 1 of 1 patient…

Staff interviews the agency failed to document the existence of complaints, investigations, and resolutions for 1 of 1 patient with complaints.

Staff interviews the plan of care failed to include all/correct medications the patient was taking for 2 of 4 patients who received home visits [#10 and 11]. The findings included: The policy, Monitoring Medications [7/1/24], was provided by RN # 7 on 5/7/25 at 11:30 am.

The agency failed to follow the physician's orders for wound care for 4 of 6 patients with a wound [2, 14, 15 and 13]. The findings included: A policy, Wound Assessment, Documentation, and Photography (revised 09/01/2024) received on 05/06/2025 at 12:37 PM from the Executive Director stated…

The agency failed to revise the plan of care to reflect current information for 1 of 1 patient requiring additional education.

The agency failed to report vital signs outside the given parameters for 2 of 16 patients [#6 and 16]. The findings included: 1.Patient #6 was admitted on 03/25/2025 with a diagnosis of chronic lymphocytic leukemia of B-cell [cancer of the blood and bone marrow]. The plan of care for…

The agency failed to accurately document a treatment that was provided for 1 of 4 patients with a home visit conducted.

The agency failed to include complete medication orders for 3 of 3 patients (Patients #11, 18, 24) on oxygen and 1 of 1 patients (Patient #24) receiving Insulin Lispro.

The agency failed to assess or obtain measurements at least every other week for 1 of 9 patients (Patient #24) with wounds.

The agency permitted caregiver(s) to perform wound care who had not demonstrated an ability to perform wound care correctly and who were not deemed competent in providing wound care for 1 of 9 (Patient #24) patients with wounds.

The agency failed to notify the physician regarding the caregiver(s) inability to provide wound care correctly and failed to notify the physician of a change in wound measurements for 1 of 9 patients (Patient #24) with wounds.

Staff interview the agency failed to provide home health aide supervision for 1 of 8 home health aide records reviewed (#16).

Staff interview the agency failed to provide Home Health Aide and Occupational Therapy services as ordered for 1 of 3 patients (Patient #2).

The Plan of Care for the certification period from 11/26/18 to 1/24/2019 revealed skilled nursing services were ordered. "Skilled nurse for insertion of 16 FR [French scale measuring system] 10 cc [cubic centimeter unit of volume] balloon indwelling catheter; Change every 3 weeks and PRN [as…

The agency failed to follow procedures for insertion of urinary catheters for one out of five patient (patient #1), resulting in trauma to the urethra.

Caregiver interview and staff interview the skilled nurse failed to document complete information in regards to who inserted indwelling catheter for 1 of 1 patients [#3]; documented inaccurate date of catheter insertion for 1 of 1 patients [#3]; and failed to document status of indwelling catheter…

Caregiver interview and staff interview the agency failed to document the existence of a complaint for 1 of 5 patients [#3] reviewed.