Centerwell Home Health

The Skilled Nurse (SN) failed to follow the Patient's Plan of Care for patient specific interventions regarding monitoring the patient's weight each visit in 1 (#2) of 13 (#1-#13) clinical records reviewed.

The Skilled Nurse (SN) failed to include all medications for reconciliation and medication interaction checks in 2 (#5,#10) of 13 (#1-#13) clinical records reviewed.

The Agency staff did not communicate with the physician about the Agency's inability to follow the patient's Plan of Care in 1 (#2) of 13 (#1-#13) clinical records reviewed.

The Agency failed to ensure a Registered Nurse (RN) conducted a review of medications in 1 (#1) of 10 (#1 - #10) Clinical Records reviewed.

The Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of patient specific interventions, education, measurable outcomes and goals identified by the Home Health Agency (HHA) and patient in 5 (#4, #6, #8, and #9) of 10 (#1 - #10) Clinical Records…

The Agency failed to provide the patient with complete and accurate written patient medication schedule / instructions in 2 (#6 and #7) of 4 (#4 - #7) home visits conducted.

The Agency failed to provide the patient with accurate written instructions for Aide services in 1 (#5) of 4 (#4 - #7) home visits conducted.

The Agency staff failed to ensure accurate and timely documentation of care coordination and communication between the healthcare team members in 1 (#10) of 10 (#1 - #10) Clinical Records reviewed.

Staff interview the Agency failed to ensure a complete Discharge/Transfer Summary was sent to the Physician after discharge in 1 (#3) of 3 (#1 - #3) Clinical Records reviewed with transfer/discharge status.

The Agency failed to update the comprehensive assessment following a change in the Patient's condition in one (#4) and at time of discharge in one ( #5 ) of 10 (#1-#10) Clinical Records reviewed.

The Agency failed to communicate discharge plans to Patients in that the Patient was not informed in advance of when home health services would end in two (#3 and #5) of 10 (#1-#10) Patients and there was no evidence of discharge planning, assessment, or communication in one (#5) of 10 (#1-#10)…

The Agency failed to provide Patients with a written copy of current medications schedule/instructions.

The Skilled Nurse (SN) failed to provide interventions ordered on the Plan of Care (POC) in that the SN failed to complete med prefills for three (#4, #5, and #10) of 10 (#1-#10) Clinical Records Reviewed.

The Agency's Physical Therapy (PT) staff failed to communicate new patient related assessment findings to the Physician resulting in nursing needs not being assessed and ineffective coordination of care in one (#6) of 10 (#1-#10) Clinical Records reviewed.