Coxhealth at Home

The agency failed to ensure that services ordered by the physician were provided as indicated in the plan of care in two (Records/Patients #1 and #3) of three records reviewed.

The agency failed to ensure one patient (Record/Patient #1) received adequate and effective discharge planning.

The agency failed to ensure the discharge summary included all necessary medical information pertaining to the patient's current course of illness and treatment for two (Record/Patient #1 and #3) of three records reviewed and failed to ensure the discharge summary was sent to the patient's health…

The agency failed to provide all services outlined in the plan of care (POC) for one (Record/Patient #1) of three records reviewed.

The agency failed to document a complete investigation and resolution for one (Record/Patient #1) of three grievances reviewed.

The agency failed to document a complete investigation and resolution for one (Record/Patient #2) of three grievances reviewed.

The agency failed to ensure care was provided as ordered by the physician in one (Records/Patients #2) of three records reviewed.

The agency failed to ensure that patient and/or caregiver education was provided in one (Records/Patients #2) of three records reviewed.

The agency met the condition of participation when the agency failed to ensure: - A complete plan of care (G574); - Promptly alert the physician to any changes in the patient's needs that suggest the plan of care should be altered (G590); - Coordinate care delivery to meet the patient's needs, and…

The agency failed to ensure a complete plan of care was developed for one patient (Record/Patient #1) of three clinical records reviewed when the agency failed to ensure the plan of care included physician orders for a Stage 3 pressure ulcer resulting in the likelihood of harm to this patient.

The agency failed to promptly alert the physician of patient needs to determine if changes in the plan of care were needed in one (Record/Patient #1) of three records reviewed resulting in the likelihood of harm to this patient.

The agency failed to effectively coordinate care to meet the needs of one patient (Record/Patient #1) of three clinical records reviewed when the agency failed to: - Obtain physician orders for wound care in a timely manner.

The agency failed to ensure nursing staff documented education with the patient's caregiver regarding wound care treatment and the competency of the caregiver to perform the wound care for one patient (Patient #3) out of three clinical records reviewed.

The agency failed to ensure a patient was treated per agency policy.