Crenshaw County Health Care Authority

The agency failed to ensure the staff was in conformance with physician orders for: 1. Teaching signs and symptoms of Hypoglycemia and Hyperglycemia.

The agency failed to ensure staff followed infection control standards and discarded contaminated gloves, performed hand hygiene and donned clean gloves prior to continuing with clean procedures.

The agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention and investigation of infectious and communicable diseases which included a method for identifying infectious and communicable disease problems and a plan for the appropriate actions that…

The Registered Nurse (RN) failed to prepare a written patient plan of care with specific instructions for the Home Health Aide (HHA).

The agency failed to ensure staff reconciled medications in 3 of 3 Home Visits (HV) conducted, including HV # 1 HV # 2, and HV # 3, 1 of 4 MR reviewed, including MR # 2, and had the potential to negatively affect all patients served by the agency.

The staff failed to develop the plan of care and include:1. Goals for Home Health Aide (HHA) services.2. Physical Therapy (PT) specific procedures and modalities for therapy services.

The agency failed to ensure agency staff entered a complete order for treatments and medications per the facility policy.

The agency failed to ensure: 1. Staff notified the physician of patient's need for a glucometer.

The agency failed to ensure the staff educated: a.

The staff failed to develop a complete and individualized Plan of Care (POC) for each patient and notify the physician with changes in the patient's condition which may indicate the need to update the POC.

The agency failed to ensure Home Health Aide services provided were performed using written instructions prepared by the Registered Nurse and met individualized patient needs.

The agency failed to ensure nursing staff completed and documented patient vital signs on all comprehensive assessments.

Staff failed to perform hand hygiene after contact with contaminated surfaces and wear gloves during potential exposure.

The Registered Nurse (RN) failed to prepare written patient care instructions for the Home Health Aide (HHA).

The agency failed to maintain an accurate record of all patient medications.

The staff failed to develop the plan of care and include: 1) Patient allergies. 2) Route of medication administration. 3) All durable medical equipment and supplies. 4) Home Health Aide (HHA) visit frequency. 5) Physical Therapy (PT) treatment interventions. 6) Peripheral inserted central catheter…

The staff failed to follow Plan of Care (POC) orders for reporting vital signs outside specific ordered patient goals (parameters) to nursing staff or the physician.

The Home Health Aide (HHA) failed to document all services ordered on the aide plan of care were provided, offered or declined.

The staff failed to document wound treatments and wound assessments according to the agency policy in 2 of 3 wound records reviewed.

The staff failed to complete medical record documentation for all treatment interventions.

A discharge summary was not completed within 5 days of discharge from the agency.