Encompass Home Health of North Carolina

The agency failed to include orders for urinary catheters for 2 of 2 patients with urinary catheters (#1, & 3) and failed to include orders for oxygen therapy for 1 of 1 patient with oxygen (#2).

The agency failed to include orders for occupational therapy (OT) for 2 of 2 patients with orders from the referring physician for OT (#1 & 3).

The RN failed to perform hand hygiene prior to entering the nursing bag and failed to place the documentation device on a clean barrier when not in use for 1 of 2 nursing home visits.

The registered nurse removed the huber needle without a physician’s order for 1 of 1 records reviewed with an implanted port (medical device that allows for the administration of treatments and blood draws) [3]; and failed to monitor weights and blood sugar levels for 4 of 19 patients [ #5, 7, 13…

The agency failed to notify the physician prior to educating a patient to increase fluid intake [diagnosis of congestive heart failure] for 1 of 1 patients [#2]; and failed to notify physician when a patient reported the home was infested with bugs for 1 of 1 patients [#9]. The findings included…

The agency failed to give proper notification prior to discharging 1 of 3 discharged patients [#1]. The findings included: The policy, Transfer or Discharge From services [revised 7/2019], was provided by Clinical Manager # 3 on 5/22/23 at approximately 12:12 pm.

The agency failed to document the existence and resolution of a complaint for 1 of 1 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 3/10/23 with admitting diagnoses of Alzheimer’s Disease and Vascular Dementia [problems with reasoning, planning, judgment, memory…

The discharge summary failed to include accurate information related to the patient's goals for 1 of 3 patients [#1]. The findings included: The policy, Clinical Record [revised 5/23/22], was provided by Clinical Manager # 3 on 5/22/23 at approximately 12:12 pm.

Findings include: Based on policy review, clinical record review, infection report, hospital records, staff interview, licensed staff failed to coordinate care with the physician and other interdisciplinary staff for 5 of 18 records reviewed (#5, 15, 17, 18, and 1).

The agency failed to follow physician’s orders related to wound care for 1 of 9 records with a wound [# 1 ]; failed to follow the physician’s order related to pressure setting for a wound vac for 1 of 1 record with a wound vac [#4],failed to notify the physician when vital signs/blood sugars fell…

Staff interviews the agency failed to change gloves [practice proper hand hygiene] when doing a dressing change for 1 of 3 visits [#7] with a dressing change.

Staff the Plan of Care [POC] failed to include all the current/correct medication/doses the patient was taking for 4 of 6 virtual visits conducted [# 6, 7, 8 and 10]; failed to include a frequency for wound care for 2 of 9 records with a wound [# 4 and 17]. The findings included: 5. Patient #8 was…

The agency failed to obtain orders for disimpaction for 1 of 1 patients that required disimpaction (#8); failed to obtain orders for wound care for 1 of 9 records with wounds [#6]. Findings include: Patient #6 was admitted on 02/14/2022 with diagnoses of Encounter for orthopedic aftercare following…

The agency failed to coordinate care between disciplines for 2 of 18 patients (#5, 17).

The agency failed to notify the physician of the need for further testing for 1 of 1 patient’s with swallowing problems; failed to notify the physician of signs or symptoms related to possible urinary tract infection for 4 of 4 patients with urinary symptoms (#5, 15, 17, and 18); failed to notify…

The agency failed to obtain a physician's order for a foam dressing for 1 of 3 charts reviewed [#1] and failed to change a dressing in accordance with the physician's order for 1 of 3 charts reviewed [#2]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 11/22/19 and a…

The agency did not follow safety practices for lab draws for 1 of 1 patients that was observed having a venipuncture.

The agency failed to follow physician orders for dressing changes for 1 of 7 patients that received a home visit (#2); and made treatment recommendations without a physician's order for 1 of 5 discharged records reviewed (#14).

Staff interviews the SN [skilled nurse] failed to provide services as ordered in the Plan of Care [POC] for the type of dressing to left buttock and right buttock for 1 of 10 patients with a wound [#1]. The findings included: The policy The Physician's Role was provided by the Branch Manager on…

The clinical record did not include weekly wound measurements for 4 of 10 patients with a wound [#1, 12, 15, and 2]; and failed to include consistent documentation regarding the presence of undermining [the tissue under the wound edges become eroded resulting in a pocket under the skin at the…