Home Health of Wilson

The agency failed to take precautions to prevent the spread of infection for 1 of 2 patients who received a skilled nurse home visit (patient #7).

The agency failed to include a complete list of medications for 2 of 4 patients with home visits conducted.

The agency failed to alert the physician of a change of condition for 2 of 2 patients with a documented change of condition (#3 and 4).

The agency failed to document blood glucose levels for 1 of 5 patients with diabetes mellitus (disease resulting in too much sugar in the blood).

Staff interview the agency failed to include Oxygen on the initial Plan of Care for 1 of 2 patients using Oxygen. [ Patient #8]. Findings included: Agency policy received from Agency Executive Director on 5/24/22 at 10:50 a.m., “Coordination of care, Admission through discharge” revised 8/1/19…

The agency failed to follow a physician’s order to perform a pre-albumin level for 1 of 18 records reviewed (Patient #5), failed to obtain an order for wound care for 1 of 4 patients with wounds (Patient #9), and failed to clarify the type and/or amount of insulin that a patient should take for 1…

Staff interview the agency failed to give notice prior to discharge for 1 of 3 discharged patients (#1).

The Plan of Care did not include the complete orders for indwelling catheter changes/maintenance for 2 of 2 records for patients with indwelling catheters (#1 and 3).

The agency failed to maintain sterile technique during a procedure that required sterile technique for 1 of 1 patient with orders for sterile dressing change.

The agency failed to update the medications with the comprehensive assessment for 3 of 7 patients that received a home visit (#13, 7, and 8).

The Plans of Care failed to include a description of the patient's risk for emergency department visits or risks for hospital re-admission or interventions to address underlying risk factors for 17 of 17 records reviewed (#1, 11, 13, 2, 3, 4, 10, 14, 9, 8, 12, 7, 16, 6, 17, 15, and 5 ), with 3 of…

And/or blood pressure) were not obtained as part of an assessment for 5 of 17 patients (#13, 5, 6, 7, and 8).