Kindred at Home 1

SN (skilled nurse) failed to create or maintain accurate, all-inclusive medication lists for three (#1, #2, #3) of 17 records reviewed (#1-#17) This includes a review to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects…

The SN failed to provide patient and/or caregiver education about prescribed oxygen use in 2 (#4, #5) of 17 (#1-#17) clinical records reviewed.

The Agency failed to ensure practitioner ordered, focused assessment was completed and documented each visit for 1 (#4) of 17 (#1-#17) clinical records reviewed.

The Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 9 (#2, #3, #4, #6, #8, #9, #12 #16, and #17) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) did not assess weights as ordered in the patients plan of care in 1 (#17) of 17 (#1 - #17) clinical records reviewed with a plan of care to report weight gain to the patient’s physician.

The SN (Skilled Nurse) failed to follow the plan of care to teach patient altered cardiovascular disease progression status on 1 (#17) out of 17 (#1 - #17) records reviewed with cardiovascualar disease.

The Agency failed to ensure written information specific to the patients Plan of Care (POC) was provided to patients or caregivers in 7 (#6 -#12) of 7 (#6 - #12) (100%) home visits conducted.

The Skilled Nurse (SN) did not include all medications during a review of the patients current medications for 2 (#7 and #14) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) did not assess vital signs or notify the Physician of blood sugar results as ordered on the Plan of Care (POC) for 2 (#10 and #13) of 17 (#1-#17) Clinical Records reviewed.

The agency staff failed to follow accepted professional standards for infection control in 1 (#10) of 3 ( #6, #8 and #10) home visits conducted with observed wound care.

The Skilled Nurse (SN) staff did not document medications, interventions or care coordination and communication between the healthcare team members in 6 (#1, #3, #4, #10, #12 and #16) of 17 (#1 - #17) Clinical Records reviewed.