Liberty Home Care

Staff interviews the LPN [licensed practical nurse] failed to report new skin breakdown to the RN [registered nurse] for 1 of 6 records with a wound [#5]. The findings included: The policy, Coordination and Communication Activities [12/2020], was provided by the agency administrator on 8/30/2022 at…

Staff the Plan of Care [POC] failed to include all medications/correct dose/strength the patient was using for 1 of 2 virtual visits [#3]; failed to include all pertinent diagnoses for 1 of 22 records [#11]; failed to include weight bearing restrictions for 1 of 22 records [#6]; failed to include…

Staff interview the agency failed to coordinate care with the physician regarding vital signs outside of parameters for 6 of 22 records reviewed (#18,5, 8, 11, 14, and 20) incorrect weight bearing status for 1 of 4 physical therapy records reviewed (#5), reported lightheadedness for 1 of 5…

Staff interview the clinical record failed to include wound measurements for 1 of 6 records with wounds (#17).

Patient/caregiver interview and staff interview the agency failed to maintain a current listing of all medications the patient was using for 2 of 7 patients visited in the home [#7 and 8]. The findings include: "Operations Manual Section 125.01 ... Revised 11/8/18 ... Medication Profile and Drug…

Staff interviews the agency failed to coordinate care with the physician for a change in condition for 1 of 1 patients (#13) with a tracheostomy (airway made that allows a person to breathe without the use of the nose or mouth).