Lifespring Home Care

The agency failed to record all patient care orders in the plans of care for 2 of 4 patients reviewed receiving wound care (Patient's # 5 and #6) Findings include: AGENCY POLICY According to the agency's policy, titled Care Planning, Coordination of Services and Quality of Care, dated 2/6/2019, (in…

The agency failed to ensure nursing staff promptly alerted the physician of changes in the patient's condition that suggested a need to alter the plan of care for 2 of 4 patients whose record was reviewed and who received skilled nursing (SN) for wound care (Patients #5 and B).

The nurse failed to ensure the patient received care in conformance with physician's orders and as indicated in the plan of care for 1 of 4 patient records reviewed who received skilled nursing (SN) for wound care (Patient B).

The agency failed to ensure skilled professionals assumed responsibility for preparing and maintaining accurate and complete clinical notes for 2 of 4 patients who received skilled nursing (SN) services specifically for wound care (Patients #5, and B).

The agency failed to ensure services and treatments were provided in conformance with physician orders for 1 of 2 patient records reviewed who had orders for Foley catheter care (Patient #7).

The agency failed to provide services and treatments only as ordered by the physician for 1 of 1 patients' record reviewed who received intravenous (IV) infusion therapy (Patient #2).

The agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient's plan of care and the written patient care instructions made an onsite visit to the patient's home no less frequently than every 14 days to conduct home care aide…

The agency failed to ensure clinical records contained accurate documentation of patient's clinical notes and plans of care for 1 of 4 patient records reviewed who received wound care (Patient #6).