Care 2 You

The facility failed to ensure the Physician was promptly notified of the patient's health status for 1 (MR #1) of 1 patient who required attention to her Intravenous access site and who was subsequently sent to the hospital, resulting in lack of Physician inclusion and oversight and the potential…

The Skilled Nurse failed to provide ongoing assessments of the patient health status for 1 (MR #1) of 1 patient who required attention to her Intravenous access site, resulting in the potential for the development of infection, decline in health status and unmet care needs.

The Agency failed to ensure the Registered Nurse provided care and services as indicated in the Plan of Care for 1 (MR #1) of 1 patient who required Skilled Nursing services for management of a peripheral access line resulting in the potential for physiological health concerns and unmet care needs.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and a history of events leading to current home care needs in…

The Agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects and drug reactions for 2 (MR#s 9 and 13) of 7 records reviewed which included major and/or duplicative drug therapies, and failed to ensure a registered nurse…

The plan of care failed to include safety parameters in which to notify the physician of worsening signs and symptoms of known diagnoses; failed to incorporate objectively measurable goals to determine the patient's progress toward achieving goals; failed to include goals that were pertinent to the…

The Agency failed to ensure Physical Therapy (PT) developed a Plan of Care that incorporated pertinent interventions concerning the patient's medical needs in 1 (MR #7) of 2 records reviewed with therapy only cases, from a total sample of 17 records, resulting in the potential for poor patient…

The Agency failed to ensure the clinical record was complete, including assessments, notes, and evaluations for 2 (MR's #7 and 11) of 2 records with therapy only services ordered, from a total of 17 records reviewed, resulting in an incomplete depiction of the patient's health status, and the…