The Care Team

The agency failed to ensure the registered nurse prepared written patient care instructions that included safety parameters and skin care instructions for 2 of 8 (P-12, 15) records reviewed in which aide services were provided, resulting in a lack of direction regarding the needs of these patients.

The agency failed to ensure patients were informed of the Administrator's name and contact information to receive complaints for 6 of 7 (P-4, 5, 7, 11, 16, 17) joint surveyor home visits, resulting in the potential for patient complaints or concerns to go unaddressed which could negatively affect…

The agency failed to ensure that 2 (P-1 and 3) of 17 patients were included in their overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning…

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, measurable data to use as a baseline for future assessments…

Discharge Or Transfer Summary Content

The agency failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 4 of 6 records in which Home Health Aide (HHa) services were provided (MR#s 2, 4, 10 and 12) from a total of 17 records reviewed, resulting in the potential for the…

The agency failed to ensure the plan of care covered all pertinent interventions with reportable safety parameters, and objectively measurable goals specific to the needs of the patient for 15 records (MR#s 1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 13, 14, 15, 16, and 17) from a total sample of 17 records…

The agency failed to ensure the registered nurse performed complete assessments and re-assessments of the patient's health status and needs in 2 of 7 records reviewed in which nursing services were provided out of a total sample of 17 records reviewed (MR#s 12 and 13), which resulted in the…

The agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge for 5 of 17 (MR#s 1, 2, 11, 12, and 13) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's…

The Agency (HHA) failed to ensure the comprehensive assessment documented the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 5 records, from a total of 17 sampled records reviewed (MR's #1, 3, 4, 11 and 12), resulting…

The agency failed to ensure the registered nurse (RN) documented a verbal order to be included in the patient's plan of care for 1 of 3 records reviewed (MR#9) in which lab work was ordered, from a total of 17 sampled records, resulting in no record of a physician's verbal order; and the agency…

The registered nurse (RN) administered treatments that were not ordered by the physician for 2 of 3 records reviewed (MR# 9, 12) in which the patients had labs drawn; and failed to ensure the RN documented weekly wound measurements for 1 of 4 records reviewed (MR#9) in which the patients had a…

The agency failed to ensure clinicians documented clear, complete and timely clinical notes in 3 of 17 records reviewed out of a total sample of 17 records reviewed (MR #4, 11, 12).

The agency failed to ensure the clinical record contained a physician order for lab work for 1 of 3 records reviewed (MR#9) in which lab work was ordered, from a total of 17 sampled records, resulting in an incomplete clinical record for this patient.