Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017035 (X3) Date Survey Completed 03/27/2025
Name of Provider or Supplier Infirmary Home Health Agency, Inc. Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 A recertification survey was conducted on 3/25/25 to 3/27/25 and Infirmary Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
G0000 A recertification survey was conducted on 3/25/25 to 3/27/25 at Infirmary HomeCare. Standard level deficiencies were citied that will require an acceptable plan of correction.  
G0464 Advise the patient of discharge for cause
CFR(s): 484.50(d)(5)(i)

(i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered;


This ELEMENT is not met as evidenced by:
Based on Medical Record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to provide the patient with notification prior to discharge.

This deficient practice did affect MR # 2, one of five discharge charts reviewed and had the potential to affect all patients served by this agency.

Findings include:

Agency Policy: Coordination of Care , from Admit Through Discharge.

Policy Number:  2.1.017

Revised Date: 9/1/24

Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. 

Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: 

Identifying patient needs through assessment and communication with other health care providers...Procedure: 

...7. Coordination of care with patient and caregiver:...

Ongoing, the patient /caregiver will be notified of:...

d. Transfer or discharge...


1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. 

A  review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the Skilled Nurse (SN) one time a week for nine weeks, for the SN to perform/instruct patient/caregiver in the procedure of wound care to right and left upper buttocks and coccyx

A review of the MR revealed the SN visit notes dated from 11/8/24 to 12/20/24  had no documentation the patient was notified of the upcoming discharge for cause on 12/30/2024.

An interview was conducted on 3/27/25 at 12:08 PM with Employee Identifier # 1, Area Administrator, who confirmed there was no documentation of  the patient's notification prior to discharge.

 
G0470 Document efforts to resolve problems
CFR(s): 484.50(d)(5)(iv)

(iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records;


This ELEMENT is not met as evidenced by:
Based on Medical Record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to document efforts to resolve the problem prior to discharge.

This deficient practice did affect MR # 2, one of five discharge charts reviewed and had the potential to affect all patients served by this agency.

Findings include:

Agency Policy: Coordination of Care, from Admit Through Discharge.

Policy Number:  2.1.017

Revised Date: 9/1/24

Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. 

Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: 

Identifying patient needs through assessment and communication with other health care providers...Procedure: 

...7. Coordination of care with patient and caregiver:...

Ongoing, the patient /caregiver will be notified of:...

d. Transfer or discharge...


1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. 

A  review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the Skilled Nurse (SN) one time a week for nine weeks.

A review of the MR revealed the SN visit notes dated from 11/8/24 to 12/20/24 had no documentation of attempts to ensure the patient adhered to the plan of care prior to the discharge on 12/30/2024.

An interview was conducted on 3/27/25 at 12:08 PM, with Employee Identifier # 1, Area Administrator, who confirmed there was no documentation of attempts to resolve the non-compliance prior to discharge.
G0536 A review of all current medications
CFR(s): 484.55(c)(5)

A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.


This ELEMENT is not met as evidenced by:
Based on medical record (MR) review, agency policy and procedure, and interviews with staff, patients, and caregivers, it was determined the agency failed to ensure medications were reconciled to include all current medications and dosages. 

This deficient practice affected four of seven Home Visit (HV) patients including HV # 3, HV # 5, HV # 7, and HV # 2, and had the potential to affect all patients admitted to this agency. 

Findings include: 

Agency Policy: Monitoring Medications

Policy Number: 10.008

Revised: 7/1/24

Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home.

Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode...

Procedure: 

...a. Through a collaborative process the care team will: 

i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies...

 


4. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, Unspecified.

A review of the HHC and POC dated 2/27/25 revealed physician's order for Skilled Nurse two visits for week one and one visit per week for eight weeks.

 A HV was conducted on 3/25/25 at 3:00 PM to observe care provided by EI # 7, Registered Nurse . 

During the HV, a review of the current medications was conducted with EI # 7 and HV # 2 and compared to the Medicine List dated 3/25/25, the following discrepancies were found:

Amlodipine 5 mg tablet. One tablet PO (by mouth) daily for hypertension. HV # 2 said he/she has been off this medication for several months, at least since last July.

Ondansetron 8 mg ODT (orally disintegrating tablet). One tablet every 8 hours/PRN (as needed) for nausea, was present in the home but not listed on the Medicine List with a fill date of 12/30/24. HV # 2 stated he/she took this only when needed.

Meloxicam 15 mg tablet. One tablet daily/PRN for pain was present in the home but not listed on the Medicine List with a fill date of 2/9/24. HV # 2 said he/she had been on that forever.

Cetirizine 10 mg tablet. One tablet daily for allergies with a fill date of 3/15/25. He/she said the "doc" just started me on that a couple of weeks ago.

Aloe Burn Relief 0.5 % (percent) topical spray weekly/PRN for pain relief when changing mediport dressing was present in the home but not on the Medicine List.. HV # 2 said his/her wife/husband purchased that a few weeks ago and asked the nurses to use it when changing the mediport dressing.

An interview was conducted on 3/27/25 at 11:53 with EI # 1, Area Administrator of Operations, who confirmed the agency failed to reconcile medications per agency policy.

2. HV # 5 was admitted to the agency on 3/3/25 with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Hypothyroidism, Unspecified. 

A HV was conducted on 3/25/25 at 1:54 PM with EI # 6, Physical Therapist, to observe care provided. 

During the HV, the surveyor compared the medications found in home to the agency medicine list (ML). The patient verified the following medication discrepancies:

Aspirin 81 mg 1 tablet twice daily was found in the home. The caregiver verbalized taking the 81 mg twice daily dosage since 2/6/25 or 2/7/25. Aspirin 81 mg 1 tablet daily was on the agency ML. 

Meloxicam 7.5 mg 1 tablet daily was on the agency ML. The caregiver verbalized the patient had not taken Meloxicam since 2022.

An interview was conducted on 3/27/25 at 12:51 PM with EI # 2, Clinical Director, who confirmed the agency failed to ensure the medications were reconciled. 

3. HV # 7 was admitted to the agency on 2/6/25 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. 

A HV was conducted on 3/26/25 at 9:12 AM with EI # 3, Occupational Therapist, to observe care provided. 

During the HV, EI # 3 and the surveyor compared the medications found in home to the agency ML. The patient verified the following medication discrepancies:

Aspirin 325 mg 1 tablet daily was found in the home. The patient verbalized taking the 325 mg dosage since August 24. Aspirin 81 mg 1 tablet daily was on the agency ML. 

Hydrochlorothiazide (HCTZ) 25 mg 1 tablet daily was found in the home. The patient verbalized taking the 25 mg dosage since December 24. HCTZ 12.5 mg three times day was on the agency ML.

Magnesium Citrate 200 mg 1 tablet daily was found in the home. The patient verbalized taking the magnesium citrate since January 25. There was no documentation of the magnesium citrate on the agency ML. 

Tramadol 50 mg 1 to 2 tablets every 8 hours as needed for pain was found in the home. The patient verbalized taking the Tramadol for the last three or four years. There was no documentation of the Tramadol on the agency ML. 

Valacyclovir 1 gm (gram) 1 tablet twice daily was found in the home. The patient verbalized taking the Valacyclovir since February 25. There was no documentation of the Valacyclovir on the agency ML. 

An interview was conducted on 3/27/25 at 12:59 PM with EI # 2 who confirmed the agency failed to ensure the medications were reconciled. 

1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Tract Infection, Unspecified Atrial Fibrillation, and COVID-19. 

A review of the Home Health Certification and Plan of Care (HHC and POC) dated 2/6/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks. 

A HV was conducted on 3/25/25 at 12:15 PM to observe care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN).

A review of the current medications was conducted with EI # 4 and HV # 3 and compared to the Medication List dated 3/25/25. The following is a list of the discrepancies:

a. Lasix 40 milligrams (mg) take one tablet two times a day was listed on the Medication List. 

HV # 3 stated he/she had been taking one tablet one time a day for one year. 

b. Coreg 3.125 mg, take one tablet daily was on the Medication List. 

HV # 3 stated the dosage was increased to 12 mg during her last physician office visit on 3/10/25. HV # 3 stated he/she had been taking three to four of the 3.125 mg tablets a day to increase the dosage. There was no new prescription of Coreg in the home. 

c. Jardiance 10 mg, take one daily, filled 3/10/25, was in the home with the current medications. HV # 3 stated the new prescription was added during her physician office visit on 3/10/25. 

An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse (RN), who confirmed the agency failed to ensure the medications were reconciled per agency policy. 
G0572 Plan of care
CFR(s): 484.60(a)(1)

Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan.


This STANDARD is not met as evidenced by:
Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency failed to follow Plan of Care (POC) ordered visit frequency.  

This deficient practice did affect two of 17 MRs reviewed including Home visit (HV) # 7, MR # 6, and had the potential to negatively affect all patients served by the agency. 

Findings include: 

Agency Policy: POC

Policy Number: 2.1.007

Revised Date: 9/1/24

Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner's orders are followed. 

Policy: Each patient has an individualized POC developed...that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. 

Procedure: 

...2. The POC includes: 

...b. Types, frequency, and duration of services required...

i. Patient specific interventions...measurable outcomes and goals identified by the agency and patient. 

 


2. MR # 6 was admitted on 2/11/25 with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia, Hypertensive Heart and Chronic Kidney Disease, and Chronic Diastolic (Congestive) Heart Failure.

Review of the Home Health Certification and Plan of Care dated 2/11/25 revealed physicians orders for Skilled Nurse (SN) one visit per week for one week, two visits per week for one week, then one visit per week for seven weeks and Physical Therapist (PT) one visit for one week, then two visits per week for eight weeks.

Review of the SN and PT Visit Notes for the week 2/23/25 to 3/1/25 revealed no SN visits were completed and one of two PT visits were completed.

There was no documentation the physician was notified of the missed visits and no documentation the agency attempted to reschedule the visits. 

An interview was conducted on 3/27/25 at 12:15 PM with EI # 9, Registered Nurse, who confirmed the agency failed to ensure the physician's orders for visit frequency were followed.

 

1. HV # 7 was admitted to the agency on 2/6/25 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. 

Review of the Physician Order dated 3/11/25 revealed an order for HHA (home health aide) once a week for four weeks. 

Review of the missed visit notification dated 3/13/25 (Thursday) revealed a missed HHA visit due to the patient having a physician appointment. 

Review of the HHA visit notes dated 3/11/25 to 3/15/25 revealed no documentation of a HHA visit or an attempt to reschedule the missed HHA visit. 

An interview was conducted on 3/27/25 at 12:57 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed there was no documentation of a HHA visit or an attempt to reschedule the missed HHA visit.
G0574 Plan of care must include the following
CFR(s): 484.60(a)(2)(i-xvi)

The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include.


This ELEMENT is not met as evidenced by:
Based on review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency failed to include patient specific interventions, measurable outcomes and goals for a peripherally inserted central catheter (PICC) in the plan of care (POC). 

This deficient practice did affect MR # 9, one of one MR reviewed with a PICC, and had the potential to effect all patients with a PICC served by the agency. 

Findings include: 

Agency Policy: POC

Policy Number: 2.1.007

Revised Date: 9/1/24

Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient...

Policy: Each patient has an individualized POC developed...that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. 

Procedure: 

...2. The POC includes: 

...i. Patient specific interventions...measurable outcomes and goals identified by the agency and patient. 

 


1. MR # 9 was admitted to the agency on 12/20/24, and recertified for continued care from 2/18/25 to 4/18/25, with diagnoses including Cellulitis of Left Lowers Limb and Disruption of External Operation (Surgical) Wound, Not Elsewhere Classified, Subsequent Encounter.

Review of the Home Health Certification (HHC) and POC dated 2/18/25 to 4/18/25 revealed an order for a skilled nurse (SN) frequency of once a week for eight weeks. There was no documentation of interventions, measurable outcomes, and goals for a PICC. 

Review of the Recertification nursing note (comprehensive assessment) dated 2/18/25 revealed the patient had a PICC to the right upper extremity. 

Review of six of six SN visits from 2/18/25 to 3/18/25 revealed site care, flushing, and/or blood was removed from the PICC line during the visit. 

An interview was conducted on 3/27/25 at 1:02 PM with Employee Identifier (EI) # 2, Clinical Director, who confirmed there was no interventions, measurable outcomes, and goals for a PICC on the patients POC.

 
G0682 Infection Prevention
CFR(s): 484.70(a)

Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases.


This STANDARD is not met as evidenced by:
Based on observation, medical record (MR) review, agency policy and procedure and interviews with staff, it was determined the agency failed to ensure:

a. Staff performed hand hygiene (HH) per agency policy.

b. Staff cleaned re-usable equipment per agency policy.

This deficient practice did affect three of seven home visits (HV) patients including HV # 3, HV # 2, HV # 4, and had the potential to affect all patients served by the agency. 

Findings include: 

Agency Policy: Cleaning of Re-Useable Equipment

Policy Number: 8.006

Revised: 6/1/22

Purpose: To assure equipment required for patient care is clean and sanitized to prevent the spread of infections.

Policy: Equipment used for more than one patient is cleaned between each patient use.

Definitions: 

Low-Level Disinfection - destroys most bacteria...Examples include at least 70 % isopropyl alcohol/ehtyl alcohol...3. Non-Critical Items - Equipment that is only meant to come in contact with intact patient skin...(...stethoscopes, blood pressure cuffs, pulse oximeters...)

Procedure: 

Non-critical items which will come in contact with intact patient skin will undergo a low-level disinfection between each patient use... Agency Policy: Hand Hygiene

 Policy Number: 8.004

 Revised Date: 5/1/19

 Purpose: To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines.

 Policy: Staff are required to perform hand hygiene (HH) prior to, at specified time points during, and following patient contact…

 Procedure:

 1. Staff performs HH …

    a. Before direct contact with the patient.

    b. Before performing an aseptic task (ergo, insertion of invasive devices, wound care).

    c. After contact with wound dressing, contaminated surfaces.

    d. If moving from a contaminated body site to a clean body site.

    e. After contact with inanimate objects.

 

5. a. …Gloves will be worn during any patient care activities or interaction with any potentially contaminated surfaces or items…

8. c. …Change gloves during patient care if moving from a contaminated body site to a clean body site.

 


2. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, unspecified.

Review of the Home HHC and POC 2/27/25 revealed physician's orders for Skilled Nurse (SN) two visits for one week and then one visit for eight weeks.

Further review of the HHC and POC revealed SN to obtain IV (intravenous) access via aseptic technique using Huber Needle. SN to change Huber needle 1x (time) a week and PRN (as needed) contamination/malfunction. Flush IV access with 10 ml (milliliter) of Normal Saline (NS) before infusion and 10 ml NS and Heparin 100 Units / (per) ml after infusion. Cleanse site with Chlorhexidine. Air dry. Apply transparent dressing weekly.

A HV was conducted on 3/25/25 at 3:00 PM to observe IV care provided by EI # 7, Registered Nurse (RN).

EI # 7 performed HH, donned gloves and began opening supplies to change the Huber Needle and begin infusion of HV # 2's antibiotic. While opening wrapped 3 ml syringes of NS, a wrapper fell to the floor. EI # 7 picked up the wrapper off of the floor and put it in the trash. EI # 7 continued opening supplies, wearing the same pair of gloves. 

EI # 7 opened a pair of sterile gloves which were donned over the contaminated gloves and began to clean the site with the Chlorhexidine prep stick. The sterile gloves were removed and a second pair of sterile gloves were donned over the previously contaminated gloves. The Huber Needle was inserted into the port site, and the dressing change was completed. The sterile gloves were removed while the contaminated non sterile gloves remained on EI # 7's hands. More adhesive was applied to the site and the non sterile gloves were removed. The trash was disposed of into HV # 2's garbage and HH was then performed.

EI # 7 failed to follow the agency policy for HH and glove use.

An interview was conducted on 3/27/25 at 11:53 PM with EI # 1, Area Administrator of Operations, who confirmed the agency failed to ensure staff followed the agency HH policy.

3. HV # 4 was admitted on 3/15/25 with diagnoses including Type Two Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease.

Review of the HHC and POC revealed Physical Therapy two times a week for seven weeks effective 3/16/25.

A HV was conducted on 3/25/25 at 4:25 PM to observe care provided by EI # 8, Physical Therapy Assistant .

EI # 8 placed a barrier on a television stand with his/her bag in the middle of the barrier. HH was performed, gloves were donned and equipment was removed from the bag and placed on the right side of the bag, on the barrier. Vital signs were obtained and used equipment was placed back on the right side of the bag, onto the barrier, contaminating the right side of the bag. 

Gloves were removed and without performing HH, an ankle circumference was obtained.

Without performing HH or donning gloves, a Sani Cloth was used to clean the used equipment that was then placed back on the contaminated right side of the barrier. The equipment was allowed to dry and without performing HH, placed back in the bag.

EI # 8 failed to follow the agency policy for HH.

An interview was conducted on 3/27/25 at 12:03 PM with EI # 1, who confirmed the agency failed to ensure the staff followed the agency HH policy.

 

 

1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Infection, Unspecified Atrial Fibrillation, and COVID-19. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/6/25 revealed physician's orders for SN one visit per week for nine weeks. 

Review of the Physician Order dated 2/19/25 revealed orders for wound care to left dorsal foot, cleanse with saline moistened gauze, apply enzymatic debriding agent Santyl Ointment to the wound bed, pack wound with Isosorbide 1/4 inch packing, cover with two inch cling, and cover with cling every day. 

A home visit was conducted on 3/25/25 at 12:15 PM to observe wound care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse. 

EI # 4 placed a barrier on a chair for bag and clean items. Blood pressure cuff and stethoscope removed from the bag, vital signs taken, and dirty items placed back on the same barrier. 

EI # 4 then wiped the reusable items with sanitizing wipes then placed the items back onto the same location of the barrier the contaminated items were removed from. 

EI # 4 then placed a barrier under HV # 3's left foot onto the floor. EI # 4 then placed HV # 3's wound supply bag onto the barrier and removed the wound supplies.

EI # 4 then removed the dressing from the left foot and disposed of the soiled dressing in a plastic bag. After providing wound care, EI # 4 removed HV # 3's wound care supplies from the side of the barrier and placed them back into the box with the patient's clean supplies. 

An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse, who confirmed the agency failed to ensure the staff followed agency infection prevention policy. 
G0706 Interdisciplinary assessment of the patient
CFR(s): 484.75(b)(1)

Ongoing interdisciplinary assessment of the patient;


This ELEMENT is not met as evidenced by:
Based on medical record (MR) review, agency policies and procedure, and interviews it was determined the agency failed to ensure:

1. Wounds were measured per the agency policy.

2. Measure the external length of a peripherally inserted central catheter (PICC) line per the agency policy. 

3. Measure the upper arm circumference of the arm with a PICC inserted. 

This deficient practice affected two of 17 MRs reviewed including MR # 9, and MR # 2, and had the potential to affect all patients admitted to this agency. 

Findings include:

Agency Policy: Wound Assessment, Documentation, and Photography

Policy Number: 2.2.001

Revised: 9/1/24

Purpose: To ensure the accurate and consistent assessment and documentation of wounds. 

Policy: 

Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the MR... assess wounds at least:

...every other week for patients receiving wound care by the agency at a frequency less than daily...

The assessment includes measurement of the length, width, and depth...

Agency Policy: Dressing Change Procedure for Central Venous, Midline, and PICC.

Policy Number: 10.027

Revised: 10/1/16

Purpose: To keep insertion sites clean, stabilize catheters, and minimize the risk of infection.

...Procedure: 

...8. Inspect catheter, catheter exit site, and surrounding skin and patient's arm, chest, and neck area. 

...c. Obtain upper arm circumference...

d. Measure external length of catheter from the insertion site to the catheter hub...

 


2. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four.

A  review of the HHC and POC dated 11/4/24 to 1/2/25 revealed an order for the SN one time a week for nine weeks, for the SN to perform/instruct patient/caregiver in the procedure of wound care to right and left upper buttocks and coccyx.

A review of two of the eight SN visit notes dated 12/12/24 and 12/20/24 revealed no documentation of a wound measurement for the right buttock, left buttock and coccyx.

An interview was conducted on 3/27/25 at 12:08 PM with EI # 1, Area Administrator, who confirmed the wounds were not measured per the agency policy. 

1. MR # 9 was admitted to the agency on 12/20/24, and recertified for continued care from 2/18/25 to 4/18/25, with diagnoses including Cellulitis of Left Lowers Limb and Disruption of External Operation (Surgical) Wound, Not Elsewhere Classified, Subsequent Encounter.

Review of six of six nursing notes dated 2/18/25 to 3/18/25 revealed the patient had a PICC to the right upper arm. 

Further review of the nursing notes dated 2/26/25, 3/4/25, and 3/12/25 revealed documentation a PICC dressing change was completed. There was no documentation of the external catheter length of the PICC on 2/26/25, 3/4/25, and 3/12/25. There was no documentation of an upper arm circumference on 3/4/25 and 3/12/25. 

An interview was conducted on 3/27/25 at 1:02 PM with EI # 2 who confirmed the external catheter length and upper arm circumference were not documented per the agency policy.
G1024 Authentication
CFR(s): 484.110(b)

Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry.


This STANDARD is not met as evidenced by:
Based on Medical Record (MR) review, The Alabama Board of Nursing 610-X-6-.06 Documentation Standards,  and staff interviews it was determined the agency failed to ensure the staff documented accurately in the patient record. 

This deficient practice did affect MR # 2, one of two indwelling catheter charts reviewed, and had the potential to affect all indwelling catheter patients served by this agency.

Findings include:

Alabama Board of Nursing
Chapter 610-x-6: Standards of Nursing Practice

Supp (Supplement): 12/31/21

610-X-6-.06 Documentation Standards


(1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.
(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... "


1. MR # 2 was admitted to the agency on 7/13/23 and recertified for continued care on 11/4/24 to 1/2/25 with a primary diagnosis of Pressure Ulcer of Sacral Region Stage Four. 

A  review of the Home Health Certification and Plan of Care dated 11/4/24 to 1/2/25 revealed an order for the SN one time a week for nine weeks, for the Skilled Nurse (SN) to perform an insertion of a 24 French 10 cubic centimeter balloon, suprapubic catheter every month, and as needed for dislodgement or blockage.

 A review of the skilled nurse visit note dated 11/13/24 revealed documentation of the suprapubic catheter change.

A review of the SN visit notes revealed the nurse documented on 11/8/24,11/22/24, 11/29/24, 12/6/24, and 12/12/24 inaccurate dates for the insertion of the suprapubic catheter.

An interview was conducted on 3/27/25 at 12:08 PM, with Employee Identifier # 1, Area Administrator, who confirmed the nurse failed to accurately document the insertion date of the suprapubic catheter.