| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017016 | (X3) Date Survey Completed 12/06/2018 |
| Name of Provider or Supplier Southeast Alabama Homecare, Llc | Street Address, City, State 804 Glover Avenue, Enterprise, 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) |
| G0716 | Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures and interviews with the staff it was determined the agency failed to ensure: 1. Wound vac ( negative pressure wound therapy) was performed per agency policy. 2. All documentation within the MR by the staff was consistent and documented according to the patients condition. This affected 3 of 11 MR's reviewed and did affect MR # 3, Home Visit (HV) # 4, HV # 1 and and had the potential to negatively affect all patients served by the agency. Findings include: Policy: Negative Pressure Wound Therapy (NPWT) Policy Number: 2.2007 Revised Date: 9/1/17 Purpose: To promote wound healing and establish competency assessment guidelines with utilizing negative pressure wound therapy. Policy: The RN (registered nurse) performs a wound assessment at least once a week during therapy... Procedure: 4. The clinician will document the number of foam/sponge pieces placed in the wound bed and the number of foam/sponge pieces removed from the wound... Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 1/1/18 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit to discharge. Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure: 5. Coordination of care among disciplines: Patient care is coordinated among various disciplines and services through care planning process to ensure continuity of care from admission to discharge... i. ...Report will include: Significant changes in the patient's condition... 1. MR # 3 was admitted to the agency on 12/9/17 with admitting diagnoses of Urinary Tract Infection, Site Not Specified, Muscle Weakness, Generalized. Review of the SN (skilled nurse) visit note dated 2/15/18 revealed under the respiratory section of the note the nurse documented the patient had abnormal breath sounds to the left lower lobe and the right lower lobe of the lungs consisting of crackles. Further review of the SN visit note revealed under Care Coordination the SN documented the RN (Registered Nurse) was notified of "vital signs within normal limits and lungs clear to auscultation bilaterally..." Review of the MR revealed there was conflicting documentation of the the breath sounds to the left and right lower lobes during the assessment. An interview was conducted with Employee Identifier (EI) # 1 Registered Nurse (RN) Director of Nursing, who confirmed the above mentioned findings. 2. HV # 4 was admitted to the agency on 11/23/18 with admitting diagnoses of Laceration Without Foreign Body, Left Lower Leg, Subsequent Encounter and Type 2 Diabetes Mellitus Without Specified Complications. Review of the SN visit notes dated 11/23/18 and 11/30/18 revealed the patient had a wound vac and the SN performed wound care during the visit. Further review of the visit note revealed the nurse failed to document the number of black foam pieces applied to the wound bed. Review of the SN visit note dated 11/28/18 revealed the nurse failed to document the amount of black foam pieces removed from the wound bed and applied to the wound bed. An interview was conducted on 12/6/18 with EI # 1 who confirmed the above mentioned findings. 3. HV # 1 was admitted to the agency on 9/26/18 with Cellulitis of Left Lower Limb, Venous Insufficiency (Chronic) (Peripheral), Non-pressure Chronic Ulcer of Left Calf with Fat Layer Exposed, Acute Embolism and Thrombosis of Left Popliteal Vein, Morbid Obesity and History of Falling. Review of the SN Visit Note Report dated 9/26/18 revealed the SN documented there were 5 sutures to the incision site of the port located at the RIGHT anterior chest. Further review of the SN Visit Note Report dated 9/26/18 revealed the nurse documented incision site was closed with 4 sutures. Review of the SN Visit Note Report dated 9/30/18 revealed the SN documented there were 4 sutures to the incision site of the port located at the RIGHT chest. Review of the SN Visit Note Report dated 10/2/18 revealed the SN documented there were no sutures to the incision site of the port located at the RIGHT anterior chest. Review of the SN Visit Note Reports dated 10/8/18 and 10/16/18 revealed the nurse documented in the wound assessment section of the note there were sutures (this portion of the note does not indicate the number of sutures) to the RIGHT subclavian surgical incision. Review of the SN Visit Note Report dated 10/22/18 revealed the nurse documented there were 5 sutures to the incision site of the port located to the LEFT anterior chest below clavicle. Further review of the SN Visit Note Report dated 10/22/18 revealed the SN documented in the wound assessment section of the note there were sutures (this portion of the note does not indicate the number of sutures) to the RIGHT subclavian surgical incision. Review of the SN Visit Note Report dated 10/30/18 revealed the SN documented in the wound assessment section of the note the surgical incision to the RIGHT subclavian was healed. Review of the MR revealed there was conflicting documentation related to the number of sutures and the location of the surgical incision (left or right subclavian). An interview was conducted on 12/6/18 at 8:26 AM with EI # 1 who verified the above findings. |