| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017016 | (X3) Date Survey Completed 06/16/2022 |
| 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) |
| 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 policy and procedure and staff interview it was determined the agency staff failed to document wound assessments per agency policy. This deficient practice did affect 1 of 6 MR's reviewed with a wound, including Home Visit (HV) # 4, and had the potential to affect all patient's with wounds served by the agency. Findings Include: Policy: Wound Assessment, Documentation and Photography Policy Number: 2.2.001 Revised Date: 12/1/21 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently...all wounds will be assessed with appropriate documentation within the medical record. Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound...Wound assessment findings will be documented... Unless otherwise ordered by the physician, the Registered Nurse (RN)…will assess wounds at least: …every other week for patients receiving wound care by the agency at a frequency less than daily... Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurement of the length (L), width (W), and Depth (D), undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound. At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound. …Procedure: …3. Document the following in the medical record: a. Wound type... …c. Stage or Thickness: …ii. For all other ulcers, document underlying etiology of the ulcer and skin involvement to include limited to breakdown of skin; fat layer exposed; necrosis of muscle; or necrosis of bone. iii. All other wounds will be described as either Partial or Full Thickness. c. (c is documented twice) Wound size: L, W and D are measured in centimeters (cm)… d. Undermining and/or Tunneling... e. Wound bed: percentage of eschar, slough, and granulation. f. Wound edges: whether open or closed. g. Drainage: odor, type (color) and amount. h. Peri wound condition. 1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7). Review of the Physician Order dated 5/31/22 revealed an order for "SN to cleanse new open areas to left lower leg with NS (Normal Saline) and pat dry with clean dry gauze. Apply Xeroform to open areas and wrap with kerlix and secure with tape during SN visit on 5/31/22..." Review of the SN Visit Note Report (VNR) dated 5/31/22 revealed no documentation wound care was provided to "...3 new open areas noted to left lower leg and two blisters that have not opened..." There was no documentation of wound measurements, wound type for the new open areas, stage or thickness of the wounds, if undermining and/or tunneling were present, wound bed appearance, if the wound edges were open or closed, the type and amount of wound drainage and peri wound condition. Review of the SN VNR's dated 6/2/22 (week of 5/29/22 - 6/4/22) and 6/7/22 (week of 6/5/22 - 6/11/22) revealed no documentation of wound measurements for the left lower leg wounds. An interview was conducted on 6/16/22 at 2:17 PM with Employee Identifier (EI) # 2, Patient Care Manager (PCM), who confirmed the SN failed to document the wound assessments of the left lower leg wounds per agency policy on 5/31/22, 6/2/22 and 6/7/22. |