| 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) |
| 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. |