| DEPARTMENT OF HEALTH AND HUMAN SERVICES | FORM APPROVED | ||
|---|---|---|---|
| CENTERS FOR MEDICARE & MEDICAID SERVICES | OMB NO. 0938-0391 | ||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION |
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER |
(X2) MULTIPLE CONSTRUCTION | (X3) DATE SURVEY COMPLETED |
| 671764 | A. BUILDING __________ B. WING ______________ |
06/23/2022 | |
| NAME OF PROVIDER OR SUPPLIER | STREET ADDRESS, CITY, STATE, ZIP | ||
| HARBOR HOSPICE OF RICHMOND, LP | 12808 WEST AIRPORT BLVD., SUITE #335, SUGAR LAND, TX, 77478 | ||
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | |||
| Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation | |||
| LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE |
TITLE |
(X6) DATE |
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| FORM CMS-2567 (02/99) Previous Versions Obsolete | |||
| (X4) ID PREFIX TAG |
SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) |
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| L0536 | |||
| 16353 The agency failed to meet the condition of participation for interdisciplinary Group, Care Planning and coordination of services as evidenced by: Based on record review and interview the hospice failed to ensure that the RN coordinator as a member of the interdisciplinary group provided coordination of care and assessment for 4 of 5 (Patient #1, #2, #3 and #4) patients reviewed with wounds. Refer to L0540 Based on record review and interview the hospice failed to include wound care in the plans of care for 4 of 5 patients (Patient #1, #2, #3 and #4) patient reviewed with wounds Refer to L0545 Based on record review and interview the agency failed to ensure that the plan of care included interventions for 1 of 5 (#1) patients experiencing pain from a wound L0546 Based on record review and interview the IDG/IDT failed to revise the plan of care to include the development of wounds for 1 of 5 patients ( #1) reviewed with wounds L0552 Based on record review and interview the hospice IDG/IDT failed to have a system in place to ensure coordination of care occurred for 4 of 5 (Patient #1, #2, #3 and #4) patients reviewed with wounds. L0554 The administrator, RN coordinator/supervising nurse and regional director were notified on 6-20-22 at 5:00 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. On 6-22-22 at 6:03 p.m., the surveyor received the hospice's accepted plan of removal. The plan of removal, dated 6-21-22, indicated the hospice would implement the following interventions to correct the immediate threat: The executive team would be reevaluating the policies to ensure completeness of wound care protocol. These policies include: Interdisciplinary Group Coordination of Care; Monitoring Patient's Response/Reporting to Physician; Patient Notification of Changes in Care; The Plan of Care. This will be completed by end of week, 06/24/2022. Licensed wound care nurse position was opened on 06/20/2022 to promote better wound outcomes regarding documentation, caregiver education, and plan of care updates. Administrator to monitor 100% compliance of Wound Care PIP spreadsheet by DON and QA Nurse for 3 months and reevaluated Quarterly. QA nurse reassessed wounds, orders were received, and treatment was initiated on 6-21-22. QA Nurse provided training to caregivers on 6-21-22. Staff in serviced and trained on 6-21-22. New Matrix Wound Care Audit Toll initiated on 6-21-22. Record review of in-service training records for the hospice's current staff indicating the hospice had provided in-service training on 6-21-22. On 6-22-23 and 6-23-22 the surveyor interviewed 8 current hospice employees which included the QA nurse, hospice aide A, hospice aide B, RN C, chaplain D, chaplain E, hospice aide F and RN G. The surveyor also interviewed patient #3 family member who stated the QA nurse trained her on wound care. All staff interviewed verified that they had been in serviced on wound care protocol as it was related to their job description. RNs indicated that they are to assess patients, document any findings notify physicians and IDT/IDG of any new findings or orders, teach caregivers. CNAs indicated that they were told to carry a skin sheet to document areas found on patients' skin and to notify the nurse. QA nurse stated they were told to document everything; the agency is hiring a wound care nurse and she will focus on teaching and keeping the QAPI going. The chaplains stated that their role was to document any reports of wounds and notify IDG/IDT. Record review of agency policies revealed changes were made to included the following: changes will be shared in IDG, missed wound care will be documented and discussed in IDG meetings, caregivers will be notified of changes in care at the time of the visit, wound assessments will be documented each visit and discussed at each IDG meeting, the patient's physician and medical director will be contacted on the same day when any changes in wound appearance and delay in availability of medications, care plans will reflect new wound care orders and treatments, the plan of care will identify the patients needs and services inclusive of wounds and wound treatments and the plan of care will contain wound care/changes/treatments. On 6-23-22 at 12:35 p.m., the administrator was informed that the IJ was removed. However deficient practice was present at a condition level. The hospice was continuing to implement the plan of removal. | |||
| L0540 | Approach To Service Delivery 418.56(a)(1) Corrected On: 07/08/2022 |
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| 16353 Based on record review and interview the hospice failed to ensure that the RN coordinator as a member of the interdisciplinary group provided coordination of care and assessment for 4 of 5 (Patient #1, #2, #3 and #4) patients reviewed with wounds. Patient #1- RN coordinator did not coordinate with the IDG/IDT regarding onset of new wounds and wound assessment of a pressure sore on . Patient foot was amputated on 5-21-22 Patient #4- RN coordinator did not coordinate with the IDG/IDT regarding patient's Stage 2 pressure sore deteriorating to a Stage 4. Patient #3- RN coordinator did not coordinate with the IDG/IDT regarding the patient's wound status and treatments for the wounds. All Patient wounds were not assessed, care was done without orders and new wounds were not reported. Patient #2- RN coordinator did not coordinate with the IDG/IDT regarding new treatment ordered and delay in the availability of treatments ordered. This failure resulted in an identification of an IJ on 6-20-22 after review by the State. While the IJ was removed on 6-23-22, the deficient practice continued at a condition level.This failure likely contributed to Patient #1's foot amputation and Patient #4's wound deteriorating to a stage and could affect any patient at risk for developing wounds or with preexisting wounds. These failures prevented the agency from addressing the care needs of the patients resulting in the deterioration and decline in their health status. The findings included: Patient #1 RR complaint intake received to the State on 6-16-22 revealed "On 5/19/2022 ...The clients physician informed ... that due to the client's condition and gangrene on the client's foot. The client would need an amputation of his foot ...On 5/20/22 the client was ...put on IV antibiotics. On 5/21/2022 at 10:00 am, The client foot had his foot amputated ..." RR of physician virtual visit note dated 1-27-22 revealed medical history of hypertension, hearing loss, hyperlipidemia and BPH. Current assessment was revealedas Advanced dementia. RR of hospice plan of care dated 1-29-22 to 4-28-22 revealed a start of care of 1-29-22. A primary diagnosis of Alzheimer's disease was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 3 wk 12 then 2 wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate then 9 PRN". Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of hospice plan of care dated 4-29-22 to 7-27-22 revealeddiscipline orders "Skilled nursing: 1 wk 13 wk 26 PRN: Symptom Management ...Aide: 3 wk 5 wk, 2 wk 1 wk, 3wk 4 wk; 2 wk 1 wk; 3 wk 2 wk; 1 wk 1wk ..." Interventions included "Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of Sn notes dated 1-29- 22, 2-2-22, 2-12-22 (missed visit) and 2-24-22 revealed no issues with skin integrity. RR of Sn notes signed by former agency employee RN H and dated 2-25-22 "N/P" under the section "Skin" The note further revealed"Cg reported pt fell this a.m. [no] injuries or wounds noted ...[right] great toe pain level 4 with touch, intermittent and sharp ...Tylenol 650 mg 2 tabs given x 2 days" RR of Sn narrative note signed by former agency employee RN H and dated 2-25-22 revealed "Spoke [wit] daughter re: small dark area bruise to [right] heel - SN instructed cg to float both heels [and] reposition every 2 hours. Cg stated, "She thinks her dad has PVD." SN discussed in detail re: disease process of PVD is a slow [and] progressive circulation disorder. It may affect any blood vessel including arteries, veins or lymphatic vessels." There was no indication that the physician or IDG/IDT was notified of area. RR of Sn notes dated 3-4-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. RR of IDG/IDT meeting notes dated 3-10-22 revealed there was no documentation concerning the patient new bruise to right heel. Further review of the record revealed no plan or interventions for the bruise was documented. RR of Sn notes dated 3-11-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. Further documentation of bilateral feet and back pain at level 5, occurs several times a day intermittently, sharp and aching. RR of Sn notes dated 3-17-22 and signed by former agency employee RN H revealed "Cg reported blister to 2nd great toe burst and has been oozing blood (sero-sanguineous color). Cg also reported pt [right] heel has gotten dark in color [and] very dry. Sn assessed wounds [and] applied dry dressings ..." The note further revealed "right heel 3.5cm x 3 cm and [right] 2nd toe 1.5 cm x 0.5 cm" Note also revealed bilateral great toe pain at level 5. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of skin sheet dated 3-17-22 and signed by former agency employee RN H revealed "Pt noted [with] black/reddened area (stage I pressure to [right] heel measuring 3.5x 3cm; skin not broken. Pt has a fluid filled (blood) blister to [right] 2nd toe measuring 1.5x0.5 cm. Pt also noted [with] a blister that burst to [ right] great toe w/small amount serosanguineous." RR of IDG/IDT meeting notes dated 3-17-22 revealed there was no documentation concerning the patient's paine level of 5, right heel, right 2nd toe or great toe wounds. Further review of the record revealed no plan or interventions for the wounds were documented. RR of Sn notes dated 3-18-22 and signed by former agency employee RN H revealed the right heel measured 3.5cm x 3 cm and [right] 2nd toe measured 1.5 cm x 0.5 cm; Under the pain section of note revealed bilateral feet pain at level 6 that is throughout the day, constant and sharp. Further documentation was noted as follows: patient pain brought to a comfortable level within 48 hours- no was marked. "Re-visit: PRN visit made for wound care ... wound care done to [right] heel [right] great toe + 2nd toe. Applied loosely wrapped gauze & instructed Cg to keep pressure off feet by applying sheets loosely ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of SN note dated 3-21-22 and signed by former agency employee RN H revealed "pain to bilateral feet at level 4 all the time constantly aching" Further documentation noted as follows: " ...has new blister on top of [right] foot (fluid filled) ...Sn instructed Cg to remove line from feet ... Sn applied bordered gauze to [right] heel & [right] foot ... [right] heel measured 3.5cm x 2 cm; area still dry dark in color [no] odor ...areas to great toe & 2nd toe have healed." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 3-24-22 revealed problem of "Pain management" under goal and interventions was revealed"No Goals and No interventions". Under the section prep notes revealed"Per Cg patient has pain to both great toes. upon assessment, patient noted with discoloration to right toe and tender to touch. Left toe tender to touch. Received order from MD ... for tramadol 50 mg every 6-8 hrs prn pain ..." There was no documentation concerning the right heel or new blister wound. RRof Sn notes dated 3-30-22 and signed by former agency employee RN H revealed pain in right heel moderate at level 5 constant. "[Right] heel noted [with] black soft eschar- Sn applied medi honey & bordered Mepilex ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of narrative note dated and signed by former agency employee RN H 3-30-22 revealed"Pt is scheduled to see VA Md on 3-31-22. Sn discussed w/cg to inform MD of [right] heel & obtain new orders if needed ..." RR of IDG/IDT meeting notes dated 3-31-22 revealed there was no documentation concerning the patient change in right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-6-22 and signed by former agency employee RN H revealed right heel was 5cmx 2 cm with purplish black soft eschar. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 4-7-22 revealed there was no documentation concerning the patient increase in size of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-13-22 and signed by former agency employee RN H revealedright heel with black eschar. Further documentation "Patient has wound to right heel. RN dressed wound with medi honey and bordered foam dressing. Cg changes dressing every other day ..." RR of IDG/IDT meeting notes dated 4-14-22 revealedunder "Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no interventions for the right heel wound were documented. RR of IDG/IDT meeting notes dated 4-21-22 revealedunder the section "Prep notes " ...Chaplain 4-20-22 ...asked if [ patient #1] had any pain and [ patient #1] spoke of pain traveling from foot up leg. [ Family member] said she had discussed this with the nurse at her last visit ..." Further review of the record revealed no plan or interventions for wounds were documented. RR Sn notes dated 4-22-22 and signed by former agency employee RN H revealed right heel measured 6x4x0.1 cm. The note further revealed" ...c/o pain [with] touch to [right] foot ...Pt noted [with] stage pressure ulcer to [right] heel. Area cleansed [with] wound cleanser, pat dry & medi honey &secured[with] bordered gauze. Cg instructed to float heels ..." Under the section "Care Coordinated/Conferenced with" revealedthe physician was contacted regarding "med-change-increase Neurontin." RR of Sn notes dated 4-27-22 revealedright heel unstageable. "[ Right] heel PS unstageable noted [with] soft black eschar over 75% of heel. Pt c/o bilateral heel pain - neuropathy (sic) ordered ..." RR of IDG/IDT meeting notes dated 4-28-22 revealedunder the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no wound care interventions for the right heel wound were documented. RRof Sn notes dated 5-2-22 revealed "Pt is at ... (respite) x1week." RR of IDG/IDT meeting notes dated 5-5-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Under the section "Infections" revealed "wound infection- unknown 2022-05-18 ...visit date 05/19/2011 13:00 warm to touch; pain; purulent [pus] drainage; odor ulcer antibiotics: yes, newly prescribed ..." RR of Sn notes dated 5-11-22 and signed by former agency employee RN H revealed right heel measured 7x6x0.1 cm, the wound bed black with mushy tissue and faint odor. Further revealed "Cg reports Pt had decline in appetite since returning home from respite on 5/10/22. Pts [right] heel is black, but fluid filled, mushy ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 5-12-22 revealed there was no documentation concerning the patient change in stats of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RRof Sn notes dated 5-18-22 and signed by former agency employee RN H revealed right heel measured 10x9x0.2 cm, the wound bed black with mushy tissue, scant amount of drainage and faint odor. Further revealed" ... [right] heel - reported by cg has been draining & has a odor. Area cleansed w/ NS, pat dry applied skin protectant, gauze, kerlix & tape. Report called to ...RN @ IPU; waiting for bed assignment." Further review of note revealed the physician was called regarding wound odor and ordered "Doxycycline 100 mg BID x 7 days." During an interview on 6-17-22 at 4:13pm the supervising nurse stated that she looked at the clinical record for patient #1 and did not see a diagnosis of PVD. The supervising nurse further stated she did not know where the former employee got that information. During an interview on 6-17-22 at 4:18 pm the director of quality assurance stated although the IDT/IDG was created on 4-14-22, 4-28-22 and 5-5-22 if the IDT/IDGs go into "pending signature" status, whatever date it is opened for the signature it will pull all the current information on the patient to date (5-19-22) and to the IDT/IDG. Patient #4 RR of Sn SOC visit note dated 2-15-22 and signed by RN I revealed under the section "Wound Assessment and Care" patient #4 had a "left inner buttocks/decubitus/pressure ulcer Stage II" RR of hospice plan of care dated 2-15-22 to 5-15-22 revealed a start of care of 2-15-22. A primary diagnosis of Senile degeneration of the brain was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 1 wk 1wk then 2 wk 11 wk; 2 wk 1 wk; 1wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate". There were no interventions revealedfor the Sn. RR of SN notes dated 2-24-22 and signed by RN J revealed" ...pt has multiple wounds to body per nurse after she completed wound care, risk for further tissue breakdown ..." Under the section "Skin" revealed"bruise BLE, BUE" RR of SN notes dated 2-28-22 signed by RN K revealedunder the section "Skin: bruise BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR Communication note created by RN N dated 3-2-22 " ... [ assisted living] requested the following supplies: Allyn dressing for sacrum ..." RR SN notes dated 3-7-22 signed by RN K revealed"bruises BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-10-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RRof SN notes dated 3-14-22 signed by RN K revealed"Pt was wheeled into her room for nursing assessment ..." There was no documentation on the note concerning the patient stage 2 pressure ulcer or bruises. RR communication note created by RN K dated 3-16-22 revealed"Patient has bruises to bilateral lower extremities and bilateral upper extremities ..." RR of IDG/IDT meeting notes dated 3-17-22 revealedunder the section "Prep notes: Patient has non-pitting edema to bilateral lower extremities with bruises to lower legs and upper arms. Band-Aid noted to upper arm, but patient refused for this nurse to assess further ..." There was no documentation of the stage 2 pressure ulcer. RR SN notes dated 3-23-22 signed by QA nurse revealed this was a missed visit. RR of IDG/IDT meeting notes dated 3-24-22 revealedunder the section "Prep notes: Patient has bruises to bilateral lower extremities and bilateral upper extremities. She remains wheelchair /bed bound. Fall precautions in place. Current plan of care remains effective ..." There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-31-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-1-22 and signed by RN L revealed under the section "Skin" no deficit was check and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-7-22 and signed by RN L revealed under the section "Skin" no deficit was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of IDG/IDT meeting notes dated 4-7-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR communication note created by Chaplain D dated 4-13-22 revealed" ...The aide informed Chaplain that [ patient #4] had a stage 2 wound on her bottom. Chaplain texted information to team." RR of IDG/IDT meeting notes dated 4-14-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-15-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-21-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked. Redness and N/A was written in the section "Wound #1" and "N/A" was written under Wound #2". The note further revealed" ...Pt assisted to bed and skin assessment completed, redness noted to sacral area no other wound noted ..." RR of IDG/IDT meeting notes dated 4-21-22 revealed there was no documentation concerning the patient redness to sacral area. Further review of the record revealed no plan or interventions for the ulcer or redness was documented. RR of SN notes dated 4-27-22 and signed by RN L revealed" ...Patient received being bathed by hospice aide ... left arm skin tear cleaned ...Old bruises noted to her bilat. Arms ..." There was no documentation concerning the patient stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 4-28-22 revealed there was no documentation concerning the patient bruises er or skin tear. Further review of the record revealed no plan or interventions for the bruises or skin tear was documented. RR of SN notes dated 5-3-22 and signed by RN L revealed"Patient received lying in bed. Skin tear to [left] arm improved ..." RR of IDG/IDT meeting notes dated 5-5-22 revealed there was no documentation concerning the patient skin tear. Further review of the record revealed no plan or interventions for the skin tear was documented. RR of unsigned SN notes dated 5-12-22 revealed under the section "skin: Wound #1- left buttock stage 3." The note further revealed"Facility Cg requested cushion order due to worsening wound to her buttock. Wound cleanse with cleanser. Pat dried medi honey applied covered with cushion dressing. TAO applied to skin tear ... [supervising nurse/RN coordinator] notified of cushion layer ..." Section for physician notification revealed"none" RR communication note dated 5-12-22 completed by the Medical director revealed" ...The patient has a stage 2 sacral wound ..." RR of IDG/IDT meeting notes dated 5-12-22 revealed there was no documentation concerning the patient stage 3 wound, skin tear or the facility request for a cushion. Further review of the record revealed no plan or interventions for the wound or skin tear was documented. RR communication note created by RN M dated 5-13-22 revealed" ... [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." RR of SN notes dated 5-17-22 and signed by RN M revealed under the section "skin: Wound #1- [left] buttock lateral stage IV with tunneling 3-4 cm wide ..." The note further revealed that the NP was notified, and new orders were received for wound care. RR communication noted dated 5-17-22 and completed by the supervisng nurse/RN coordinator revealed "Facility requested a wheelchair cushion for the patient. Notified [DME company] ..." RR communication note dated 5-18-22 and completed by RN M revealed" ...The patient has a stage 4 pressure ulcer at the left lateral buttocks region, open to air, no odor or drainage ...NP notified for wound care order needs ..." RR of IDG/IDT meeting notes dated 5-19-22 revealedunder the section "Prep notes: Facility requested a wheelchair cushion for the patient. Notified [DME company] ... and ... [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." The IDT/IDG further revealedthe wound care treatment under the section "Change in orders" There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. RR of SN notes dated 5-20-22 and signed by RN M revealed" ...wound care done" RR skin sheet dated 5-20-22 and signed by RN M revealed"Pt stage IV wound on [left] lateral buttocks area noted open to air, no visible drainage on site, noted foul odor. New wound care order per NP (to clean wound care spray, dry apply medi honey, cover with gauze) implemented ...NP notified regarding foul odor from site, awaiting further order ..." RR communication note dated 5-23-22 and completed by RN M revealed "Pt stage 4 wound on left lateral buttocks area noted open to air, no visible drainage on site. Noted new foul odor coming from site. New orders for wound care per ...NP implemented ... NP notified for further advise for wound care. Awaiting on new order." RR of IDG/IDT meeting notes dated 5-26-22 revealedunder section "Change in orders- start pt Keflex 500 mg PO BID x 7days ..." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. RR of SN notes dated 6-1-22 and signed by QA nurse revealed "Received pt sitting on her couch, pt seems withdrawn lethargy and agitated when touched. Pt moaned during dressing change. SN provided wound care to buttocks and skin tear." RR of IDG/IDT meeting notes dated 6-2-22 revealedunder the "Prep note" section a summary of chaplain note from 5-13-22, communication note from 5-17-22, Skin sheet from 5-20-22, SN note from 5-17-22. RR of IDG/IDT meeting notes dated 6-9-22 revealedunder "Current orders: Other- Apply Neosporin daily to the left arm skin tear and cover with a nonstick dressing; Clean with wound care spray, dry and apply medi honey, cover with gauze." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. During an interview on 6-19-22 at 8:00 pm patient #4 family member stated the patient had a wound on her buttock early on, but he thought that the agency had gotten the wound well. During an interview on 6-20-22 at 9:27 am hospice aide B (performed care to patient #4 from 4-5-22 to 4-28-22) stated that she showered patient #4 one time and remembered the patient's skin was paper thin. Hospice aide B further stated there was one time when she had finished showering patient #4 and an agency nurse visited the patient. Hospice aide B stated that she showed the agency nurse( unknown) that patient #4 skin was fragile and had a sore on her bottom. Hospice aide B stated, "I showed the agency nurse, but I don't know what he did because I left, I had been there before him." During a concurrent interview on 6-20-22 at 3:33 pm with the supervising nurse/RN coordinator and the administrator, the supervising nurse/RN coordinator stated that the nurses were supposed to address the buttock wound in Sn notes and the IDG/IDT should have included a care plan for wound care for patient #4 since she was admitted with a pressure sore, Patient #3 RR of SOC SN visit dated 4-28-22 and signed by RN O revealed under section "Wound Assessment and Care" as follows: "1. Dorsal back sacrum/decubitus/ pressure ulcer suspected deep tissue injury; wound bed -clean, bed color- red, covered with Meplex foam. 2. left dorsal foot heel/decubitus/pressure ulcer suspected deep tissue injury: covered with Meplex foam 3. left head eyebrow/other: wound bed- eschar; cleaned with Vashe; application/packing-medi honey; wound care frequency- PRN 3 times/week 4. left lateral leg knee/decubitus/pressure ulcer Stage II: wound bed -eschar; cleaned with- Vashe; application/packing other- Medi Honey; wound care frequency- PRN 3 times/week 5. left posterior arm elbow/skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 6. right dorsal arm elbow/ skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 7. right lateral foot ankle/decubitus/pressure ulcer unstageable: wound bed - slough; bed color-yellow; cleaned with Vashe; application/packing-Thera honey gel; covered with Meplex foam; wound care frequency- daily ..." RR physicians order dated 4-28-22 revealed for right heel "cleanse wound w/ Vashe solution, leave Vashe saturated gauze on wound, for 2-3 minutes, pat dry, apply gentamycin ointment to wound bed, cover w/ dry gauze, secure w/tape then cover w/ comprilan daily. Sn to perform weekly & cg to perform on the other days." RR of Sn note dated 4-29-22 and signed by former agency employee RN H revealed left heel wound measured 2.5x 1 cm, wound bed- purple, tissue-soft with no drainage; right ankle measured 2 x 1.5 cm, wound bed- yellow and tissue -soft. There was no documentation of wound care given or the status of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator who stated if wound care had been done it would be revealed in the nurse's notes. RR Sn note dated 5-3-22 and signed by former agency employee RN H revealed " ...wound care done to [right] elbow, [right] heel & sacral. [right] elbow cleansed [with] NS, pat dry applied dry bordered gauze to wound, [right] heel cleansed [with NS pat dry applied gentamycin ointment covered with bordered gauze and covered with tubi grip, sacral decubitus allewn applied, instructed Cg to not let wounds get wet ..." There was no documentation of the status/treatment of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator, the administrator stated that she did not see on the note where the left elbow, left eyebrow, left dorsal foot heel or left knee wounds were treated. RR of IDG/IDT meeting notes dated 5-5-22 revealed there was no documentation concerning the patient wounds or skin tears. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-9-22 and signed by former agency employee RN H revealed the right ankle wound measured 1.5x1x0.1 cm, wound bed -crusty, tissue-soft and no drainage; right elbow measured 2x1x0.1 cm, wound bed- pink, tissue-pink and draining a scant amount of serous drainage. The note further revealed" ...wound care done to wounds-cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip. Cg reported blisters to buttocks, area is fluid filled. Sn administered sacral Meplex & change prn. [left] knee skin tear noted 0.5x0.5x0.1 cm & lg blister to buttocks 7x5 cm." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. There was no evidence that the physician or IDG/IDT was notified of new blisters and left knee skin tear. RR of physician orders revealed no order noted to "cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip." During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator. The supervising nurse/RN coordinator stated she did not see where the IDG/IDT was notified of new blisters or skin tear nor did she see the order for Mepilex to sacral area. RR of IDG/IDT meeting notes dated 5-12-22 revealed under the section "Prep notes " completed by former agency employee RN H revealed -Patient has a wound to right heel measuring [ not measurements documented], right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." There was no documentation concerning the patient left knee skin tear. Further review of the record revealed no plan or interventions for the other wounds or skin tears was documented. RR of SN note dated 5-19-22 and signed by former agency employee RN H revealed under the section " Ssin- See Skin SHeet " RR of skin sheet dated 5-19-22 and signed by former agency employee RN H revealed "Sn informed Cg on status of wounds. Wound care was done as follows: cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze. Sacral area- instructed cg to keep area clean & dry & apply skin protectant to area as needed ..." Furtheer review ofskin sheet diagram revealedleft knee skin tear, right elbow skin tear, new stage 2 with macerati | |||
| on on buttock, and right ankle stage 2. The section of the SN note dated 5-19-22 for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-20-22 at 4:39 p.m. the supervising nurse/ RN coordinator was observed looking through the computerized record for patient #3 for the wound care physician order "cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze". The supervising nurse/ RN coordinator stated that she did not see the order in the record. RR of IDG/IDT meeting notes dated 5-19-22 revealed there was no documentation concerning the patient wounds, new stage 2 with maceration or skin tears. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-25-22 and signed by former agency employee RN H revealed" ...Sn instructed Cg on continuing to monitor skin & any changes ...wound care to left ankle done as follows cleanse w/Normal saline or wound cleanser, pat dry, apply Meplex or bordered gauze. [right] elbow cleansed w/NS, pat dry, applied Meplex or bordered gauze ..." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. RRof Sn skin sheet dated 5-25-22 and signed by former agency employee RN H revealed"[right] ankle noted [with] scant soft yellow slough, wound edges are pink. [right] elbow has a scab. [left] knee area has healed completely. Pt noted with small 1x1 cm skin tear on top of [right] foot ...area covered w/bordered gauze & Sn instructed Cg to apply TAO if needed." RR of IDG/IDT meeting notes dated 5-26-22 revealed there was no documentation concerning the patient new wounds to left ankle, new stage 2 with maceration or new skin tear to top of right foot. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn notes dated 6-3-22 and signed by QA nurse revealed" ...SN provided wound care to pts right ankle and foot" RR of IDG/IDT meeting notes dated 6-2-22 revealedunder "Current orders: Other- SN to cleanse areas with Normal Saline or wound cleanser, pat dry, and cover with Meplex/bordered gauze to right ankle and right elbow and as needed if soiled. Changed to active 5-26-22. " Under the section "Prep notes -Patient has a wound to right heel measuring, right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." RR of Sn notes dated 6-8-22 and signed by RN L revealed" ... Multiple pressure ulcers that appear to be healing noted to [right] elbow, [right] ankle, [left] ankle. All clean with wound cleanser, pat dry, covered with island dressing. Also left ankle appears healing Sn completed wound care" The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-19-22 at 1:23 pm the family member of patient #3 stated the wound to the left eyebrow was healed, he still has areas to buttocks and ankles. The family member further stated that the patient had not had a nurse in two weeks. She stated she spoke to the agency social worker and asked where the nurse was because the patient wounds had not been treated and he had not had a bowel movement in close to 10 days. The family member further stated she did not know how to do dressing changes. During an interview on 6-20-22 at 4:56 p.m. the supervising nurse/ RN coordinator stated the wound to patient #3 left ankle looks like it is a new wound. Patient #2 RR Sn SOC visit dated 5-12-22 adn signed by the supervising nurse/RN coordinator revealed under the section "Wound Assessment and Care" as follows: Left foot 2nd toe/venous stasis ulcer- wound bed- eschar, dry; bed color- black; no drainage, no odor ..." There was no treatment noted for the wound. Further review of note revealedunder the section "Integumentary- bruising right thigh anterior and gangrene 2nd right toe" RR non visit report dated 5-16-22 revealed"no answer to phone/home" RR of IDG/IDT meeting notes dated 5-19-22 revealed under the section "Prep Notes " ' completed by QA Nurse- " Pt complained of toe pain. Pt has gangrene to his 2nd toe, pt's wife would like something to put on it." RR of order from physician A dated 5-19-22 revealed"Apply TAO to 2(sic) toe daily and leave open to air." RR of SN note dated 5-26-22 and signed by RN L revealed "paint to left 2nd gangrene toe ...routine visit completed ..." There was no documentation of wound care treatment done. RR of order from physician B dated 5-26-22 revealed"paint 2nd toe with Iodine daily and leave open to air." RR of IDG/IDT meeting notes dated 5-26-22 revealed there was no documentation concerning the patient Left foot 2nd toe/venous stasis ulcer. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn note dated 6-2-22 and signed by QA nurse revealed"wound care provided to second toe TAO applied ..." RR of IDG/IDT meeting notes dated 6-2-22 under the section "Change in Orders: Other - Paint 2(sic) toe with iodine daily and leave to open air., Start Date: 5/26/2022" During an interview on 6-17-22 at 12:19 pm the supervising nurse/RN coordinator stated she was not sure who the nurse was for the visit made on 6-11-22 but she did not see documentation on the note concerning wound care. The supervising nurse/RN coordinator stated she would see if the nurse turned in a skin sheet for the visit. Further interview at 1:08 pm the supervising nurse/RN coordinator stated upon any admission they talked to the doctor about any issue and anything pertinent for the patient. "On patient #2 [the doctor] said to just observe the toe." The supervising nurse/RN coordinator then stated she was not sure where she would have revealedthe physician instructions to observe patient #2 toe. The supervising nurse/RN coordinator then stated she believed the patients well-being and care would be affected to not have all the information needed in the IDG/IDT meetings. During an interview on 6-17-22 at 12:23 pm patient #2 family member stated she kept patient #2 wound clean. The agency gave her some wound spray to use but she did not remember the name. The family member stated the nurse only check patient #2 vital signs and look at the wound but do no treatment to the wound. The family member also stated that she applies Iodosorb 10 mg every other day to patient #2's toe. The cream was previously used on another toe. The family member further stated the QA nurse put the TAO on the wound on 6-2-22 before she found the Iodosorb cream. The family member then stated the QA nurse was the only nurse to put something on the toe, the other nurse just looked. The family member stated that the toe is drying up pretty good now, it is not leaking anymore. The family member stated the toe was leaking pus and blood last weekend. During further interview at 3:49 pm the family member stated that she informed the agency nurses of the wound leaking last weekend. "I make sure I show them. Whenever they come out." The family member then stated she showed the cream she was using on patient #2 toe to the QA nurse. During an interview on 6-17-22 at 12:49 pm the QA nurse stated she got text messages of the orders written on 5-19-22 for Tao and 5-26-22 for Iodine. Surveyor reviewed text messages and paper physician orders. The QA nurse stated other nurses would have known what the orders were because they talk about it in the IDG/IDT meetings. QA nurse was informed the IDG/IDT on 5-19-22 and 5-26-22 did not have any information concerning patient #2 toe. The QA Nurse stated, "Normally we would have discussed it." The QA nurse further stated she notified the family membr about the wound order received on 5-26-22, but the medication has been on back order and the agency just received it on 5-13-22. The QA nurse stated patient #2 wasn't getting any treatment and on 6-2-22 she put the TAO on his toe "So at least he would get something." Further interview on 6-17-22 at 4:28 pm the QA nurse stated she did not receive any orders on what to do while the iodine was on back order. "That's why I used TAO." The QA nurse stated that the family member of patient 32 talked to her about using the cream on patient #2. The QA nurse stated another doctor had given the family member the cream and she really liked it so she told the family member when she found it to send a picture of it or show her and she would see it the agency could order the medication. The QA nurse stated the family member never showed her the medication and she did not mention it to the IDG/IDT. Record review of policy titled "Interdisciplinary Group Coordination of Care" revised on 5-05/2016 revealed" ... It will be the responsibility of the Clinical Supervisor to assign a case manager who is a registered nurse. The Case manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge ...It will be the responsibility of the RN Case Manager to facilitate communication about changes in the patient's status among interdisciplinary group members and the patient's physician ..." During an interview on 6-17-22 at 3:05 pm the supervising nurse stated the discussion in IDT/IDG about wound care patients would be to see if there are any concerns. Further stated that the nurse would give a short blurb of the patients wound. The supervising nurse then stated the discussion should be captured in the IDT/IDG documentation as well as any interventions. After review of patient #1 IDG/IDT's meeting notes the supervising nurse stated, "Don't look like we are doing a very good job at that." During an interview on 6-20-22 at 3:51 pm the administrator stated that the supervising nurse was the RN coordinator for the IDG/IDT. During an interview on 6-20-22 at 3:53 p.m. The supervising nurse/ RN coordinator stated she makes sure that the IDG/IDT has all the current information about patient's by looking at prep notes completed by agency staff, communication notes, emails that are done daily about patients and in the event of an urgent message texts that are sent regarding patients. | |||
| L0545 | Content Of Plan Of Care 418.56(c) Corrected On: 07/08/2022 |
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| 16353 Based on record review and interview the hospice failed to include wound care in the plans of care for 4 of 5 patients (Patient #1, #2, #3 and #4) patient reviewed with wounds. Patient #1- Plans of care were not updated to reflect new onset wounds, pain and changes in wound status . The patient's foot was amputated on 5-21-22 Patient #4 - plan of care for stage 2 wound was not initiated on admission or updated when wound deteriorated to a Stage 4. Patient #3- was admitted with 7 wounds. No plan of care for wounds was initiated on admission or updated when new wounds developed. Patient had not had a skilled nurse visit since 6-8-22. Patient #2- was admitted with a gangrenous wound,no plan of care for wounds was initiated on admission or updated on subsequent POCs. Wound treatment was not given as ordered. This failure resulted in an identification of an IJ on 6-20-22 after review by the State. While the IJ was removed on 6-23-22, the deficient practice continued at a condition level. This failure to include wound care on the plans of care could affect any patient at risk for developing wounds or with preexisting wounds. This deficient practice resulted in Patient #1 experiencing pain, and deterioration in his wound and an amputation of his foot; Patient #2 received the incorrect treatment by the agency LVN and family member; Patient #3's new wounds were not reported, treatments were administered without an order and Patient #4's wound deteriorated to a stage 4 wound. The findings included: Patient #1 RR complaint intake received to the State on 6-16-22 revealed "On 5/19/2022 ...The Patients physician informed ... that due to the Patient's condition and gangrene on the Patient's foot. The Patient would need an amputation of his foot ...On 5/20/22 the Patient was ...put on IV antibiotics. On 5/21/2022 at 10:00 am, The Patient foot had his foot amputated ..." RR of physician virtual visit note dated 1-27-22 revealed medical history of hypertension, hearing loss, hyperlipidemia and BPH. Current assessment was revealed as Advanced dementia. RR of hospice plan of care dated 1-29-22 to 4-28-22 revealed a start of care of 1-29-22. A primary diagnosis of Alzheimer's disease was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 3 wk 12 then 2 wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate then 9 PRN". Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia Patient ..., assess Patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of hospice plan of care dated 4-29-22 to 7-27-22 revealed discipline orders "Skilled nursing: 1 wk 13 wk 26 PRN: Symptom Management ...Aide: 3 wk 5 wk, 2 wk 1 wk, 3wk 4 wk; 2 wk 1 wk; 3 wk 2 wk; 1 wk 1wk ..." Interventions included "Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia Patient ..., assess Patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of Sn notes dated 1-29- 22, 2-2-22, 2-12-22 (missed visit) and 2-24-22 revealed no issues with skin integrity. RR of Sn notes signed by former agency employee RN H and dated 2-25-22 "N/P" under the section "Skin" The note further revealed "Cg reported pt fell this a.m. [no] injuries or wounds noted ...[right] great toe pain level 4 with touch, intermittent and sharp ...Tylenol 650 mg 2 tabs given x 2 days" RR of Sn narrative note signed by former agency employee RN H and dated 2-25-22 revealed "Spoke [wit] daughter re: small dark area bruise to [right] heel - SN instructed cg to float both heels [and] reposition every 2 hours. Cg stated, "She thinks her dad has PVD." SN discussed in detail re: disease process of PVD is a slow [and] progressive circulation disorder. it may affect any blood vessel including arteries, veins or lymphatic vessels." There was no indication that the physician or IDG/IDT was notified of area. RR of Sn notes dated 3-4-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. RR of IDG/IDT meeting notes dated 3-10-22 revealed under the section " Care Plan- changes in care plan : no changes since last IDG " . Further review on the note revealed there was no documentation concerning the Patient new bruise to right heel. Further review of the record revealed no plan or interventions for the bruise was documented. RR of Sn notes dated 3-11-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. Further documentation of bilateral feet and back pain at level 5, occurs several times a day intermittently, sharp and aching. RR of Sn notes dated 3-17-22 and signed by former agency employee RN H revealed "Cg reported blister to 2nd great toe burst and has been oozing blood (sero-sanguineous color). Cg also reported pt [right] heel has gotten dark in color [and] very dry. Sn assessed wounds [and] applied dry dressings ..." The note further revealed "right heel 3.5cm x 3 cm and [right] 2nd toe 1.5 cm x 0.5 cm" Note also revealed bilateral great toe pain at level 5. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of skin sheet dated 3-17-22 and signed by former agency employee RN H revealed "Pt noted [with] black/reddened area (stage I pressure to [right] heel measuring 3.5x 3cm; skin not broken. Pt has a fluid filled (blood) blister to [right] 2nd toe measuring 1.5x0.5 cm. Pt also noted [with] a blister that burst to [ right] great toe w/small amount serosanguineous." RR of IDG/IDT meeting notes dated 3-17-22 revealed under the section "Care Plan- changes in care plan : no changes since last IDG". Further review on the note revealed there was no documentation concerning the Patient's paine level of 5, right heel, right 2nd toe or great toe wounds. Further review of the record revealed no plan or interventions for the wounds were documented. RR of Sn notes dated 3-18-22 and signed by former agency employee RN H revealed the right heel measured 3.5cm x 3 cm and [right] 2nd toe measured 1.5 cm x 0.5 cm; Under the pain section of note revealed bilateral feet pain at level 6 that is throughout the day, constant and sharp. Further documentation was noted as follows: Patient pain brought to a comfortable level within 48 hours- no was marked. "Re-visit: PRN visit made for wound care ... wound care done to [right] heel [right] great toe + 2nd toe. Applied loosely wrapped gauze & instructed Cg to keep pressure off feet by applying sheets loosely ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of SN note dated 3-21-22 and signed by former agency employee RN H revealed "pain to bilateral feet at level 4 all the time constantly aching" Further documentation noted as follows: " ...has new blister on top of [right] foot (fluid filled) ...Sn instructed Cg to remove line from feet ... Sn applied bordered gauze to [right] heel & [right] foot ... [right] heel measured 3.5cm x 2 cm; area still dry dark in color [no] odor ...areas to great toe & 2nd toe have healed." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 3-24-22 the section "Care Plan- changes in care plan : no changes since last IDG". Further review of the notes revealed problem of "Pain management" under goal and interventions was revealed "No Goals and No interventions". Under the section prep notes revealed "Per Cg Patient has pain to both great toes. upon assessment, Patient noted with discoloration to right toe and tender to touch. Left toe tender to touch. Received order from MD ... for tramadol 50 mg every 6-8 hrs prn pain ..." There was no documentation concerning the right heel or new blister wound. RR of Sn notes dated 3-30-22 and signed by former agency employee RN H revealed pain in right heel moderate at level 5 constant. "[Right] heel noted [with] black soft eschar- Sn applied medi honey & bordered Mepilex ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of narrative note dated and signed by former agency employee RN H 3-30-22 revealed "Pt is scheduled to see VA Md on 3-31-22. Sn discussed w/cg to inform MD of [right] heel & obtain new orders if needed ..." RR of IDG/IDT meeting notes dated 3-31-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". Further review revealed there was no documentation concerning the Patient change in right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-6-22 and signed by former agency employee RN H revealed right heel was 5cmx 2 cm with purplish black soft eschar. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 4-7-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". The notes revealed there was no documentation concerning the Patient increase in size of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-13-22 and signed by former agency employee RN H revealed right heel with black eschar. Further documentation "Patient has wound to right heel. RN dressed wound with medi honey and bordered foam dressing. Cg changes dressing every other day ..." RR of IDG/IDT meeting notes dated 4-14-22 revealed under "Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22- [date nurse in IPU added problem to care plan])". However, urther review of the record revealed no interventions for the right heel wound were documented. RR of IDG/IDT meeting notes dated 4-21-22 the section "Care Plan- changes in care plan : no changes since last IDG". Review of the section "Prep notes " ...[Chaplain D] 4-20-22 ...asked if [ Patient #1] had any pain and [ Patient #1] spoke of pain traveling from foot up leg. [ Family member] said she had discussed this with the nurse at her last visit ..." Further review of the record revealed no plan or interventions for wounds were documented. RR Sn notes dated 4-22-22 and signed by former agency employee RN H revealed right heel measured 6x4x0.1 cm. The note further revealed" ...c/o pain [with] touch to [right] foot ...Pt noted [with] stage pressure ulcer to [right] heel. Area cleansed [with] wound cleanser, pat dry & medi honey &secured[with] bordered gauze. Cg instructed to float heels ..." Under the section "Care Coordinated/Conferenced with" revealed the physician was contacted regarding "med-change-increase Neurontin." RR of Sn notes dated 4-27-22 revealed right heel unstageable. "[ Right] heel PS unstageable noted [with] soft black eschar over 75% of heel. Pt c/o bilateral heel pain - neuropathy (sic) ordered ..." RR of IDG/IDT meeting notes dated 4-28-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22 [date nurse in IPU added problem to care plan])". Further review of the record revealed no wound care interventions for the right heel wound were documented. RR of Sn notes dated 5-2-22 revealed "Pt is at ... (respite) x1week." RR of IDG/IDT meeting notes dated 5-5-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22 [date nurse in IPU added problem to care plan])". Under the section "Infections" revealed "wound infection- unknown 2022-05-18 ...visit date 05/19/2011 13:00 warm to touch; pain; purulent [pus] drainage; odor ulcer antibiotics: yes, newly prescribed ..." RR of Sn notes dated 5-11-22 and signed by former agency employee RN H revealed right heel measured 7x6x0.1 cm, the wound bed black with mushy tissue and faint odor. Further revealed "Cg reports Pt had decline in appetite since returning home from respite on 5/10/22. Pts [right] heel is black, but fluid filled, mushy ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 5-12-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient change in status of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn notes dated 5-18-22 and signed by former agency employee RN H revealed right heel measured 10x9x0.2 cm, the wound bed black with mushy tissue, scant amount of drainage and faint odor. Further revealed" ... [right] heel - reported by cg has been draining & has a odor. Area cleansed w/ NS, pat dry applied skin protectant, gauze, kerlix & tape. Report called to ...RN @ IPU; waiting for bed assignment." Further review of note revealed the physician was called regarding wound odor and ordered "Doxycycline 100 mg BID x 7 days." During an interview on 6-17-22 at 4:13pm the supervising nurse stated that she looked at the clinical record for Patient #1 and did not see a diagnosis of PVD. The supervising nurse further stated she did not know where the former employee got that information. During an interview on 6-17-22 at 4:18 pm the director of quality assurance stated the reason that care plan problems not genenerated until 5-19-22 were on the 4-14-22, 4-28-22 and 5-5-22 IDG/IDT meeting notes was because when the meeting note go into "pending signature" status[ on the computerized system] , whatever date the meeting note is opened to sign [ by a member of the IDG/IDT] it [ the computerized system] will pull all the current information on the Patient [ in the system] and [ put the information] onto the IDT/IDG meeting note. Patient #4 RR of Sn SOC visit note dated 2-15-22 and signed by RN I revealed under the section "Wound Assessment and Care" Patient #4 had a "left inner buttocks/decubitus/pressure ulcer Stage II" RR of hospice plan of care dated 2-15-22 to 5-15-22 revealed a start of care of 2-15-22. A primary diagnosis of Senile degeneration of the brain was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 1 wk 1wk then 2 wk 11 wk; 2 wk 1 wk; 1wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate". There were no interventions revealed for the Sn. RR of SN notes dated 2-24-22 and signed by RN J revealed" ...pt has multiple wounds to body per nurse after she completed wound care, risk for further tissue breakdown ..." Under the section "Skin" revealed "bruise BLE, BUE" RR of SN notes dated 2-28-22 signed by RN K revealed under the section "Skin: bruise BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR Communication note created by RN N dated 3-2-22 " ... [ assisted living] requested the following supplies: Allyn dressing for sacrum ..." RR SN notes dated 3-7-22 signed by RN K revealed "bruises BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-10-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 3-14-22 signed by RN K revealed "Pt was wheeled into her room for nursing assessment ..." There was no documentation on the note concerning the Patient stage 2 pressure ulcer or bruises. RR communication note created by RN K dated 3-16-22 revealed "Patient has bruises to bilateral lower extremities and bilateral upper extremities ..." RR of IDG/IDT meeting notes dated 3-17-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". The section "Prep notes: Patient has non-pitting edema to bilateral lower extremities with bruises to lower legs and upper arms. Band-Aid noted to upper arm, but Patient refused for this nurse to assess further ..." There was no documentation of the stage 2 pressure ulcer. RR SN notes dated 3-23-22 signed by QA nurse revealed this was a missed visit. RR of IDG/IDT meeting notes dated 3-24-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". The section "Prep notes: Patient has bruises to bilateral lower extremities and bilateral upper extremities. She remains wheelchair /bed bound. Fall precautions in place. Current plan of care remains effective ..." There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-31-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-1-22 and signed by RN L revealed under the section "Skin" no deficit was check and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-7-22 and signed by RN L revealed under the section "Skin" no deficit was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of IDG/IDT meeting notes dated 4-7-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR communication note created by Chaplain D dated 4-13-22 revealed" ...The aide informed Chaplain that [ Patient #4] had a stage 2 wound on her bottom. Chaplain texted information to team." RR of IDG/IDT meeting notes dated 4-14-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-15-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-21-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked. Redness and N/A was written in the section "Wound #1" and "N/A" was written under Wound #2". The note further revealed" ...Pt assisted to bed and skin assessment completed, redness noted to sacral area no other wound noted ..." RR of IDG/IDT meeting notes dated 4-21-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient redness to sacral area. Further review of the record revealed no plan or interventions for the ulcer or redness was documented. RR of SN notes dated 4-27-22 and signed by RN L revealed" ...Patient received being bathed by hospice aide ... left arm skin tear cleaned ...Old bruises noted to her bilat. Arms ..." There was no documentation concerning the Patient stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 4-28-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient bruises er or skin tear. Further review of the record revealed no plan or interventions for the bruises or skin tear was documented. RR of SN notes dated 5-3-22 and signed by RN L revealed "Patient received lying in bed. Skin tear to [left] arm improved ..." RR of IDG/IDT meeting notes dated 5-5-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient skin tear. Further review of the record revealed no plan or interventions for the skin tear was documented. RR of unsigned SN notes dated 5-12-22 revealed under the section "skin: Wound #1- left buttock stage 3." The note further revealed "Facility Cg requested cushion order due to worsening wound to her buttock. Wound cleanse with cleanser. Pat dried medi honey applied covered with cushion dressing. TAO applied to skin tear ... [supervising nurse/RN coordinator] notified of cushion layer ..." Section for physician notification revealed "none" RR communication note dated 5-12-22 completed by the Medical director revealed" ...The Patient has a stage 2 sacral wound ..." RR of IDG/IDT meeting notes dated 5-12-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient stage 3 wound, skin tear or the facility request for a cushion. Further review of the record revealed no plan or interventions for the wound or skin tear was documented. RR communication note created by RN M dated 5-13-22 revealed" ... [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." RR of SN notes dated 5-17-22 and signed by RN M revealed under the section "skin: Wound #1- [left] buttock lateral stage IV with tunneling 3-4 cm wide ..." The note further revealed that the NP was notified, and new orders were received for wound care. RR communication noted dated 5-17-22 and completed by the supervising nurse/RN coordinator revealed "Facility requested a wheelchair cushion for the Patient. Notified [DME company] ..." RR communication note dated 5-18-22 and completed by RN M revealed" ...The Patient has a stage 4 pressure ulcer at the left lateral buttocks region, open to air, no odor or drainage ...NP notified for wound care order needs ..." RR of IDG/IDT meeting notes dated 5-19-22 revealed under the section "Prep notes: [ supervising nurse/Rn coordinator]- Facility requested a wheelchair cushion for the Patient. Notified [DME company].confirmed with administrator " [Chaplain D]- [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." The IDT/IDG further revealed the wound care treatment under the section "Change in orders" There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG section " Care Plan " . RR of SN notes dated 5-20-22 and signed by RN M revealed" ...wound care done" RR skin sheet dated 5-20-22 and signed by RN M revealed "Pt stage IV wound on [left] lateral buttocks area noted open to air, no visible drainage on site, noted foul odor. New wound care order per NP (to clean wound care spray, dry apply medi honey, cover with gauze) implemented ...NP notified regarding foul odor from site, awaiting further order ..." RR communication note dated 5-23-22 and completed by RN M revealed "Pt stage 4 wound on left lateral buttocks area noted open to air, no visible drainage on site. Noted new foul odor coming from site. New orders for wound care per ...NP implemented ... NP notified for further advise for wound care. Awaiting on new order." RR of IDG/IDT meeting notes dated 5-26-22 revealed under section "Change in orders- start pt Keflex 500 mg PO BID x 7days ..." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG section " Care PLan " . RR of SN notes dated 6-1-22 and signed by QA nurse revealed "Received pt sitting on her couch, pt seems withdrawn lethargy and agitated when touched. Pt moaned during dressing change. SN provided wound care to buttocks and skin tear." RR of IDG/IDT meeting notes dated 6-2-22 revealed under the "Prep note" section a summary of chaplain note from 5-13-22, communication note from 5-17-22, Skin sheet from 5-20-22, SN note from 5-17-22. There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG meeting note section " Care PLan". RR of IDG/IDT meeting notes dated 6-9-22 revealed under "Current orders: Other- Apply Neosporin daily to the left arm skin tear and cover with a nonstick dressing; Clean with wound care spray, dry and apply medi honey, cover with gauze." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG meeting note section section " Care PLan". During an interview on 6-19-22 at 8:00 pm Patient #4 family member stated the Patient had a wound on her buttock early on, but he thought that the agency had gotten the wound well. During an interview on 6-20-22 at 9:27 am hospice aide B (performed care to Patient #4 from 4-5-22 to 4-28-22) stated that she showered Patient #4 one time and remembered the Patient's skin was paper thin. Hospice aide B further stated there was one time when she had finished showering Patient #4 and an agency nurse visited the Patient. Hospice aide B stated that she showed the agency nurse( unknown) that Patient #4 skin was fragile and had a sore on her bottom. Hospice aide B stated, "I showed the agency nurse, but I don't know what he did because I left, I had been there before him." During a concurrent interview on 6-20-22 at 3:33 pm with the supervising nurse/RN coordinator and the administrator, the supervising nurse/RN coordinator stated that the nurses were supposed to address the buttock wound in Sn notes and the IDG/IDT should have included a care plan for wound care for Patient #4 since she was admitted with a pressure sore, Patient #3 RR of SOC SN visit dated 4-28-22 and signed by RN O revealed under section "Wound Assessment and Care" as follows: "1. Dorsal back sacrum/decubitus/ pressure ulcer suspected deep tissue injury; wound bed -clean, bed color- red, covered with Meplex foam. 2. left dorsal foot heel/decubitus/pressure ulcer suspected deep tissue injury: covered with Meplex foam 3. left head eyebrow/other: wound bed- eschar; cleaned with Vashe; application/packing-medi honey; wound care frequency- PRN 3 times/week 4. left lateral leg knee/decubitus/pressure ulcer Stage II: wound bed -eschar; cleaned with- Vashe; application/packing other- Medi Honey; wound care frequency- PRN 3 times/week 5. left posterior arm elbow/skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 6. right dorsal arm elbow/ skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 7. right lateral foot ankle/decubitus/pressure ulcer unstageable: wound bed - slough; bed color-yellow; cleaned with Vashe; application/packing-Thera honey gel; covered with Meplex foam; wound care frequency- daily ..." RR physicians order dated 4-28-22 revealed for right heel "cleanse wound w/ Vashe solution, leave Vashe saturated gauze on wound, for 2-3 minutes, pat dry, apply gentamycin ointment to wound bed, cover w/ dry gauze, secure w/tape then cover w/ comprilan daily. Sn to perform weekly & cg to perform on the other days." RR of Sn note dated 4-29-22 and signed by former agency employee RN H revealed left heel wound measured 2.5x 1 cm, wound bed- purple, tissue-soft with no drainage; right ankle measured 2 x 1.5 cm, wound bed- yellow and tissue -soft. There was no documentation of wound care given or the status of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator who stated if wound care had been done it would be revealed in the nurse's notes. RR Sn note dated 5-3-22 and signed by former agency employee RN H revealed " ...wound care done to [right] elbow, [right] heel & sacral. [right] elbow cleansed [with] NS, pat dry applied dry bordered gauze to wound, [right] heel cleansed [with NS pat dry applied gentamycin ointment covered with bordered gauze and covered with tubi grip, sacral decubitus allewn applied, instructed Cg to not let wounds get wet ..." There was no documentation of the status/treatment of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator, the administrator stated that she did not see on the note where the left elbow, left eyebrow, left dorsal foot heel or left knee wounds were treated. RR of IDG/IDT meeting notes dated 5-5-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient wounds or skin tears. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-9-22 and signed by former agency employee RN H revealed the right ankle wound measured 1.5x1x0.1 cm, wound bed -crusty, tissue-soft and no drainage; right elbow measured 2x1x0.1 cm, wound bed- pink, tissue-pink and draining a scant amount of serous drainage. | |||
| The note further revealed" ...wound care done to wounds-cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip. Cg reported blisters to buttocks, area is fluid filled. Sn administered sacral Meplex & change prn. [left] knee skin tear noted 0.5x0.5x0.1 cm & lg blister to buttocks 7x5 cm." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. There was no evidence that the physician or IDG/IDT was notified of new blisters and left knee skin tear. RR of physician orders revealed no order noted to "cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip." During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator. The supervising nurse/RN coordinator stated she did not see where the IDG/IDT was notified of new blisters or skin tear nor did she see the order for Mepilex to sacral area. RR of IDG/IDT meeting notes dated 5-12-22 revealed under the section "Prep notes " completed by former agency employee RN H revealed -Patient has a wound to right heel measuring [ not measurements documented], right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." There was no documentation concerning the Patient left knee skin tear. Further review of the record on the section " Care Plan " revealed " no changes since last IDG " , plan or interventions for the other wounds or skin tears was documented. RR of SN note dated 5-19-22 and signed by former agency employee RN H revealed under the section " Ssin- See Skin SHeet " RR of skin sheet dated 5-19-22 and signed by former agency employee RN H revealed "Sn informed Cg on status of wounds. Wound care was done as follows: cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze. Sacral area- instructed cg to keep area clean & dry & apply skin protectant to area as needed ..." Furtheer review ofskin sheet diagram revealedleft knee skin tear, right elbow skin tear, new stage 2 with maceration on buttock, and right ankle stage 2. The section of the SN note dated 5-19-22 for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-20-22 at 4:39 p.m. the supervising nurse/ RN coordinator was observed looking through the computerized record for Patient #3 for the wound care physician order "cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze". The supervising nurse/ RN coordinator stated that she did not see the order in the record. RR of IDG/IDT meeting notes dated 5-19-22 revealed there was no documentation concerning the Patient wounds, new stage 2 with maceration or skin tears. Further review of the section " Care Plan " revealed " no changes since last IDG meeting. " No plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-25-22 and signed by former agency employee RN H revealed" ...Sn instructed Cg on continuing to monitor skin & any changes ...wound care to left ankle done as follows cleanse w/Normal saline or wound cleanser, pat dry, apply Meplex or bordered gauze. [right] elbow cleansed w/NS, pat dry, applied Meplex or bordered gauze ..." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. RR of Sn skin sheet dated 5-25-22 and signed by former agency employee RN H revealed"[right] ankle noted [with] scant soft yellow slough, wound edges are pink. [right] elbow has a scab. [left] knee area has healed completely. Pt noted with small 1x1 cm skin tear on top of [right] foot ...area covered w/bordered gauze & Sn instructed Cg to apply TAO if needed." RR of IDG/IDT meeting notes dated 5-26-22 revealed there was no documentation concerning the Patient new wounds to left ankle, new stage 2 with maceration or new skin tear to top of right foot. Further review of the section " Care Plan" revealed " no changes since last IDG meeting." No plan or interventions for the wound or skin tears were documented. RR of Sn notes dated 6-3-22 and signed by QA nurse revealed" ...SN provided wound care to pts right ankle and foot" RR of IDG/IDT meeting notes dated 6-2-22 revealed under " Care Plan-no changes since last IDG meeting." Under "Current orders: Other- SN to cleanse areas with Normal Saline or wound cleanser, pat dry, and cover with Meplex/bordered gauze to right ankle and right elbow and as needed if soiled. Changed to active 5-26-22. " Under the section "Prep notes [ RN H]-Patient has a wound to right heel measuring[ no size documented] , right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." RR of Sn notes dated 6-8-22 and signed by RN L revealed" ... Multiple pressure ulcers that appear to be healing noted to [right] elbow, [right] ankle, [left] ankle. All clean with wound cleanser, pat dry, covered with island dressing. Also left ankle appears healing Sn completed wound care" The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-19-22 at 1:23 pm the family member of Patient #3 stated the wound to the left eyebrow was healed, he still has areas to buttocks and ankles. The family member further stated that the Patient had not had a nurse in two weeks. She stated she spoke to the agency social worker and asked where the nurse was because the Patient wounds had not been treated and he had not had a bowel movement in close to 10 days. The family member further stated she did not know how to do dressing changes. During an interview on 6-20-22 at 4:56 p.m. the supervising nurse/ RN coordinator stated the wound to Patient #3 left ankle looks like it is a new wound. Patient #2 RR Sn SOC visit dated 5-12-22 and signed by the supervising nurse/RN coordinator revealed under the section "Wound Assessment and Care" as follows: Left foot 2nd toe/venous stasis ulcer- wound bed- eschar, dry; bed color- black; no drainage, no odor ..." There was no treatment noted for the wound. Further review of note revealed under the section "Integumentary- bruising right thigh anterior and gangrene 2nd right toe" RR non visit report dated 5-16-22 revealed "no answer to phone/home" RR of IDG/IDT meeting notes dated 5-19-22 revealed under the section "Prep Notes " ' completed by QA Nurse- " Pt complained of toe pain. Pt has gangrene to his 2nd toe, pt's wife would like something to put on it." RR of order from physician A dated 5-19-22 revealed "Apply TAO to 2(sic) toe daily and leave open to air." RR of SN note dated 5-26-22 and signed by RN L revealed "paint to left 2nd gangrene toe ...routine visit completed ..." There was no documentation of wound care treatment done. RR of order from physician B dated 5-26-22 revealed "paint 2nd toe with Iodine daily and leave open to air." RR of IDG/IDT meeting notes dated 5-26-22 revealed under " Care Plan section- no changes since last IDg meeting " . There was no documentation concerning the Patient Left foot 2nd toe/venous stasis ulcer. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn note dated 6-2-22 and signed by QA nurse revealed "wound care provided to second toe TAO applied ..." RR of IDG/IDT meeting notes dated 6-2-22 under the section "Change in Orders: Other - Paint 2(sic) toe with iodine daily and leave to open air., Start Date: 5/26/2022" During an interview on 6-17-22 at 12:19 pm the supervising nurse/RN coordinator stated she was not sure who the nurse was for the visit made on 6-11-22 but she did not see documentation on the note concerning wound care. The supervising nurse/RN coordinator stated she would see if the nurse turned in a skin sheet for the visit. Further interview at 1:08 pm the supervising nurse/RN coordinator stated upon any admission they talked to the doctor about any issue and anything pertinent for the Patient. "On Patient #2 [the doctor] said to just observe the toe." The supervising nurse/RN coordinator then stated she was not sure where she would have revealed the physician instructions to observe Patient #2 toe. The supervising nurse/RN coordinator then stated she believed the Patients well-being and care would be affected to not have all the information needed in the IDG/IDT meetings. During an interview on 6-17-22 at 12:23 pm Patient #2 family member stated she kept Patient #2 wound clean. The agency gave her some wound spray to use but she did not remember the name. The family member stated the nurse only check Patient #2 vital signs and look at the wound but do no treatment to the wound. The family member also stated that she applies Iodosorb 10 mg every other day to Patient #2's toe. The cream was previously used on another toe. The family member further stated the QA nurse put the TAO on the wound on 6-2-22 before she found the Iodosorb cream. The family member then stated the QA nurse was the only nurse to put something on the toe, the other nurse just looked. The family member stated that the toe is drying up pretty good now, it is not leaking anymore. The family member stated the toe was leaking pus and blood last weekend. During further interview at 3:49 pm the family member stated that she informed the agency nurses of the wound leaking last weekend. "I make sure I show them. Whenever they come out." The family member then stated she showed the cream she was using on Patient #2 toe to the QA nurse. During an interview on 6-17-22 at 12:49 pm the QA nurse stated she got text messages of the orders written on 5-19-22 for Tao and 5-26-22 for Iodine. Surveyor reviewed text messages and paper physician orders. The QA nurse stated other nurses would have known what the orders were because they talk about it in the IDG/IDT meetings. QA nurse was informed the IDG/IDT on 5-19-22 and 5-26-22 did not have any information concerning Patient #2 toe. The QA Nurse stated, "Normally we would have discussed it." The QA nurse further stated she notified the family member about the wound order received on 5-26-22, but the medication has been on back order and the agency just received it on 5-13-22. The QA nurse stated Patient #2 wasn't getting any treatment and on 6-2-22 she put the TAO on his toe "So at least he would get something." Further interview on 6-17-22 at 4:28 pm the QA nurse stated she did not receive any orders on what to do while the iodine was on back order. "That's why I used TAO." The QA nurse stated that the family member of Patient #2 talked to her about using the cream on Patient #2. The QA nurse stated another doctor had given the family member the cream and she really liked it so she told the family member when she found it to send a picture of it or show her and she would see it the agency could order the medication. The QA nurse stated the family member never showed her the medication and she did not mention it to the IDG/IDT. During an interview on 6-17-22 at 3:05 pm the supervising nurse stated the discussion in IDT/IDG about wound care Patients would be to see if there are any concerns. Further stated that the nurse would give a short blurb of the Patients wound. The supervising nurse then stated the discussion should be captured in the IDT/IDG documentation as well as any interventions. After review of Patient #1 IDG/IDT's the supervising nurse stated, "Don't look like we are doing a very good job at that." During an interview on 6-20-22 at 3:51 pm the administrator stated that the supervising nurse was the RN coordinator for the IDG/IDT. During an interview on 6-20-22 at 3:53 p.m. The supervising nurse/ RN coordinator stated she makes sure that the IDG/IDT has all the current information about Patient's by looking at prep notes completed by agency staff, communication notes, emails that are done daily about Patients and in the event of an urgent message texts that are sent regarding Patients. In Further interview the supervising nurse/ RN coordinator stated the nurse who does the inital assessment on the Patient would be responsible for ensuring all problems and issues are carried over to the care plan, then they are assigned to a case manager. Record review of policy revised on 0/52016 titled " The Plan of Care" documented " The plan of care will be based on the initial , comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days... Any changes in the Patient condition must result in a change in the plan of care, prior to the implementation of the new service..." Record review of policy titled "Interdisciplinary Group Coordination of Care" revised on 5-05/2016 documented " ... it will be the responsibility of the Clinical Supervisor to assign a case manager who is a registered nurse. The Case manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge ...it will be the responsibility of the RN Case Manager to facilitate communication about changes in the Patient's status among interdisciplinary group members and the Patient's physician ..." The administrator, RN coordinator/supervising nurse and regional director were notified on 6-20-22 at 5:00 p.m. that an immediate jeopardy situation had been identified due to the above failure. On 6-22-22 at 6:03 p.m., the surveyor received the hospice's accepted plan of removal. The plan of removal, dated 6-21-22, indicated the hospice would implement the following interventions to correct the immediate jeopardy: The executive team would be reevaluating the policies to ensure completeness of wound care protocol. These policies include: Interdisciplinary Group Coordination of Care; Monitoring Patient's Response/Reporting to Physician; Patient Notification of Changes in Care; The Plan of Care. This will be completed by end of week, 06/24/2022. Licensed wound care nurse position was opened on 06/20/2022 to promote better wound outcomes regarding documentation, caregiver education, and plan of care updates. Administrator to monitor 100% compliance of Wound Care PIP spreadsheet by DON and QA Nurse for 3 months and reevaluated Quarterly. QA nurse reassessed wounds, orders were received, and treatment was initiated on 6-21-22. QA Nurse provided training to caregivers on 6-21-22. Staff in serviced and trained on 6-21-22. New Matrix Wound Care Audit Toll initiated on 6-21-22. Record review of in-service training records for the hospice's current staff indicating the hospice had provided in-service training on 6-21-22. On 6-22-23 and 6-23-22 the surveyor interviewed 8 current hospice employees which included the QA nurse, hospice aide A, hospice aide B, RN C, chaplain D, chaplain E, hospice aide F and RN G. The surveyor also interviewed Patient #3 family member who stated the QA nurse trained her on wound care. All staff interviewed verified that they had been in serviced on wound care protocol as it was related to their job description. RNs indicated that they are to assess Patients, document any findings notify physicians and IDT/IDG of any new findings or orders, teach caregivers. CNAs indicated that they were told to carry a skin sheet to document areas found on Patients' skin and to notify the nurse. QA nurse stated they were told to document everything; the agency is hiring a wound care nurse and she will focus on teaching and keeping the QAPI going. The chaplains stated that their role was to document any reports of wounds and notify IDG/IDT. Record review of agency policies revealed changes were made to include the following: changes will be shared in IDG, missed wound care will be documented and discussed in IDG meetings, caregivers will be notified of changes in care at the time of the visit, wound assessments will be documented each visit and discussed at each IDG meeting, the Patient's physician and medical director will be contacted on the same day when any changes in wound appearance and delay in availability of medications, care plans will reflect new wound care orders and treatments, the plan of care will identify the Patients' needs and services inclusive of wounds and wound treatments and the plan of care will contain wound care/changes/treatments. On 6-23-22 at 12:35 p.m., the administrator was informed that the it was removed. However deficient practice was present at a condition level. The hospice was continuing to implement the plan of removal. | |||
| L0546 | |||
| 16353 Based on record review and interview the agency failed to ensure that the plan of care included interventions for 1 of 5 ( #1) patients experiencing pain from a wound Patient #1 plan of care did not include interventions to manage his pain levels when his wound started giving him pain that reached levels between 4 to 6 on a scale of 10 The failure to not include a plan of care for pain management could affect any patient at risk for pain. This deficient practice could result in patients having inadequate pain management and with unrelieved pain. Findings include: RR complaint intake received to the State on 6-16-22 revealed "On 5/19/2022 ...The clients physician informed ... that due to the client's condition and gangrene on the client's foot. The client would need an amputation of his foot ...On 5/20/22 the client was ...put on IV antibiotics. On 5/21/2022 at 10:00 am, The client foot had his foot amputated ..." RR of physician virtual visit note dated 1-27-22 revealed medical history of hypertension, hearing loss, hyperlipidemia and BPH. Current assessment was revealed as Advanced dementia. RR of hospice plan of care dated 1-29-22 to 4-28-22 revealed a start of care of 1-29-22. A primary diagnosis of Alzheimer's disease was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 3 wk 12 then 2 wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate then 9 PRN". Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of hospice plan of care dated 4-29-22 to 7-27-22 revealed discipline orders "Skilled nursing: 1 wk 13 wk 26 PRN: Symptom Management ...Aide: 3 wk 5 wk, 2 wk 1 wk, 3wk 4 wk; 2 wk 1 wk; 3 wk 2 wk; 1 wk 1wk ..." Interventions included "Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of Sn notes dated 1-29- 22, 2-2-22, 2-12-22 (missed visit) and 2-24-22 revealed no issues with skin integrity. RR of Sn notes signed by former agency employee RN H and dated 2-25-22 "N/P" under the section "Skin" The note further revealed "Cg reported pt fell this a.m. [no] injuries or wounds noted ...[right] great toe pain level 4 with touch, intermittent and sharp ...Tylenol 650 mg 2 tabs given x 2 days" RR of Sn narrative note signed by former agency employee RN H and dated 2-25-22 revealed "Spoke [wit] daughter re: small dark area bruise to [right] heel - SN instructed cg to float both heels [and] reposition every 2 hours. Cg stated, "She thinks her dad has PVD." SN discussed in detail re: disease process of PVD is a slow [and] progressive circulation disorder. It may affect any blood vessel including arteries, veins or lymphatic vessels." There was no indication that the physician or IDG/IDT was notified of area. RR of Sn notes dated 3-4-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. RR of IDG/IDT meeting notes dated 3-10-22 revealed there was no documentation concerning the patient new bruise to right heel. Further review of the record revealed no plan or interventions for the bruise was documented. RR of Sn notes dated 3-11-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. Further documentation of bilateral feet and back pain at level 5, occurs several times a day intermittently, sharp and aching. RR of Sn notes dated 3-17-22 and signed by former agency employee RN H revealed "Cg reported blister to 2nd great toe burst and has been oozing blood (sero-sanguineous color). Cg also reported pt [right] heel has gotten dark in color [and] very dry. Sn assessed wounds [and] applied dry dressings ..." The note further revealed "right heel 3.5cm x 3 cm and [right] 2nd toe 1.5 cm x 0.5 cm" Note also revealed bilateral great toe pain at level 5. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of skin sheet dated 3-17-22 and signed by former agency employee RN H revealed "Pt noted [with] black/reddened area (stage I pressure to [right] heel measuring 3.5x 3cm; skin not broken. Pt has a fluid filled (blood) blister to [right] 2nd toe measuring 1.5x0.5 cm. Pt also noted [with] a blister that burst to [ right] great toe w/small amount serosanguineous." RR of IDG/IDT meeting notes dated 3-17-22 revealed there was no documentation concerning the patient's paine level of 5, right heel, right 2nd toe or great toe wounds. Further review of the record revealed no plan or interventions for the wounds were documented. RR of Sn notes dated 3-18-22 and signed by former agency employee RN H revealed the right heel measured 3.5cm x 3 cm and [right] 2nd toe measured 1.5 cm x 0.5 cm; Under the pain section of note revealed bilateral feet pain at level 6 that is throughout the day, constant and sharp. Further documentation was noted as follows: patient pain brought to a comfortable level within 48 hours- no was marked. "Re-visit: PRN visit made for wound care ... wound care done to [right] heel [right] great toe + 2nd toe. Applied loosely wrapped gauze & instructed Cg to keep pressure off feet by applying sheets loosely ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of SN note dated 3-21-22 and signed by former agency employee RN H revealed "pain to bilateral feet at level 4 all the time constantly aching" Further documentation noted as follows: " ...has new blister on top of [right] foot (fluid filled) ...Sn instructed Cg to remove line from feet ... Sn applied bordered gauze to [right] heel & [right] foot ... [right] heel measured 3.5cm x 2 cm; area still dry dark in color [no] odor ...areas to great toe & 2nd toe have healed." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 3-24-22 revealed problem of "Pain management" under goal and interventions was revealed "No Goals and No interventions". Under the section prep notes revealed "Per Cg patient has pain to both great toes. upon assessment, patient noted with discoloration to right toe and tender to touch. Left toe tender to touch. Received order from MD ... for tramadol 50 mg every 6-8 hrs prn pain ..." There was no documentation concerning the right heel or new blister wound. RR of Sn notes dated 3-30-22 and signed by former agency employee RN H revealed pain in right heel moderate at level 5 constant. "[Right] heel noted [with] black soft eschar- Sn applied medi honey & bordered Mepilex ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of narrative note dated and signed by former agency employee RN H 3-30-22 revealed "Pt is scheduled to see VA Md on 3-31-22. Sn discussed w/cg to inform MD of [right] heel & obtain new orders if needed ..." RR of IDG/IDT meeting notes dated 3-31-22 revealed there was no documentation concerning the patient change in right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-6-22 and signed by former agency employee RN H revealed right heel was 5cmx 2 cm with purplish black soft eschar. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 4-7-22 revealed there was no documentation concerning the patient increase in size of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-13-22 and signed by former agency employee RN H revealed right heel with black eschar. Further documentation "Patient has wound to right heel. RN dressed wound with medi honey and bordered foam dressing. Cg changes dressing every other day ..." RR of IDG/IDT meeting notes dated 4-14-22 revealed under "Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no interventions for the right heel wound were documented. RR of IDG/IDT meeting notes dated 4-21-22 revealed under the section "Prep notes " ...Chaplain 4-20-22 ...asked if [ patient #1] had any pain and [ patient #1] spoke of pain traveling from foot up leg. [ Family member] said she had discussed this with the nurse at her last visit ..." Further review of the record revealed no plan or interventions for wounds were documented. RR Sn notes dated 4-22-22 and signed by former agency employee RN H revealed right heel measured 6x4x0.1 cm. The note further revealed" ...c/o pain [with] touch to [right] foot ...Pt noted [with] stage pressure ulcer to [right] heel. Area cleansed [with] wound cleanser, pat dry & medi honey &secured[with] bordered gauze. Cg instructed to float heels ..." Under the section "Care Coordinated/Conferenced with" revealed the physician was contacted regarding "med-change-increase Neurontin." RR of Sn notes dated 4-27-22 revealed right heel unstageable. "[ Right] heel PS unstageable noted [with] soft black eschar over 75% of heel. Pt c/o bilateral heel pain - neuropathy (sic) ordered ..." RR of IDG/IDT meeting notes dated 4-28-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no wound care interventions for the right heel wound were documented. RR of Sn notes dated 5-2-22 revealed "Pt is at ... (respite) x1week." RR of IDG/IDT meeting notes dated 5-5-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Under the section "Infections" revealed "wound infection- unknown 2022-05-18 ...visit date 05/19/2011 13:00 warm to touch; pain; purulent [pus] drainage; odor ulcer antibiotics: yes, newly prescribed ..." RR of Sn notes dated 5-11-22 and signed by former agency employee RN H revealed right heel measured 7x6x0.1 cm, the wound bed black with mushy tissue and faint odor. Further revealed "Cg reports Pt had decline in appetite since returning home from respite on 5/10/22. Pts [right] heel is black, but fluid filled, mushy ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 5-12-22 revealed there was no documentation concerning the patient change in stats of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn notes dated 5-18-22 and signed by former agency employee RN H revealed right heel measured 10x9x0.2 cm, the wound bed black with mushy tissue, scant amount of drainage and faint odor. Further revealed" ... [right] heel - reported by cg has been draining & has a odor. Area cleansed w/ NS, pat dry applied skin protectant, gauze, kerlix & tape. Report called to ...RN @ IPU; waiting for bed assignment." Further review of note revealed the physician was called regarding wound odor and ordered "Doxycycline 100 mg BID x 7 days." During an interview on 6-17-22 at 3:07 pm the supervisng nurse/RN coordinator stated the care plan should have pain mamgement for everyone on service. During an interview on 6-17-22 at 4:13 pm the supervising nurse stated that she looked at the clinical record for patient #1 and did not see a diagnosis of PVD. The supervising nurse further stated she did not know where the former employee got that information. During an interview on 6-17-22 at 4:18 pm the director of quality assurance stated although the IDT/IDG meeting notes were created on 4-14-22, 4-28-22 and 5-5-22 if the IDT/IDGs go into "pending signature" status, whatever date it is opened for the signature it will pull all the current information on the patient to date (5-19-22) and to the IDT/IDG. Record review of revised policy dated 05/2016 titled " The Plan of Care" documented ".. The plan of care will identify the patient's needs, including the management of pain and discomfort and symptom relief...The plan of care will contain ...Pain and symptom management interventions..." | |||
| L0552 | |||
| 16353 Based on record review and interview the IDG/IDT failed to revise the plan of care to include the development of wounds for 1 of 5 patients ( #1) reviewed with wounds Patient #1- Plans of care were not updated to reflect new onset wounds, pain and changes in wound status. Patient's foot was amputated on 5-21-22 This failure to include wound care on the plans of care could affect any patient at risk for developing wounds or with preexisting wounds. This deficient practice resulted in Patient #1 experiencing pain, deterioration in his wound and likely contributed to the amputation of his foot. Findings Include: RR complaint intake received to the State on 6-16-22 revealed "On 5/19/2022 ...The Patients physician informed ... that due to the Patient's condition and gangrene on the Patient's foot. The Patient would need an amputation of his foot ...On 5/20/22 the Patient was ...put on IV antibiotics. On 5/21/2022 at 10:00 am, The patient had his foot amputated ..." RR of physician virtual visit note dated 1-27-22 revealed medical history of hypertension, hearing loss, hyperlipidemia and BPH. Current assessment was revealed as Advanced dementia. RR of hospice plan of care dated 1-29-22 to 4-28-22 revealed a start of care of 1-29-22. A primary diagnosis of Alzheimer's disease was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 3 wk 12 then 2 wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate then 9 PRN". Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia Patient ..., assess Patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of hospice plan of care dated 4-29-22 to 7-27-22 revealed discipline orders "Skilled nursing: 1 wk 13 wk 26 PRN: Symptom Management ...Aide: 3 wk 5 wk, 2 wk 1 wk, 3wk 4 wk; 2 wk 1 wk; 3 wk 2 wk; 1 wk 1wk ..." Interventions included "Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia Patient ..., assess Patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of Sn notes dated 1-29- 22, 2-2-22, 2-12-22 (missed visit) and 2-24-22 revealed no issues with skin integrity. RR of Sn notes signed by former agency employee RN H and dated 2-25-22 "N/P" under the section "Skin" The note further revealed "Cg reported pt fell this a.m. [no] injuries or wounds noted ...[right] great toe pain level 4 with touch, intermittent and sharp ...Tylenol 650 mg 2 tabs given x 2 days" RR of Sn narrative note signed by former agency employee RN H and dated 2-25-22 revealed "Spoke [wit] daughter re: small dark area bruise to [right] heel - SN instructed cg to float both heels [and] reposition every 2 hours. Cg stated, "She thinks her dad has PVD." SN discussed in detail re: disease process of PVD is a slow [and] progressive circulation disorder. it may affect any blood vessel including arteries, veins or lymphatic vessels." There was no indication that the physician or IDG/IDT was notified of area. RR of Sn notes dated 3-4-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. RR of IDG/IDT meeting notes dated 3-10-22 revealed under the section " Care Plan- changes in care plan : no changes since last IDG " . Further review on the note revealed there was no documentation concerning the Patient new bruise to right heel. Further review of the record revealed no plan or interventions for the bruise was documented. RR of Sn notes dated 3-11-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. Further documentation of bilateral feet and back pain at level 5, occurs several times a day intermittently, sharp and aching. RR of Sn notes dated 3-17-22 and signed by former agency employee RN H revealed "Cg reported blister to 2nd great toe burst and has been oozing blood (sero-sanguineous color). Cg also reported pt [right] heel has gotten dark in color [and] very dry. Sn assessed wounds [and] applied dry dressings ..." The note further revealed "right heel 3.5cm x 3 cm and [right] 2nd toe 1.5 cm x 0.5 cm" Note also revealed bilateral great toe pain at level 5. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of skin sheet dated 3-17-22 and signed by former agency employee RN H revealed "Pt noted [with] black/reddened area (stage I pressure to [right] heel measuring 3.5x 3cm; skin not broken. Pt has a fluid filled (blood) blister to [right] 2nd toe measuring 1.5x0.5 cm. Pt also noted [with] a blister that burst to [ right] great toe w/small amount serosanguineous." RR of IDG/IDT meeting notes dated 3-17-22 revealed under the section "Care Plan- changes in care plan : no changes since last IDG". Further review on the note revealed there was no documentation concerning the Patient's paine level of 5, right heel, right 2nd toe or great toe wounds. Further review of the record revealed no plan or interventions for the wounds were documented. RR of Sn notes dated 3-18-22 and signed by former agency employee RN H revealed the right heel measured 3.5cm x 3 cm and [right] 2nd toe measured 1.5 cm x 0.5 cm; Under the pain section of note revealed bilateral feet pain at level 6 that is throughout the day, constant and sharp. Further documentation was noted as follows: Patient pain brought to a comfortable level within 48 hours- no was marked. "Re-visit: PRN visit made for wound care ... wound care done to [right] heel [right] great toe + 2nd toe. Applied loosely wrapped gauze & instructed Cg to keep pressure off feet by applying sheets loosely ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of SN note dated 3-21-22 and signed by former agency employee RN H revealed "pain to bilateral feet at level 4 all the time constantly aching" Further documentation noted as follows: " ...has new blister on top of [right] foot (fluid filled) ...Sn instructed Cg to remove line from feet ... Sn applied bordered gauze to [right] heel & [right] foot ... [right] heel measured 3.5cm x 2 cm; area still dry dark in color [no] odor ...areas to great toe & 2nd toe have healed." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 3-24-22 the section "Care Plan- changes in care plan : no changes since last IDG". Further review of the notes revealed problem of "Pain management" under goal and interventions was revealed "No Goals and No interventions". Under the section prep notes revealed "Per Cg Patient has pain to both great toes. upon assessment, Patient noted with discoloration to right toe and tender to touch. Left toe tender to touch. Received order from MD ... for tramadol 50 mg every 6-8 hrs prn pain ..." There was no documentation concerning the right heel or new blister wound. RR of Sn notes dated 3-30-22 and signed by former agency employee RN H revealed pain in right heel moderate at level 5 constant. "[Right] heel noted [with] black soft eschar- Sn applied medi honey & bordered Mepilex ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of narrative note dated and signed by former agency employee RN H 3-30-22 revealed "Pt is scheduled to see VA Md on 3-31-22. Sn discussed w/cg to inform MD of [right] heel & obtain new orders if needed ..." RR of IDG/IDT meeting notes dated 3-31-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". Further review revealed there was no documentation concerning the Patient change in right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-6-22 and signed by former agency employee RN H revealed right heel was 5cmx 2 cm with purplish black soft eschar. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 4-7-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". The notes revealed there was no documentation concerning the Patient increase in size of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-13-22 and signed by former agency employee RN H revealed right heel with black eschar. Further documentation "Patient has wound to right heel. RN dressed wound with medi honey and bordered foam dressing. Cg changes dressing every other day ..." RR of IDG/IDT meeting notes dated 4-14-22 revealed under "Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22- [date nurse in IPU added problem to care plan])". However, urther review of the record revealed no interventions for the right heel wound were documented. RR of IDG/IDT meeting notes dated 4-21-22 the section "Care Plan- changes in care plan : no changes since last IDG". Review of the section "Prep notes " ...[Chaplain D] 4-20-22 ...asked if [ Patient #1] had any pain and [ Patient #1] spoke of pain traveling from foot up leg. [ Family member] said she had discussed this with the nurse at her last visit ..." Further review of the record revealed no plan or interventions for wounds were documented. RR Sn notes dated 4-22-22 and signed by former agency employee RN H revealed right heel measured 6x4x0.1 cm. The note further revealed" ...c/o pain [with] touch to [right] foot ...Pt noted [with] stage pressure ulcer to [right] heel. Area cleansed [with] wound cleanser, pat dry & medi honey &secured[with] bordered gauze. Cg instructed to float heels ..." Under the section "Care Coordinated/Conferenced with" revealed the physician was contacted regarding "med-change-increase Neurontin." RR of Sn notes dated 4-27-22 revealed right heel unstageable. "[ Right] heel PS unstageable noted [with] soft black eschar over 75% of heel. Pt c/o bilateral heel pain - neuropathy (sic) ordered ..." RR of IDG/IDT meeting notes dated 4-28-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22 [date nurse in IPU added problem to care plan])". Further review of the record revealed no wound care interventions for the right heel wound were documented. RR of Sn notes dated 5-2-22 revealed "Pt is at ... (respite) x1week." RR of IDG/IDT meeting notes dated 5-5-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22 [date nurse in IPU added problem to care plan])". Under the section "Infections" revealed "wound infection- unknown 2022-05-18 ...visit date 05/19/2011 13:00 warm to touch; pain; purulent [pus] drainage; odor ulcer antibiotics: yes, newly prescribed ..." RR of Sn notes dated 5-11-22 and signed by former agency employee RN H revealed right heel measured 7x6x0.1 cm, the wound bed black with mushy tissue and faint odor. Further revealed "Cg reports Pt had decline in appetite since returning home from respite on 5/10/22. Pts [right] heel is black, but fluid filled, mushy ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 5-12-22 revealed the section "Care Plan- changes in care plan : no changes since last IDG". There was no documentation concerning the Patient change in status of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn notes dated 5-18-22 and signed by former agency employee RN H revealed right heel measured 10x9x0.2 cm, the wound bed black with mushy tissue, scant amount of drainage and faint odor. Further revealed" ... [right] heel - reported by cg has been draining & has a odor. Area cleansed w/ NS, pat dry applied skin protectant, gauze, kerlix & tape. Report called to ...RN @ IPU; waiting for bed assignment." Further review of note revealed the physician was called regarding wound odor and ordered "Doxycycline 100 mg BID x 7 days." During an interview on 6-17-22 at 4:13pm the supervising nurse stated that she looked at the clinical record for Patient #1 and did not see a diagnosis of PVD. The supervising nurse further stated she did not know where the former employee got that information. During an interview on 6-17-22 at 4:18 pm the director of quality assurance stated the reason that care plan problems not genenerated until 5-19-22 were on the 4-14-22, 4-28-22 and 5-5-22 IDG/IDT meeting notes was because when the meeting note go into "pending signature" status[ on the computerized system] , whatever date the meeting note is opened to sign [ by a member of the IDG/IDT] it [ the computerized system] will pull all the current information on the Patient [ in the system] and [ put the information] onto the IDT/IDG meeting note. During an interview on 6-20-22 at 3:53 p.m., the supervising nurse/ RN coordinator stated she made sure that the IDG/IDT had all the current information about patients by looking at prep notes completed by agency staff, communication notes, emails that were done daily about patients and in the event of an urgent message texts that were sent regarding patients. Record review of policy revised on 05/2016 titled " The Plan of Care" documented " The plan of care will be based on the initial , comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days... Any changes in the Patient condition must result in a change in the plan of care, prior to the implementation of the new service..." | |||
| L0554 | Coordination Of Services 418.56(e)(1) Corrected On: 07/08/2022 |
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| 16353 Based on record review and interview the hospice IDG/IDT failed to have a system in place to ensure coordination of care occurred for 4 of 5 (Patient #1, #2, #3 and #4) patients reviewed with wounds. Patient #1- IDG/IDT did not coordinate with Sn regarding onset of new wounds and wound assessment of a pressure sore . Patient foot was amputated on 5-21-22 Patient #4-the IDG/IDT did not coordinate with Sn and chaplain D regarding patient's Stage 2 pressure sore deteriorating to a Stage 4. Patient #3- the IDG/IDT did not coordinate with Sn regarding the patient's wound status and treatments for the wounds. All Patient wounds were not assessed, care was done without orders and new wounds were not reported. Patient #2- the IDG/IDT did not coordinate with QA nurse regarding new treatment ordered and delay in the availability of treatments ordered. This failure resulted in an identification of an IJ on 6-20-22 after review by the State. While the IJ was removed on 6-23-22, the deficient practice continued at a condition level. This failure of the IDG/IDT to coordinate care with all agency personnel caring for patients with wounds could affect any patient at risk for developing wounds or with preexisting wounds. This deficient practice could result in the development of new pressure ulcers and/or the deterioration of existing pressure ulcers The findings included: Patient #1 RR complaint intake received to the State on 6-16-22 revealed "On 5/19/2022 ...The clients physician informed ... that due to the client's condition and gangrene on the client's foot. The client would need an amputation of his foot ...On 5/20/22 the client was ...put on IV antibiotics. On 5/21/2022 at 10:00 am, The client foot had his foot amputated ..." RR of physician virtual visit note dated 1-27-22 revealed medical history of hypertension, hearing loss, hyperlipidemia and BPH. Current assessment was revealed as Advanced dementia. RR of hospice plan of care dated 1-29-22 to 4-28-22 revealed a start of care of 1-29-22. A primary diagnosis of Alzheimer's disease was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 3 wk 12 then 2 wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate then 9 PRN". Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of hospice plan of care dated 4-29-22 to 7-27-22 revealed discipline orders "Skilled nursing: 1 wk 13 wk 26 PRN: Symptom Management ...Aide: 3 wk 5 wk, 2 wk 1 wk, 3wk 4 wk; 2 wk 1 wk; 3 wk 2 wk; 1 wk 1wk ..." Interventions included "Interventions for Sn included "assess mental status/orientation, assess pain level and discomfort for non-verbal dementia patient ..., assess patient safety, potential for injury to self or others; to teach reinforce safety/falls prevention measures". Goals included "Sn: family/caregiver will demonstrate measures to maintain skin integrity ..." RR of Sn notes dated 1-29- 22, 2-2-22, 2-12-22 (missed visit) and 2-24-22 revealed no issues with skin integrity. RR of Sn notes signed by former agency employee RN H and dated 2-25-22 "N/P" under the section "Skin" The note further revealed "Cg reported pt fell this a.m. [no] injuries or wounds noted ...[right] great toe pain level 4 with touch, intermittent and sharp ...Tylenol 650 mg 2 tabs given x 2 days" RR of Sn narrative note signed by former agency employee RN H and dated 2-25-22 revealed "Spoke [wit] daughter re: small dark area bruise to [right] heel - SN instructed cg to float both heels [and] reposition every 2 hours. Cg stated, "She thinks her dad has PVD." SN discussed in detail re: disease process of PVD is a slow [and] progressive circulation disorder. It may affect any blood vessel including arteries, veins or lymphatic vessels." There was no indication that the physician or IDG/IDT was notified of area. RR of Sn notes dated 3-4-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. RR of IDG/IDT meeting notes dated 3-10-22 revealed there was no documentation concerning the patient new bruise to right heel. Further review of the record revealed no plan or interventions for the bruise was documented. RR of Sn notes dated 3-11-22 and signed by former agency employee RN H revealed "N/A" under the skin section of the note. Further documentation of bilateral feet and back pain at level 5, occurs several times a day intermittently, sharp and aching. RR of Sn notes dated 3-17-22 and signed by former agency employee RN H revealed "Cg reported blister to 2nd great toe burst and has been oozing blood (sero-sanguineous color). Cg also reported pt [right] heel has gotten dark in color [and] very dry. Sn assessed wounds [and] applied dry dressings ..." The note further revealed "right heel 3.5cm x 3 cm and [right] 2nd toe 1.5 cm x 0.5 cm" Note also revealed bilateral great toe pain at level 5. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of skin sheet dated 3-17-22 and signed by former agency employee RN H revealed "Pt noted [with] black/reddened area (stage I pressure to [right] heel measuring 3.5x 3cm; skin not broken. Pt has a fluid filled (blood) blister to [right] 2nd toe measuring 1.5x0.5 cm. Pt also noted [with] a blister that burst to [ right] great toe w/small amount serosanguineous." RR of IDG/IDT meeting notes dated 3-17-22 revealed there was no documentation concerning the patient's paine level of 5, right heel, right 2nd toe or great toe wounds. Further review of the record revealed no plan or interventions for the wounds were documented. RR of Sn notes dated 3-18-22 and signed by former agency employee RN H revealed the right heel measured 3.5cm x 3 cm and [right] 2nd toe measured 1.5 cm x 0.5 cm; Under the pain section of note revealed bilateral feet pain at level 6 that is throughout the day, constant and sharp. Further documentation was noted as follows: patient pain brought to a comfortable level within 48 hours- no was marked. "Re-visit: PRN visit made for wound care ... wound care done to [right] heel [right] great toe + 2nd toe. Applied loosely wrapped gauze & instructed Cg to keep pressure off feet by applying sheets loosely ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of SN note dated 3-21-22 and signed by former agency employee RN H revealed "pain to bilateral feet at level 4 all the time constantly aching" Further documentation noted as follows: " ...has new blister on top of [right] foot (fluid filled) ...Sn instructed Cg to remove line from feet ... Sn applied bordered gauze to [right] heel & [right] foot ... [right] heel measured 3.5cm x 2 cm; area still dry dark in color [no] odor ...areas to great toe & 2nd toe have healed." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 3-24-22 revealed problem of "Pain management" under goal and interventions was revealed "No Goals and No interventions". Under the section prep notes revealed "Per Cg patient has pain to both great toes. upon assessment, patient noted with discoloration to right toe and tender to touch. Left toe tender to touch. Received order from MD ... for tramadol 50 mg every 6-8 hrs prn pain ..." There was no documentation concerning the right heel or new blister wound. RR of Sn notes dated 3-30-22 and signed by former agency employee RN H revealed pain in right heel moderate at level 5 constant. "[Right] heel noted [with] black soft eschar- Sn applied medi honey & bordered Mepilex ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of narrative note dated and signed by former agency employee RN H 3-30-22 revealed "Pt is scheduled to see VA Md on 3-31-22. Sn discussed w/cg to inform MD of [right] heel & obtain new orders if needed ..." RR of IDG/IDT meeting notes dated 3-31-22 revealed there was no documentation concerning the patient change in right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-6-22 and signed by former agency employee RN H revealed right heel was 5cmx 2 cm with purplish black soft eschar. The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 4-7-22 revealed there was no documentation concerning the patient increase in size of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR Sn notes dated 4-13-22 and signed by former agency employee RN H revealedright heel with black eschar. Further documentation "Patient has wound to right heel. RN dressed wound with medi honey and bordered foam dressing. Cg changes dressing every other day ..." RR of IDG/IDT meeting notes dated 4-14-22 revealed under "Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no interventions for the right heel wound were documented. RR of IDG/IDT meeting notes dated 4-21-22 revealed under the section "Prep notes " ...Chaplain 4-20-22 ...asked if [ patient #1] had any pain and [ patient #1] spoke of pain traveling from foot up leg. [ Family member] said she had discussed this with the nurse at her last visit ..." Further review of the record revealed no plan or interventions for wounds were documented. RR Sn notes dated 4-22-22 and signed by former agency employee RN H revealed right heel measured 6x4x0.1 cm. The note further revealed" ...c/o pain [with] touch to [right] foot ...Pt noted [with] stage pressure ulcer to [right] heel. Area cleansed [with] wound cleanser, pat dry & medi honey &secured[with] bordered gauze. Cg instructed to float heels ..." Under the section "Care Coordinated/Conferenced with" revealed the physician was contacted regarding "med-change-increase Neurontin." RR of Sn notes dated 4-27-22 revealed right heel unstageable. "[ Right] heel PS unstageable noted [with] soft black eschar over 75% of heel. Pt c/o bilateral heel pain - neuropathy (sic) ordered ..." RR of IDG/IDT meeting notes dated 4-28-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Further review of the record revealed no wound care interventions for the right heel wound were documented. RR of Sn notes dated 5-2-22 revealed "Pt is at ... (respite) x1week." RR of IDG/IDT meeting notes dated 5-5-22 revealed under the Care Plan" section "Changes in Care Plan: Problem 3. Impaired Skin Integrity; Discipline: RN (5/19/22)" Under the section "Infections" revealed "wound infection- unknown 2022-05-18 ...visit date 05/19/2011 13:00 warm to touch; pain; purulent [pus] drainage; odor ulcer antibiotics: yes, newly prescribed ..." RR of Sn notes dated 5-11-22 and signed by former agency employee RN H revealed right heel measured 7x6x0.1 cm, the wound bed black with mushy tissue and faint odor. Further revealed "Cg reports Pt had decline in appetite since returning home from respite on 5/10/22. Pts [right] heel is black, but fluid filled, mushy ..." The section for "care coordination/conferenced with and physician contacted" was left blank. RR of IDG/IDT meeting notes dated 5-12-22 revealed there was no documentation concerning the patient change in stats of the right heel wound. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn notes dated 5-18-22 and signed by former agency employee RN H revealed right heel measured 10x9x0.2 cm, the wound bed black with mushy tissue, scant amount of drainage and faint odor. Further revealed" ... [right] heel - reported by cg has been draining & has a odor. Area cleansed w/ NS, pat dry applied skin protectant, gauze, kerlix & tape. Report called to ...RN @ IPU; waiting for bed assignment." Further review of note revealed the physician was called regarding wound odor and ordered "Doxycycline 100 mg BID x 7 days." During an interview on 6-17-22 at 4:13pm the supervising nurse stated that she looked at the clinical record for patient #1 and did not see a diagnosis of PVD. The supervising nurse further stated she did not know where the former employee got that information. During an interview on 6-17-22 at 4:18 pm the director of quality assurance stated although the IDT/IDG was created on 4-14-22, 4-28-22 and 5-5-22 if the IDT/IDGs go into "pending signature" status, whatever date it is opened for the signature it will pull all the current information on the patient to date (5-19-22) and to the IDT/IDG. Patient #4 RR of Sn SOC visit note dated 2-15-22 and signed by RN I revealed under the section "Wound Assessment and Care" patient #4 had a "left inner buttocks/decubitus/pressure ulcer Stage II" RR of hospice plan of care dated 2-15-22 to 5-15-22 revealed a start of care of 2-15-22. A primary diagnosis of Senile degeneration of the brain was noted. Orders included "Sn 1 w13 wk 39 PRN symptom management; Aide- 1 wk 1wk then 2 wk 11 wk; 2 wk 1 wk; 1wk 1 wk; Chaplain to assess and evaluate; Medical social worker assess and evaluate". There were no interventions revealed for the Sn. RR of SN notes dated 2-24-22 and signed by RN J revealed" ...pt has multiple wounds to body per nurse after she completed wound care, risk for further tissue breakdown ..." Under the section "Skin" revealed "bruise BLE, BUE" RR of SN notes dated 2-28-22 signed by RN K revealed under the section "Skin: bruise BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR Communication note created by RN N dated 3-2-22 " ... [ assisted living] requested the following supplies: Allyn dressing for sacrum ..." RR SN notes dated 3-7-22 signed by RN K revealed "bruises BLE, BUE". There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-10-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 3-14-22 signed by RN K revealed "Pt was wheeled into her room for nursing assessment ..." There was no documentation on the note concerning the patient stage 2 pressure ulcer or bruises. RR communication note created by RN K dated 3-16-22 revealed "Patient has bruises to bilateral lower extremities and bilateral upper extremities ..." RR of IDG/IDT meeting notes dated 3-17-22 revealed under the section "Prep notes: Patient has non-pitting edema to bilateral lower extremities with bruises to lower legs and upper arms. Band-Aid noted to upper arm, but patient refused for this nurse to assess further ..." There was no documentation of the stage 2 pressure ulcer. RR SN notes dated 3-23-22 signed by QA nurse revealed this was a missed visit. RR of IDG/IDT meeting notes dated 3-24-22 revealed under the section "Prep notes: Patient has bruises to bilateral lower extremities and bilateral upper extremities. She remains wheelchair /bed bound. Fall precautions in place. Current plan of care remains effective ..." There was no documentation of the stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 3-31-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-1-22 and signed by RN L revealed under the section "Skin" no deficit was check and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-7-22 and signed by RN L revealed under the section "Skin" no deficit was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of IDG/IDT meeting notes dated 4-7-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR communication note created by Chaplain D dated 4-13-22 revealed" ...The aide informed Chaplain that [ patient #4] had a stage 2 wound on her bottom. Chaplain texted information to team." RR of IDG/IDT meeting notes dated 4-14-22 revealed there was no documentation concerning the patient stage 2 pressure ulcer or bruises. Further review of the record revealed no plan or interventions for the ulcer or bruises was documented. RR of SN notes dated 4-15-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked, and N/A was written in the section "Wound #1 and Wound #2" There was no documentation of the stage 2 pressure ulcer or bruises. RR of SN notes dated 4-21-22 and signed by RN L revealed under the section "Skin" no deficit and warm/dry was checked. Redness and N/A was written in the section "Wound #1" and "N/A" was written under Wound #2". The note further revealed" ...Pt assisted to bed and skin assessment completed, redness noted to sacral area no other wound noted ..." RR of IDG/IDT meeting notes dated 4-21-22 revealed there was no documentation concerning the patient redness to sacral area. Further review of the record revealed no plan or interventions for the ulcer or redness was documented. RR of SN notes dated 4-27-22 and signed by RN L revealed" ...Patient received being bathed by hospice aide ... left arm skin tear cleaned ...Old bruises noted to her bilat. Arms ..." There was no documentation concerning the patient stage 2 pressure ulcer. RR of IDG/IDT meeting notes dated 4-28-22 revealed there was no documentation concerning the patient bruises er or skin tear. Further review of the record revealed no plan or interventions for the bruises or skin tear was documented. RR of SN notes dated 5-3-22 and signed by RN L revealed "Patient received lying in bed. Skin tear to [left] arm improved ..." RR of IDG/IDT meeting notes dated 5-5-22 revealed there was no documentation concerning the patient skin tear. Further review of the record revealed no plan or interventions for the skin tear was documented. RR of unsigned SN notes dated 5-12-22 revealed under the section "skin: Wound #1- left buttock stage 3." The note further revealed "Facility Cg requested cushion order due to worsening wound to her buttock. Wound cleanse with cleanser. Pat dried medi honey applied covered with cushion dressing. TAO applied to skin tear ... [supervising nurse/RN coordinator] notified of cushion layer ..." Section for physician notification revealed "none" RR communication note dated 5-12-22 completed by the Medical director revealed" ...The patient has a stage 2 sacral wound ..." RR of IDG/IDT meeting notes dated 5-12-22 revealed there was no documentation concerning the patient stage 3 wound, skin tear or the facility request for a cushion. Further review of the record revealed no plan or interventions for the wound or skin tear was documented. RR communication note created by RN M dated 5-13-22 revealed" ... [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." RR of SN notes dated 5-17-22 and signed by RN M revealed under the section "skin: Wound #1- [left] buttock lateral stage IV with tunneling 3-4 cm wide ..." The note further revealed that the NP was notified, and new orders were received for wound care. RR communication noted dated 5-17-22 and completed by the supervising nurse/RN coordinator revealed "Facility requested a wheelchair cushion for the patient. Notified [DME company] ..." RR communication note dated 5-18-22 and completed by RN M revealed" ...The patient has a stage 4 pressure ulcer at the left lateral buttocks region, open to air, no odor or drainage ...NP notified for wound care order needs ..." RR of IDG/IDT meeting notes dated 5-19-22 revealed under the section "Prep notes: Facility requested a wheelchair cushion for the patient. Notified [DME company] ... and ... [assisted living staff] requested visit because sacral wound has worsen and she has skin tears that need attention. Chaplain [D] texted [ assisted living staff] concerns to [supervising nurse/RN coordinator] ... [supervising nurse/RN coordinator] contacted Chaplain [D] to verify information to address it." The IDT/IDG further revealedthe wound care treatment under the section "Change in orders" There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. RR of SN notes dated 5-20-22 and signed by RN M revealed" ...wound care done" RR skin sheet dated 5-20-22 and signed by RN M revealed "Pt stage IV wound on [left] lateral buttocks area noted open to air, no visible drainage on site, noted foul odor. New wound care order per NP (to clean wound care spray, dry apply medi honey, cover with gauze) implemented ...NP notified regarding foul odor from site, awaiting further order ..." RR communication note dated 5-23-22 and completed by RN M revealed "Pt stage 4 wound on left lateral buttocks area noted open to air, no visible drainage on site. Noted new foul odor coming from site. New orders for wound care per ...NP implemented ... NP notified for further advise for wound care. Awaiting on new order." RR of IDG/IDT meeting notes dated 5-26-22 revealed under section "Change in orders- start pt Keflex 500 mg PO BID x 7days ..." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. RR of SN notes dated 6-1-22 and signed by QA nurse revealed "Received pt sitting on her couch, pt seems withdrawn lethargy and agitated when touched. Pt moaned during dressing change. SN provided wound care to buttocks and skin tear." RR of IDG/IDT meeting notes dated 6-2-22 revealed under the "Prep note" section a summary of chaplain note from 5-13-22, communication note from 5-17-22, Skin sheet from 5-20-22, SN note from 5-17-22. RR of IDG/IDT meeting notes dated 6-9-22 revealed under "Current orders: Other- Apply Neosporin daily to the left arm skin tear and cover with a nonstick dressing; Clean with wound care spray, dry and apply medi honey, cover with gauze." There were no other plans or interventions concerning the stage 4 wound noted on the IDT/IDG. During an interview on 6-19-22 at 8:00 pm patient #4 family member stated the patient had a wound on her buttock early on, but he thought that the agency had gotten the wound well. During an interview on 6-20-22 at 9:27 am hospice aide B (performed care to patient #4 from 4-5-22 to 4-28-22) stated that she showered patient #4 one time and remembered the patient's skin was paper thin. Hospice aide B further stated there was one time when she had finished showering patient #4 and an agency nurse visited the patient. Hospice aide B stated that she showed the agency nurse( unknown) that patient #4 skin was fragile and had a sore on her bottom. Hospice aide B stated, "I showed the agency nurse, but I don't know what he did because I left, I had been there before him." During a concurrent interview on 6-20-22 at 3:33 pm with the supervising nurse/RN coordinator and the administrator, the supervising nurse/RN coordinator stated that the nurses were supposed to address the buttock wound in Sn notes and the IDG/IDT should have included a care plan for wound care for patient #4 since she was admitted with a pressure sore, Patient #3 RR of SOC SN visit dated 4-28-22 and signed by RN O revealed under section "Wound Assessment and Care" as follows: "1. Dorsal back sacrum/decubitus/ pressure ulcer suspected deep tissue injury; wound bed -clean, bed color- red, covered with Meplex foam. 2. left dorsal foot heel/decubitus/pressure ulcer suspected deep tissue injury: covered with Meplex foam 3. left head eyebrow/other: wound bed- eschar; cleaned with Vashe; application/packing-medi honey; wound care frequency- PRN 3 times/week 4. left lateral leg knee/decubitus/pressure ulcer Stage II: wound bed -eschar; cleaned with- Vashe; application/packing other- Medi Honey; wound care frequency- PRN 3 times/week 5. left posterior arm elbow/skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 6. right dorsal arm elbow/ skin tear: wound bed- clean, moist; bed color- red, pink; cleaned with Vashe; covered with - Kerralite cool dressing; wound care frequency- prn 1 times/week 7. right lateral foot ankle/decubitus/pressure ulcer unstageable: wound bed - slough; bed color-yellow; cleaned with Vashe; application/packing-Thera honey gel; covered with Meplex foam; wound care frequency- daily ..." RR physicians order dated 4-28-22 revealed for right heel "cleanse wound w/ Vashe solution, leave Vashe saturated gauze on wound, for 2-3 minutes, pat dry, apply gentamycin ointment to wound bed, cover w/ dry gauze, secure w/tape then cover w/ comprilan daily. Sn to perform weekly & cg to perform on the other days." RR of Sn note dated 4-29-22 and signed by former agency employee RN H revealed left heel wound measured 2.5x 1 cm, wound bed- purple, tissue-soft with no drainage; right ankle measured 2 x 1.5 cm, wound bed- yellow and tissue -soft. There was no documentation of wound care given or the status of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator who stated if wound care had been done it would be revealed in the nurse's notes. RR Sn note dated 5-3-22 and signed by former agency employee RN H revealed " ...wound care done to [right] elbow, [right] heel & sacral. [right] elbow cleansed [with] NS, pat dry applied dry bordered gauze to wound, [right] heel cleansed [with NS pat dry applied gentamycin ointment covered with bordered gauze and covered with tubi grip, sacral decubitus allewn applied, instructed Cg to not let wounds get wet ..." There was no documentation of the status/treatment of the other wounds. During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator, the administrator stated that she did not see on the note where the left elbow, left eyebrow, left dorsal foot heel or left knee wounds were treated. RR of IDG/IDT meeting notes dated 5-5-22 revealed there was no documentation concerning the patient wounds or skin tears. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-9-22 and signed by former agency employee RN H revealed the right ankle wound measured 1.5x1x0.1 cm, wound bed -crusty, tissue-soft and no drainage; right elbow measured 2x1x0.1 cm, wound bed- pink, tissue-pink and draining a scant amount of serous drainage. The note further revealed" ...wound care done to wounds-cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip. Cg reported blisters to buttocks, area is fluid filled. Sn administered sacral Meplex & change prn. [left] knee skin tear noted 0.5x0.5x0.1 cm & lg blister to buttocks 7x5 cm." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. There was no evidence that the physician or IDG/IDT was notified of new blisters and left knee skin tear. RR of physician orders revealed no order noted to "cleansed all [with] NS, pat dry, applied gentamycin ointment and bordered gauze& sealed with tubi grip." During a concurrent review of SN notes on 6-20-22 at 4:30 p.m. with the administrator and supervising nurse/RN coordinator. The supervising nurse/RN coordinator stated she did not see where the IDG/IDT was notified of new blisters or skin tear nor did she see the order for Mepilex to sacral area. RR of IDG/IDT meeting notes dated 5-12-22 revealed under the section "Prep notes " completed by former agency employee RN H revealed -Patient has a wound to right heel measuring [ not measurements documented], right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." There was no documentation concerning the patient left knee skin tear. Further review of the record revealed no plan or interventions for the other wounds or skin tears was documented. RR of SN note dated 5-19-22 and signed by former agency employee RN H revealed under the section " Ssin- See Skin SHeet " RR of skin sheet dated 5-19-22 and signed by former agency employee RN H revealed "Sn informed Cg on status of wounds. Wound care was done as follows: cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze. Sacral area- instructed cg to keep area clean & dry & apply skin protectant to area as needed ..." Furtheer review ofskin sheet diagram revealedleft knee skin tear, right elbow skin tear, new stage 2 with maceration on buttock, and right ankle stage 2. The section of the SN note da | |||
| ted 5-19-22 for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-20-22 at 4:39 p.m. the supervising nurse/ RN coordinator was observed looking through the computerized record for patient #3 for the wound care physician order "cleansed all areas w/ NS, pat dry, applied xeroform to wound bed & applied bordered gauze". The supervising nurse/ RN coordinator stated that she did not see the order in the record. RR of IDG/IDT meeting notes dated 5-19-22 revealed there was no documentation concerning the patient wounds, new stage 2 with maceration or skin tears. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn note dated 5-25-22 and signed by former agency employee RN H revealed" ...Sn instructed Cg on continuing to monitor skin & any changes ...wound care to left ankle done as follows cleanse w/Normal saline or wound cleanser, pat dry, apply Meplex or bordered gauze. [right] elbow cleansed w/NS, pat dry, applied Meplex or bordered gauze ..." The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. RR of Sn skin sheet dated 5-25-22 and signed by former agency employee RN H revealed"[right] ankle noted [with] scant soft yellow slough, wound edges are pink. [right] elbow has a scab. [left] knee area has healed completely. Pt noted with small 1x1 cm skin tear on top of [right] foot ...area covered w/bordered gauze & Sn instructed Cg to apply TAO if needed." RR of IDG/IDT meeting notes dated 5-26-22 revealed there was no documentation concerning the patient new wounds to left ankle, new stage 2 with maceration or new skin tear to top of right foot. Further review of the record revealed no plan or interventions for the wound or skin tears were documented. RR of Sn notes dated 6-3-22 and signed by QA nurse revealed" ...SN provided wound care to pts right ankle and foot" RR of IDG/IDT meeting notes dated 6-2-22 revealed under "Current orders: Other- SN to cleanse areas with Normal Saline or wound cleanser, pat dry, and cover with Meplex/bordered gauze to right ankle and right elbow and as needed if soiled. Changed to active 5-26-22. " Under the section "Prep notes -Patient has a wound to right heel measuring, right elbow, and both buttocks due to pressure ulcer. Right heel wound care: Cleanse with saline, pat dry, apply Gentamycin ointment. Right elbow- skin tear; Cleanse with NS, pat dry cover with dry bordered gauze. Buttocks: Cleanse with NS, pat dry, Apply allevyn dressing." RR of Sn notes dated 6-8-22 and signed by RN L revealed" ... Multiple pressure ulcers that appear to be healing noted to [right] elbow, [right] ankle, [left] ankle. All clean with wound cleanser, pat dry, covered with island dressing. Also left ankle appears healing Sn completed wound care" The section for "care coordination/conferenced with, physician contacted Re and order changes" was left blank. During an interview on 6-19-22 at 1:23 pm the family member of patient #3 stated the wound to the left eyebrow was healed, he still has areas to buttocks and ankles. The family member further stated that the patient had not had a nurse in two weeks. She stated she spoke to the agency social worker and asked where the nurse was because the patient wounds had not been treated and he had not had a bowel movement in close to 10 days. The family member further stated she did not know how to do dressing changes. During an interview on 6-20-22 at 4:56 p.m. the supervising nurse/ RN coordinator stated the wound to patient #3 left ankle looks like it is a new wound. Patient #2 RR Sn SOC visit dated 5-12-22 and signed by the supervising nurse/RN coordinator revealed under the section "Wound Assessment and Care" as follows: Left foot 2nd toe/venous stasis ulcer- wound bed- eschar, dry; bed color- black; no drainage, no odor ..." There was no treatment noted for the wound. Further review of note revealed under the section "Integumentary- bruising right thigh anterior and gangrene 2nd right toe" RR non visit report dated 5-16-22 revealed "no answer to phone/home" RR of IDG/IDT meeting notes dated 5-19-22 revealed under the section "Prep Notes " ' completed by QA Nurse- " Pt complained of toe pain. Pt has gangrene to his 2nd toe, pt's wife would like something to put on it." RR of order from physician A dated 5-19-22 revealed "Apply TAO to 2(sic) toe daily and leave open to air." RR of SN note dated 5-26-22 and signed by RN L revealed "paint to left 2nd gangrene toe ...routine visit completed ..." There was no documentation of wound care treatment done. RR of order from physician B dated 5-26-22 revealed "paint 2nd toe with Iodine daily and leave open to air." RR of IDG/IDT meeting notes dated 5-26-22 revealed there was no documentation concerning the patient Left foot 2nd toe/venous stasis ulcer. Further review of the record revealed no plan or interventions for the wound were documented. RR of Sn note dated 6-2-22 and signed by QA nurse revealed "wound care provided to second toe TAO applied ..." RR of IDG/IDT meeting notes dated 6-2-22 under the section "Change in Orders: Other - Paint 2(sic) toe with iodine daily and leave to open air., Start Date: 5/26/2022" During an interview on 6-17-22 at 12:19 pm the supervising nurse/RN coordinator stated she was not sure who the nurse was for the visit made on 6-11-22 but she did not see documentation on the note concerning wound care. The supervising nurse/RN coordinator stated she would see if the nurse turned in a skin sheet for the visit. Further interview at 1:08 pm the supervising nurse/RN coordinator stated upon any admission they talked to the doctor about any issue and anything pertinent for the patient. "On patient #2 [the doctor] said to just observe the toe." The supervising nurse/RN coordinator then stated she was not sure where she would have revealed the physician instructions to observe patient #2 toe. The supervising nurse/RN coordinator then stated she believed the patients well-being and care would be affected to not have all the information needed in the IDG/IDT meetings. During an interview on 6-17-22 at 12:23 pm patient #2 family member stated she kept patient #2 wound clean. The agency gave her some wound spray to use but she did not remember the name. The family member stated the nurse only check patient #2 vital signs and look at the wound but do no treatment to the wound. The family member also stated that she applies Iodosorb 10 mg every other day to patient #2's toe. The cream was previously used on another toe. The family member further stated the QA nurse put the TAO on the wound on 6-2-22 before she found the Iodosorb cream. The family member then stated the QA nurse was the only nurse to put something on the toe, the other nurse just looked. The family member stated that the toe is drying up pretty good now, it is not leaking anymore. The family member stated the toe was leaking pus and blood last weekend. During further interview at 3:49 pm the family member stated that she informed the agency nurses of the wound leaking last weekend. "I make sure I show them. Whenever they come out." The family member then stated she showed the cream she was using on patient #2 toe to the QA nurse. During an interview on 6-17-22 at 12:49 pm the QA nurse stated she got text messages of the orders written on 5-19-22 for Tao and 5-26-22 for Iodine. Surveyor reviewed text messages and paper physician orders. The QA nurse stated other nurses would have known what the orders were because they talk about it in the IDG/IDT meetings. QA nurse was informed the IDG/IDT on 5-19-22 and 5-26-22 did not have any information concerning patient #2 toe. The QA Nurse stated, "Normally we would have discussed it." The QA nurse further stated she notified the family member about the wound order received on 5-26-22, but the medication has been on back order and the agency just received it on 5-13-22. The QA nurse stated patient #2 wasn't getting any treatment and on 6-2-22 she put the TAO on his toe "So at least he would get something." Further interview on 6-17-22 at 4:28 pm the QA nurse stated she did not receive any orders on what to do while the iodine was on back order. "That's why I used TAO." The QA nurse stated that the family member of patient 32 talked to her about using the cream on patient #2. The QA nurse stated another doctor had given the family member the cream and she really liked it so she told the family member when she found it to send a picture of it or show her and she would see it the agency could order the medication. The QA nurse stated the family member never showed her the medication and she did not mention it to the IDG/IDT. During an interview on 6-17-22 at 3:05 pm the supervising nurse stated the discussion in IDT/IDG about wound care patients would be to see if there are any concerns. Further stated that the nurse would give a short blurb of the patients wound. The supervising nurse then stated the discussion should be captured in the IDT/IDG documentation as well as any interventions. After review of patient #1 IDG/IDT's the supervising nurse stated, "Don't look like we are doing a very good job at that." During an interview on 6-20-22 at 3:51 pm the administrator stated that the supervising nurse was the RN coordinator for the IDG/IDT. During an interview on 6-20-22 at 3:53 p.m. The supervising nurse/ RN coordinator stated she makes sure that the IDG/IDT has all the current information about patient's by looking at prep notes completed by agency staff, communication notes, emails that are done daily about patients and in the event of an urgent message texts that are sent regarding patients. RR of revised policy dated 05/2016 titled " Interdisciplinary Group Coordination of Care" documented " It will be the responsibility of the RN Case Manager to facilitate communication about changes in patient's status among the interdisciplinary group members and the patient's attending physician...written evidence of care coordination will be found in the plan of care and /or interdisciplinary group meeting forms in the patient's clinical record..." | |||