Adoration Home Health

The agency staff failed to follow out the plan of care for assessing patients with Congestive Heart Failure (CHF) in 3 (#5, #7, #9) of 18, (#1-#18) medical records reviewed.

The Agency failed to ensure there were assessments and measurements of wounds to demonstrate progress toward healing in3 (#4, #6, & #8) of 18, (#1-#18) clinical records reviewed that have wounds being treated by the agency.

The Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 4 (#7, #9, #15, #17) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to include all medications in the medication interaction check for 7 (#2, #3, #5, #6, #9, #11, #15) of 17 (#1-#17) records reviewed.

The agency failed to educate or document patients response to education and teaching in one #9 of 17 (#1-#17) clinical records reviewed.

The Skilled Nurse (SN) failed to ensure complete, plain language medication administration instructions were documented on 1 (#8) of 17 (#1-#17) of clinical record reviewed.

The Agency failed to ensure written information specific to the patients Plan of Care (POC) was provided to patients or caregivers in 7 (#6 -#12) of 7 (#6 - #12) home visits conducted.

The Skilled Nurse (SN) did not include all medications during a review of medications the patient was currently using in 1 (#7) of 17 (#1 - #17) Clinical Records reviewed.

The Clinical Manager did not ensure coordination of care between Nursing and Physical Therapy regarding interventions related to Cardiopulmonary Assessments and Heart Failure Symptoms in 1 (#6) of 5 (#3, #6, #11, #13 and #15) Clinical Records reviewed with a pertinent diagnosis of Heart Failure.

The Agency staff did not document care coordination and communication between the healthcare team members and the Patient/Caregiver in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed.