Assistedcare Home Health Inc

The registered nurse (RN) failed to perform hand hygiene after removing soiled gloves, failed to remove soiled gloves and perform hand hygiene after handling contaminated objects, failed to remove contaminated gloves and perform hand hygiene before handling clean supplies, failed to remove gloves…

The agency failed to include bleeding precautions in the plan of care for 4 of 8 patients taking anticoagulants (prevents blood clots) (#’s 2, 6, 11, & 18) and 1 of 6 patients taking antiplatelets (prevents blood clots) (#4).

The registered nurses failed to notify changes of condition for 2 of 15 active patients (#’s15 & 20) and the physical therapist failed to notify a physician of abnormal blood sugar readings for 1 of 8 patients with diabetes mellitus (condition where the body cannot properly use sugar) (#6).

Staff interviews the agency failed to alert the relevant physician of changes in the patient’s condition that suggested expected outcomes were not being achieved for 1 of 3 records reviewed.

The agency failed to provide adequate notice of discharge to the patient and/or responsible party or physician for 1 of 3 records reviewed.

The agency failed to conduct an ordered medical social work evaluation for 1 of 1 record reviewed with orders for medical social work evaluation.

The agency failed to maintain an accurate medication list for 3 of 6 home visits conducted during survey (Patients #13, #14 and #15).

The agency failed to notify the physician of a patient's inability to attend wound clinic appointments (#2) for 1 of 1 patients with wound clinic referrals and failed to notify the physician of changes in weight for 1 of 2 patients with an order for weight monitoring (#15).

Staff interviews the agency failed to prepare accurate clinical notes for 1 of 5 discharged patients (#3) and failed to include Central Line measurements for 1 of 1 patient with a central line (#8).

The allegation that the agency failed to provide timely notification of discharge to 1 of 3 patients (Patient #1) is substantiated.

Staff interviews the agency failed to do ensure aide supervisory visits were performed for 1 of 1 charts receiving aide services [#6]. The findings included: The policy, Responsibilities/Supervision [6/26/20], was provided by the agency administrator on 6/4/21 at approximately 1 pm.

The POC did not include an order for the SN to prefill a medication tray.

Staff interviews skilled nursing failed to provide an ongoing interdisciplinary assessment [consistent wound measurements] with 2 of 2 patients with a wound vac [#3 and 5]. The findings included: The policy, “All Wounds” no date, was provided by the agency director on 6/3/21 at approximately 3 pm.

The agency failed to communicate with the physician changes related to a wound vac for 1 of 2 patients with a wound vac [#3]. The findings included: Patient # 3 had a Start of Care [SOC] date of 9/23/20 and a diagnosis of Pressure Ulcer of Left Buttock Stage II and Type 2 Diabetes Mellitus with…

The agency failed to document a complete wound assessment for 1 of 6 patients (Patient #4) with wounds.

Staff interview the agency failed to follow physician orders for PICC [Peripheral Inserted Central Catheter] line care for 1 of 2 patients with PICC lines [#4]. The findings include: Review of the agency "Care Planning Process" policy received on 8/15/18 from the COO [chief operations officer]…

Staff interview the agency failed to implement agency's policy in regards the patient's right to participate in plan of care for 1 of 1 patients [#1]. The findings include: Review of the agency "Rights/Responsibilities" policy received on 8/15/18 from the COO [chief operations officer] [#3E]…

Staff interview the agency failed to provide complainant with resolution of the complaint for 1 of 1 patients [#1]. The findings include: Review of the agency "Complaint/Grievance Process" policy received on 8/15/18 from the COO [chief operations officer] [#3E] revealed, "POLICY # Rl.11 ...…

Staff interview the agency failed to coordinate missed visits with the physician for 2 of 2 patients [#1 and 4]; and failed to coordinate plans for Hospice care with the physician for 1 of 1 patients [#1] patients.

Staff interview the agency failed to follow orders as listed on the Plan of Care for PICC (Peripheral Inserted Central Catheter) lines.

The agency failed to review all medications the patient was currently taking for 5 out of 7 patients visited in the home [#7, 8, 9, 12 and 6]. The findings include: The "Medication Checklist" document was provided by the Director of Performance and Improvement and Education on 5/11/18 at 3:12 p.m.

Patient interview and staff interview the agency failed to include on the Plan of Care blood sugar parameters for 1 of 1 patients [#12] and failed to include psychosocial and cognition, all equipment needed for safety measures, all medications, and education and training to facilitate timely…