Aveanna Healthcare

The agency failed to follow the physician approved plan of care and failed to follow the agency Aide Assignment and Duties (Care Plan) policy.

The agency failed to follow the physician approved plan of care, and failed to follow the agency's Aide Assignment and Duties (Care Plan) policy.

The home health agency is out of compliance with the Condition of Participation of Patient Rights, for failure to address patient neglect (Patient #2) in February 2020 by a Licensed Practical Nurse (LPN).

The home health agency is out of compliance with the Condition of Participation of Skilled Professional Services for the failure to ensure the delivery of nursing services in accordance with accepted standards, and agency policies and procedures during and after the physical, verbal and…

The agency was out of compliance with the Condition of Participation of Organization and Administration, when the Governing Body lacked involvement in the Quality Assessment and Performance Improvement (QAPI) activities to ensure the developement of interventions to prevent the recurrence of abuse…

The agency nurse failed to follow the agency policies and procedures for the provision of care and infection control practices.

The agency Governing Body failed to demonstrate adequate oversight of the Quality Assurance program in order to prevent recurrence of abuse and neglect incidents, through appropriate root cause analysis and developement of interventions.

The facility failed to ensure the patients were free from abuse and neglect which resulted in Immediate Jeopardy.

The agency failed to notify the patient's physician of several incidents of verbal, physical and psychological abuse from the agency nurse to the patient.

The agency nurses failed to protect the patient from injuries and neglect through a lack of bath water temperature checking, a lack of appropriate use of the shower wand, a lack of timely response from the registered nurses to assess the extent of the burn injuries, and a lack of re-education of…

The agency failed to ensure the activities of the Quality Assessment and Performance Improvement Program (QAPI) focused on the problem-prone areas such as the lack of thermometer in the home to check to bath water temperature, the nurse's inappropriate technique during the shower, and the…

The agency nurses failed to follow the agency policies and procedures to ensure bath safety and provide for timely assessment of the patient after the patient was burned in the bath water.

The agency Governing Body failed to ensure staff were following policies and procedures to ensure care in a safe setting, failed to ensure registered nurses (RN) were following policies regarding supervision of Licensed practical Nurses (LPN), and failed to ensure the effectiveness of the Quality…

The agency nurses failed to follow the agency policies and procedures to ensure bath safety and provide for timely assessment of the patient after the patient was burned in the bath water.

The agency Governing Body failed to ensure the safety of the services provided, and the effectiveness of the Quality Assessment and Performance Improvement Program.

The agency policies and procedures with the agency Administrator on 10/10/19 and LPN # 6 on 10/15/19 failed to indicate that LPN # 6 ensured the patient's safety and prevented injuries by checking the bath water temperature before placing the patient on the chair in the tub.

The agency nurses failed to update the plan of care after the incidents to reflect the patient's condition and the necessary interventions to meet the patient's additional needs.

The agency failed to ensure the activities of the Quality Assessment and Performance Improvement Program (QAPI) focused on the problem-prone areas.

The agency failed to ensure the activities of the Quality Assessment and Performance Improvement Program (QAPI) considered the severity of the problems associated with the burn incidents.

The agency Quality Assessment and Performance Improvement program failed to develop timely and appropriate interventions to immediately correct recurrent problems that threatened the patient's health and safety.

The agency registered nurses (RN) failed to directly assess the patient in response to the LPN notification of the burn incident.

The agency registered nurses (RN) failed to ensure oversight of the services provided by the LPN.

The agency Administrator failed to ensure the safety of the services provided, and failed to implement interventions to prevent the recurrence of injuries to patients.

The agency Clinical Manager failed to ensure that registered nurses were re-educated to assess the patient's change in condition.

For three of three patients (Patients #1, 4 and 5) with specific services outlined in the plan of care, the agency nurses failed to provide the services as ordered by the physicians, including the lack of oxygen monitoring for patients with a tracheostomy and/or on ventilator, the lack of nursing…

Failed to identify the development of a comprehensive program with a detailed process for tracking events, measuring quality indicators, recording adverse events, analyzing causes and effects, determining trends and patterns in order to apply the resulting knowledge towards an improvement in safety…

The agency nurses failed to ensure the use of Morphine during autonomic storms was authorized, failed to take the necessary actions when the ventilator sent a message, failed to follow the agency policies and procedures on reporting malfunction of equipment, on reporting the inability to monitor…

The Governing Authority failed to provide oversight of the Quality Assurance and Performance Improvement Program, and ensure the conclusion of comprehensive investigations into the equipment malfunction, into the lack of Registered Nurse/RN assessments, staff awaken by ventilator alarms, an aborted…

The agency failed to ensure the completion of timely, accurate and authentic nursing documentation, including the documentation of equipment malfunction, patient's changes in condition and the sequence of events that lead to the two patients' hospitalization.

The agency failed to develop a quality assurance program that included measurable quality indicators, with tracking of the indicators, analysis of the outcomes and their effects on patient safety and quality of care.

For two of two patients (Patients # 4 and 7) who did not receive adequate nursing interventions during a change in condition and/or required an emergency transfer to the hospital, the agency failed to conduct a comprehensive investigation and failed to document the incident as an adverse event…

The agency nurses failed to ensure the services were authorized, failed to take the necessary actions, failed to follow the agency policies and procedures, and/or the agency failed to develop policies and procedures to ensure the safe delivery of nursing services.

The Governing Body failed to provide oversight of the Quality Assurance and Performance Improvement Program, and ensure the conclusion of comprehensive investigations into the equipment malfunction, lack of Registered Nurse/RN assessments, staff awaken by ventilator alarms, aborted 911 call, lack…

The agency failed to ensure the completion of timely, accurate and authentic nursing documentation.

The agency nurses failed to provide the services as ordered by the physicians.

The on-call registered nurse/RN failed to directly assess the patient and/or failed to alert a nursing supervisor to the need for an onsite assessment.

The agency Registered Nurse/RN failed to include in the plan of care, the emergency procedures to address the patient's comfort and safety during episodes of autonomic storms, and failed to include in the plan of care the use of Morphine for specific symptoms during an autonomic storm.

The agency nurses failed to provide the necessary services in accordance with the plan of care.

The agency nurses failed to communicate with the physician to clarify the inconsistencies in the orders for tracheostomy tube care, and/or failed to obtain clarification from the physician, the respiratory therapist and/or the Durable Medical Equipment/DME company regarding the orders for the…

The agency failed to provide Registered Nurse/RN oversight of the Licensed Practical Nurse/LPN activities in the patient's home.

The agency Administrator failed to conduct comprehensive investigations into the equipment malfunction, lack of Registered Nurse/RN assessments, staff awaken by ventilator alarms, aborted 911 call, lack of case-specific orientation, lack of supervisory visits, and lack of care-planning for…

The agency Administrator failed to provide written documentation of the person pre-designated by the Governing Body to fulfill the Administrator's role in the Administrator's absence.

The agency Clinical Manager failed to ensure adequate Registered Nurse/RN oversight of the Licensed Practical Nurse/LPN activities in the patient's home.

The agency failed to ensure the plan of care included the use of the ceiling lift and/or specific recommendations for safety.

The agency staff failed to communicate with the physician to clarify the orders prior to implementation.

The agency Governing Authority failed to provide oversight of the quality of services and performance improvement activities.

The agency Governing Authority failed to provide oversight of the quality of services and performance improvement activities.

The agency failed to ensure the plan of care included the use of the ceiling lift and/or specific recommendations for safety.

The agency failed to alert the physician to the need for updating the plan of care with specific instructions for ceiling lift use and patient safety.

The agency staff failed to communicate with the physician to clarify the orders prior to implementation.

The agency failed to ensure the supervision of nursing services.

The agency Administrator failed to provide oversight of the quality of services and performance improvement activities.

The agency Clinical Manager failed to provide oversight of the quality of services and performance improvement activities.

The agency failed to ensure the revision of the individualized plan of care with specific instructions for ceiling lift use and patient safety.

The agency failed to use the appropriate references to teach the staff the use of the lifts.