Axiom Home Care

The Agency failed to ensure the Registered Nurse prepared complete written instructions for patient safety needs in 5 (P-1, 4, 5, 10 and 14) of 5 records in which aide services were provided, resulting in the potential for unsafe, substandard care and unmet care needs.

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 1 (P-9) of 17 records reviewed, resulting in a delay in determining the immediate care and support needs for this patient.

The agency failed to ensure the patient’s clinical record documented all medications, failed to ensure the comprehensive assessment included a review of all medications to determine any potential adverse effects, and failed to ensure the physician was notified of potential drug interactions for 5…

The agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 15 (P-1, 2, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) of 17 records reviewed, resulting in the potential for poor patient…

The agency failed to ensure visit frequencies were provided only as ordered by the physician for 1 (P-17) of 17 records reviewed, resulting in the potential for the provision of inappropriate care and services.

The Agency had failed to promptly notify the Physician concerning weight change outside of vital sign parameters for 1 (P-11) of 5 patients with congestive heart failure, resulting in a potential poor clinical outcome.

The agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 3 (P-1, 4, 7) of 17 records reviewed, resulting in the potential for poor patient outcomes for these patients.

The agency failed to ensure clinical notes were accurate for 3 (P-8, 13 and 17) of 17 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients.

The Agency failed to ensure a discharge summary was complete, provided the patient's current health status at the time of discharge and progress toward goals in 3 (P-1, 16 and 17) of 5 closed records, resulting in the potential for unidentified continuing health care concerns and unmet care needs.