Baxter Health Home Health

The Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 4 (#6, #11, #12 and #15) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients’ medications in 1 (#8) of 5 (#1, #8, #9 #12 and #14) Clinical Records reviewed with orders for O2. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by…

Agency staff Clinicians failed to include parameters of what constitute a significant change in patient condition of when to notify the physician in 4 (#2, #5, #12, and #14) of 17 (#1 - #17) Clinical Records reviewed.

This Element was not met As evidenced by: A review of Clinical Record #2 revealed the following: 1. A document titled home Health Certification and Plan of Care dated 2/17/2022 through 4/17/2022 showed no evidence of physician’s orders, interventions or goals for ST (speech therapist).

The Skilled Nurse (SN) failed to alert the Physician to changes in patient’s condition which may have necessitated an alteration in the Plan of Care (POC) in 1 (#7) of 17 (#1-#17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to follow the written Plan of Care (POC) in 1 (#15) of 17 (#1 - #17) Clinical Records reviewed.

The Agency failed to ensure written information specific to the patients Plan of Care (POC) was provided to patients or caregivers in 6 (#11, #13, #14, #15, 16 and #17) of 7 (#11 - #17) home visits conducted.

The Registered Nurse (RN) failed to complete an aide assignment specific to the patients individual needs in 1 (#9 ) of 2 (#6 and #9) patients receiving Home Health Aide (HHA) services.

The Skilled Nurse (SN) failed to document medications currently used by the Patient on the "Medication Profile" (form used by the Agency to document all patient medications) and failed to document a Physician's order for medication in 1 (#16) of 17 (#1 - #17) Clinical Records reviewed.