Chi St Vincent Hot Springs Health at Home

This STANDARD is NOT MET as evidenced by: Based on Clinical Record Review, observation and staff interview, it was determined the Agency Staff failed to ensure 16 of 18 records reviewed had an individualized plan of care that identified the patient-specific measurable outcomes and goals which were…

The Agency failed to assure all medications were included in a comprehensive medication review to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with…

The Agency staff failed to ensure the patients Plan of Care (POC) included the required elements of all patient specific interventions, education, measurable outcomes, goals and supplies and equipment specific to the individual patient in 1 (#13) 0f 18 records reviewed.

The Agency failed to ensure documentation of wound measurements and assessment, including late entry documentation, of all assessments and wound measurement in 1 (#13) of 18 (#1-#18) medical records reviewed.

The Agency staff failed to follow the Attending Physician orders contained in the Plan of Care (POC) for 4 (#3, #7, #9, #10 and #12) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to complete a Drug Regimen Review to include all current medications the patient was taking in 6 (#2, #4, #5, #7, #9, and #12) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 1 (#3) of 1 (#3) home visits conducted where the Patient was receiving wound care.

The Skilled Nurse (SN) failed to include Chemotherapy medications (medications used to treat certain types of cancer) during the review of the Patient's medications in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed.

The Skilled Nurse (SN) failed to assess the Patient's weight as ordered on the Plan of Care (POC) for 1 (#13) of 7 (#1, #9 - #11, #13 and #15 - #16) Clinical Records reviewed requiring cardiovascular assessments.