Commonspirit Health

The agency failed to incorporate assessment findings about pain into individualized care planning, resulting in inadequate interventions to meet patient needs.

The Agency failed to ensure comprehensive care planning and coordination in eight (#8, #9, #12, #16, #18) of 28 records reviewed (#1-#28).

The Agency failed to implement infection prevention and control procedures in 3 (#13, #14, #15) of 7 (#9-#15) of home visits observed.

The agency failed to follow its own policy of timeframes for documentation of skilled visits in three (#15, #20, #21) of 28 (#1-#28) clinical records reviewed.

The Agency failed to develop and implement a comprehensive plan of care that accurately reflected the patient's "Patient-specific measurable outcome" for 4 (#12, #16, #18, #21) of 28 (#1-#28), needs, goals, and physician-ordered interventions.

The agency failed to provide written information and instructions specific to the patients and their caregivers in 5 (#10, #12, #13, #13, #14, #15) of 7 (#9-#15) home visits conducted.

Agency staff did not adhere to infection prevention precautions in three (#13, #14, #15) of seven (#9-#15) home visit observations.

The agency did not provide infection control education to 3 (#4, #5, #6) of 4 (#4 - #7) Skilled Nurses (SN) observed.

The agency failed to investigate complaints in 7 (#1, #20, #21, #23, #24, #25, #26) of 28 (#1 - #28) clinical records reviewed.

The agency failed to incorporate the patient's strengths, goals, and care preferences into the care planning process, resulting in care that did not align with the patient's identified needs and measurable outcomes.

The agency failed to assure Medical Marijuana was included in a review for all other Patient medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and…

The Agency failed to promptly notify the patient's physician(s) or allowed practitioner(s) of changes in the patient's condition or needs that indicated unmet care outcomes or required modifications to the plan of care in 5 (#15, #16, #17, #20, #22) of 28 (#1-#28) Clinical Records reviewed.

This failed practice had the potential to affect all patients on census and future census, in that, not using a current practice for pain assessment and implementing interventions based on those assessments could negatively impact a patient's healthcare, increase rehospitalization rates, and delay…

The Skilled Nurse (SN) and the Occupational Therapist (OT) did not follow the Attending Physician orders for visit frequency ordered in the Plan of Care in 1 (#12) of 13 (#1 - #13) Clinical Records reviewed.

With no additional documentation provided, Agency Personnel #1 confirmed SN did not document the physicians order for patient #6 catheter removal.

The Skilled Nurse (SN) failed to notify the physician of a change in the patient's condition in 1 (#1) of 13 (#1-#13) clinical records reviewed This failed practice by the SN has the potential to affect all patients on census in that communication of the patients' changes directly impact the Plan…

The Agency failed to participate in a full-scale community-based exercise in order to analyze the Agency's emergency preparedness program on an annual basis.

The Agency failed to ensure there was an effective process to provide written information specific to the patients Plan of Care (POC) to patients or caregivers in 5 (#5 - #9) of 5 (#5 - #9) home visits conducted.

The Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of all medication and treatments in 2 (#9 and #11) of 13 (#1 - #13) Clinical Records reviewed.

The Skilled Nurse (SN) failed to follow Physician orders for wound care and treatments for 1 (#9) of 2 ( #7 and #9) wound care skills observation during home visits.

The Skilled Nurse (SN) failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 1 (#4) of 13 (#1 - #13) Clinical Records reviewed.

Physical Therapy (PT) and/or Occupational Therapy (OT) failed to provide timely oversight of the Home Health Aides (HHA) through on-site Supervisory Aide Visits (SAV) every 14 days in 1 (#3) of 1 (#3) Clinical Records reviewed with orders for PT, OT, and HHA services.

The Agency failed to ensure Criminal History Record Checks were completed on all Home Health Aide (HHA) employees no less than one time every five years as required for continued employment.

The Skilled Nurse (SN) staff did not accurately document care provided including all medications and interventions in 1 (#9) of 13 (#1 - #13) Clinical Records reviewed.