Guardian Home Health

Patient interview the agency failed to review all current medications for 1 of 1 home visits conducted (#3).

Staff interviews the agency failed to follow the Plan of Care [POC] related to obtain lab work for 1 of 10 active patients [#14]; failed to follow the POC related to amount of blood to discard [dispose] of when obtaining blood from a PICC [peripherally inserted central catheter] for lab work for 1…

Direct observation and staff interview the agency staff failed to use aseptic technique while collecting a blood specimen during a home visit for 1 of 7 visits observed (#12).

Staff interviews the SN [skilled nurse] failed to obtain wound measurements for 1 of 3 patients with a wound [#13]. The findings included: Review of a policy “Wound Assessment, Documentation, and Photography”, revised 08/01/22 was received from the executive director on 04/18/23 at 2:10 p.m.

Staff interview the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed (#6).

The agency failed to include all medications on the plan of care for 7 of 17 patients (#8,12,2, 7, 9, 11,13); failed to update the Plan of Care with the current/correct medications for 1 of 2 patients with a ROC [resumption of care-comprehensive assessment completed after an inpatient stay] (#2).

The agency failed to include all orders in the plan of care for 1 of 10 active patients [#13]. The findings included: 1A.

Staff interviews the agency failed to notify the physician of low oxygen saturations for 1 of 2 patients with supplemental oxygen orders [#13]. The findings included: The policy, Coordination of Care [4/1/23], was provided by the agency director on 4/18/23 at 2:10 pm.

The agency failed to ensure level 2 medication interactions [severe interaction-requires the physician to be notified and wait for a response from the physician] were addressed by the physician for 2 of 5 discharged patients [#2,5]. The findings included: 1. Patient # 2 had a Start of Care date of…

Staff interview the agency failed to measure wounds for 1 of 3 patients with wounds (#3) failed to document patient/caregiver education related to wound care for 1 of 3 patients with a wound (#13); failed to document correct PICC line measurements for 1 of 2 patients with a PICC line [peripherally…

Staff interviews the agency failed to coordinate care between staff for 1 of 3 patients records reviewed (#1).

Staff interview the agency failed to include all medications on the plan of care for 1 of 3 patients on oxygen (#9).

Staff interview the agency failed to measure wounds for 5 of 10 patients with wounds (#1,11,12,13, & 20).