Kaiser Foundation Hospital Home Health - Martinez

The home health agency’s licensed nursing staff did not develop a comprehensive assessment for 5 of 21 sampled patients (Patients 1, 2, 13, 14, 15).

The Home Health Agency’s Licensed nursing staff did not update the plan of care for 4 of 21 sampled patients.

The agency failed to ensure the Plan of Care (POC) included all necessary information needed to direct individualized care when it did not include caregiver training and education on monitoring Patient 10’s ileostomy (ileum, longest section of the small intestine) output.

The licensed nursing staff did not coordinate care for four of 21 sampled patients (Patients 3, 4, 10, 20) when: 1. Patients 3 and 20 had changes in conditions which were reported to the physician and Nurse Practitioner.

The agency failed to ensure three of 17 sampled, selected patients (Patient 14, 6 and 10) received the services in 48 hours after the referral.

The agency nurse failed to practice standard infection control for one of 17 sampled selected patients (Patient 16) during the home visit for Patient 16. This deficient practice had the potential to result in cross-contamination and transfer of infection to other people who were in contact with…

The agency failed to ensure one of 17 sample selected patients (Patient 14) received the services based on the frequency of the plan of care when, Patient 14 had a missed visit by the nurse on 3/18/23 and the nurse did not re-arrange the visit for the same week.

The agency failed to ensure one of 17 sampled patients (Patient 6) received services within five days after the initial assessment.

The agency failed to measure the wound for one of 17 sampled patients (Patient 1).

The agency failed to conduct an initial assessment visits within 48 hours of referral for two (Patients 13 and 14) of 17 sampled patients and five (Patient 18, 19, 20, 21, 22 and 23) of six randomly sampled patients.

The agency failed to coordinate services and notify the doctor regarding the delay of start of care (SOC) for one (Patient 18) of five randomly sampled patients.