Liberty Home Care II, LLC

Staff interviews the Registered Nurse failed to complete a wound assessment and obtain measurements for 2 of 3 patients with a wound [#1 and #2]. The findings included: The policy, Wound Assessment, Home Care [2/20/23], was provided by the agency administrator on 1/17/24 at approximately 3 pm.

Staff interviews the home health aide plan of care failed to include all the required patient care instructions for 1 of 2 patients receiving aide services [#1]. The findings included: The policy, Home Health Aide Care Plan and Documentation [reviewed 4/21], was provided by the agency administrator…

The Plan of Care [POC] failed to include all the required components on for 2 of 10 patients [#1 and 3] The findings included: 1. Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of consciousness [brain bleed]. Review of the…

Staff interviews the Registered Nurse applied a dressing to a wound without an order for 1 of 3 patients with a wound [#1]; and advised the caregiver to use Desitin [barrier cream] without an order for 1 of 3 patients with a wound [#1]. 1A.

Staff interview the agency failed to coordinate care with the physician for missed visits for 1 of 3 patients with a wound (#2), notify the physician of a blood pressure out of parameters for 1 of 10 patients (#1), and notify the physician of wound care performed not as ordered for 1 of 3 patients…

The Registered Nurse failed to document the type of wound care completed when a new pressure injury was noted for 1 of 3 patients with a wound [#1]. The findings included: Patient # 1 had a Start of Care date of 10/27/22 and an admitting diagnosis of traumatic subdural hemorrhage with loss of…

Staff interviews the agency failed to coordinate care with the physician for a blood sugar outside of parameters for 1 of 2 patients (#3) with diabetes.

Staff interview the agency failed to follow the plan of care as ordered by the physician for skilled nursing visits for 1 of 6 patients with skilled nursing (#2).