Madison Home Care

Staff interview the agency failed to provide home health aide supervision for 1 of 2 home health aide records reviewed (#7).

The agency failed to notify the physician of increased weakness and low blood pressures in 1 of 2 discharged patients (#2).

Staff interviews the RN [registered nurse failed to obtain weekly wound measurements for 1 of 2 patients with a wound [#1]. The findings included: The agency protocol, “________ [agency name] Home Care and Hospice Wound Protocol 2021, was provided by RN # 2 on 10/10/22 at 2:30 pm.

The agency failed to notify the patient of pending discharge for cause prior to discharge for 1 of 1 patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing…

Staff interviews the agency failed to attempt to resolve an issue concerning the patient before discharging for cause for 1 of 1 patient discharged for cause [#1]. The findings included: The policy, Discharge of Patients [revised 3/07], was provided by RN # 2 on 10/10/22 at 2 pm.

Staff interviews the Plan of Care failed to include all medications/complete directions for use the patient was using at the time of admission for 1 of 3 patients [#1]. The findings included: 1A.

The RN [registered nurse] failed to provide blood sugar monitoring/assessment in accordance with the physician’s order for 1 of 2 diabetic patients [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical…

Staff interviews the RN [registered nurse] failed to document consistent information related to patient discharge from the agency for 1 of 1 of patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change…

The agency failed to complete a discharge summary for 1 of 1 patient discharged for cause [#1]. The findings included: Patient # 1 had a Start of Care date of 7/25/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Type 2 Diabetes with Diabetic Peripheral…

The agency failed to conduct with initial assessment within 48 hours of referral or a physician ordered start of care date for 3 of 10 patients (#3, 5, and 6).

Staff interview the agency instructed on/provided treatments that were not included on the Plan of Care for 3 of 10 patients (#2, 4, and 6).

The agency failed to update the physician on changes/significant findings in patient condition for 3 of 10 patients (#5, 6, and 9).

Staff interviews the Plan of Care failed to contain an order for staff to prefill a pillbox for 1 of 3 patients who received home visits [#3]. The findings included: Patient # 3 had a Start of Care [SOC] date of 10/11/17 and diagnoses of Chronic Venous Hypertension with Ulcer and Inflammation…

Agency policy review and staff interviews nursing failed to provide wound care in accordance with the Plan of Care for 2 of 3 charts reviewed with wound care orders [#3 and 6]; and changed the PICC (peripherally inserted central catheter-used to administer IV medications) line dressing without an…

Agency policy review and staff interviews nursing failed to communicate changes to the physician in the patient's condition in 2 of 5 active charts reviewed [#7 and 6]; and physical therapy failed to communicate changes to the physician in the patient's condition in and 1 of 3 patients who received…

The home health aide (HHA) provided services that were not included in the plan of care for 1 of 2 patients that had HHA orders (#6).