Pruitthealth at Home - Wake

Condition level Determination The cumulative effect of this systemic problem resulted in the agency’s ability to ensure that the physicians are promptly notified of the need for changes to the plan of care and the inability to complete care as ordered.

The registered nurses failed to obtain PICC (peripherally inserted central catheter) line measurements for 1 of 3 patients with a PICC line (#12); and failed to obtain Labs for 1 of 3 patients with lab orders (#13); and failed to measure wounds for 1 of 8 patients with wound (#17).

The agency failed to provide notice of the patient’s rights and responsibilities in a language understandable for 1 of 1 patient with Spanish as the preferred language (# 11).

The agency failed to include all medications in the plan of care for 1 of 2 patients with a urinary tract infection (#3); and 1 of 2 patients with a home visit conducted (#17).

The occupation therapist failed to contact the physician for an order prior to documenting an order for a delayed assessment for 1 of 3 patients with a delayed occupation therapy assessment (#9).

The clinicians failed to provide services as ordered in the plan of care for 6 of 16 active patients (#’s 8, 9, 11, 14, 18, &20).

The agency failed to provide accurate documentation for 6 of 20 patients with record reviews.

Home health aides failed to notify the physicians of missed visits for 13 of 16 active patient records reviewed (#’s 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20); and failed to notify the physician of a new wound for 1 of 8 patients with wounds (#17); and failed to notify the physician of a low…

The registered nurse documented Licensed Practical Nurse (LPN) supervisory visits for patients that did not receive care from an LPN for 3 of 16 active patients (#13, 17, 19).

Staff interviews the agency failed to notify the physician of a patient’s weight change for 1 of 1 patient with orders for weight monitoring (#2) and of a patient’s noncompliance of medication orders 1 of 6 active patients.

The agency failed to notify the physician of refusals of treatment for 1 of 1 patient with frequent refusals of treatment.

The Occupational Therapist (OT) failed to perform hand hygiene prior to entering the clinical bag after handling the patient’s medication bottles and touching the household items for 1 of 4 patient observations.

The agency failed to include all medications in the plan of care for 3 of 4 patients with home visits.

Staff interviews the agency failed to obtain an order for a PT/INR (Prothrombin Time and International Ratio, a blood test that measures how long it takes blood to clot) for 1 of 1 patient receiving PT/INR testing.

Staff interviews the agency fail to obtain wound measurements for 2 of 9 (#1, 15) patient with wounds and failed to obtain Peripherally Inserted Central Catheter (PICC, intravenous access that can be used for a prolonged time for the administration of medications.) line measurements for 1 of 1…

Staff interviews the agency failed to follow orders on the Plan of Care [POC] related to changing a PICC [peripherally inserted central catheter] line dressing for 1 of 2 patients with a PICC [#1]; follow wound care orders for 1 of 4 patients with wounds [#4, ]; to change an indwelling catheter…

The agency failed to obtain orders for the application of a dressing for 1 of 1 patient with a new wound [# 8]. The findings included: Patient # 8 had a Start of Care [SOC] date of 3/10/21 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non Pressure Chronic Ulcer of Right…

The clinical record failed to reveal any recorded weights during the episode.

The RN/LPN failed to provide accurate documentation related to PICC [peripherally inserted central catheter]line measurements for 2 of 2 patients with a PICC line [#1 and 4]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 2/25/21 and admitting diagnoses of…

The agency failed to communicate with the physician when a PICC [peripherally inserted central catheter] line dressing change was not performed for 1 of 2 patients with a PICC line [#1]; failed to notify the physician of a new open area for 1 of 4 patients with wounds [#8]. The findings included…

The agency failed to conduct visits according to the Plan of Care and to document 2 of 3 skilled nursing visits conducted for 1 of 1 patients with wounds (#1) Cross refer to : 484.75(b)(3) tag G710 484.75(b)(6) tag G716

Client record review and staff interview the agency failed to follow the plan of care related to skilled nursing visits for 1 of 1 patients with a wound (#1).

Client record review and staff interview the agency failed to document skilled nursing visits in the clinical record for 1 of 1 patients with a wound (#1).