Rest Haven Illiana Christian Convalescent Home

The skilled nurse failed to ensure professional practices for the resumption of care was followed as directed by the primary care physician in 1 of 1 clinical record reviewed with resumption of care (ROC), out of a total of 5 active clinical records reviewed.

The home health agency failed to ensure all patients received proper written notice in advance of terminating services for 1 of 1 discharged patient who received speech therapy (ST) services, from a total of 2 closed clinical records reviewed.

The home health agency failed to ensure a review of all current medications was performed for 1 of 3 patients where a home visit was conducted.

The home health agency failed to ensure the plan of care was individualized to meet the needs for 2 of 3 patients where a home visit was conducted, from a total of 5 active clinical records reviewed.

The home health agency failed to ensure the plan of care was revised to disclose current, accurate patient information for 1 of 1 patient with a resumption of care (ROC), from a total of 5 active clinical records reviewed.

The home health agency failed to coordinate care delivery to ensure the patient's needs were met for 1 of 1 patient who had a resumption of care (ROC), from a total of 5 active clinical records reviewed.

The home health agency failed to ensure detailed instructions pertinent to the patient’s care were provided for 1 of 1 patient with home health aide services, from a total sample of 5 active clinical records reviewed.

The home health agency failed to ensure: the plan of care was individualized to meet the patient needs (see tag G0570), the plan of care was followed (see tag G0572), the individualized plan of care included all services, safety measures, medications and treatments (see tag G0574), services and…

The home health agency failed to ensure OASIS data accurately reflected the patient's status at the time of assessment in 1 of 7 patient records reviewed with a home visit.

The home health agency failed to ensure the plan of care was followed in 8 of 17 patient records reviewed (#2, #4, #7, #8, #9, #10, #12, #13).

The agency failed to track adverse patient events in 4 of 5 patients with falls (#1, #3, #4, #7).

The home health agency failed to ensure all employees practiced universal precautions in 2 of 7 home visits observed (#5, #7).

The home health agency failed to ensure all entries in the clinical record were complete and appropriately authenticated in 2 of 5 records reviewed receiving only skilled nursing (#2, #9).

The home health agency failed to provide the patient and caregivers with information for other agencies or resources who may be able to provide care in 1 of 5 discharged patient records reviewed.

The agency failed to provide services and treatments only as ordered by a physician in 2 of 12 records reviewed receiving physical therapy (#4, #16).

The agency failed to promptly alert the physician to changes in the patient's condition in 1 of 7 records reviewed with a home visit (#4).

The agency failed to ensure they addressed the need for a medical social worker for the possibility of community resources and the addition of home health aide services to assist with personal care and activities of daily living for 3 of 13 patient records reviewed (#4, #5, & #13) (see G570)…

The agency failed to ensure it had solicited volunteers for service during a disaster or emergency, to include the their roles for integration with health care professionals during the disaster/emergency for 1 of 1 home health agency disaster preparedness plan.

The facility failed to develop a method for sharing information and medical documentation for patients under the agency's care during disaster relief purposes for 1 of 1 agency emergency preparedness plan.

The agency failed to ensure care and services were provided per the plan of care for 6 (#1, #6, #7, & #8, #10, & #13) of 13 patient patient records reviewed.

The agency failed to ensure the home health aide assignment plans of care were accurate, specific, and contained information pertinent to the care of the patient in 6 patients (#3, #5, #8, #10, #11, & #12) in a total sample of 13 records reviewed.

The agency failed to ensure the discharge summary was appropriately authenticated that included not only the clinician's signature and date but also the time for 1 (#13) 4 records review of discharged patients in a total sample of 13. Findings include: Review of clinical record #13 on 5-29-19…

The agency failed to ensure the patient's right to a confidential and secure clinical record for 1 (#10) of 13 patient records reviewed.

The agency failed to ensure the Registered Nurse completed a comprehensive assessment along with the OASIS assessment for 1 of 13 patient records reviewed.

The agency failed to ensure a comprehensive assessment was completed and included pertinent information needed for the development of the plan of care for 3 of 13 patient records reviewed.

The agency failed to ensure a current and up-to-date listing of medications which included a check for side effects & interactions at the time of the 60-day comprehensive reassessment for 2 (#6 & #7) of 13 patient records reviewed.

The home health agency failed to ensure the OASIS resumption of care assessment was completed post hospitalization for 1 (#11) of 13 patient records reviewed.

The agency failed to update the patient's comprehensive assessment to evaluate the patient's progress in meeting their goals for 1 patient (#8) of a total sample of 13 patients.

The agency failed to ensure all pertinent information was included and medications were accurate in the plan of care (POC) in 8 (# 1, # 3, # 4, # 6, #8, #9, #11, and #13) out 13 patient records reviewed.

The agency failed to the plan of care was updated to include resumption of care orders for 1 (#11) of 3 records reviewed of patients with resumption of care orders in a sample of 13. Findings include Review of clinical record #11 on 5-29-19, start of care 11-8-18, evidenced a POC for the…

The agency failed to ensure skilled nursing did not provide a treatment absent of a physician's order for 2 (#7, 10) of 13 records reviewed.

The agency failed to ensure verbal orders were put into writing and signed/ dated by the ordering physician for 13 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, & #13) of a total sample of 13 records reviewed.

The agency failed to ensure skilled nursing staff promptly alerted the physician when the patient's oxygen saturation levels fluctuated and the patient's oxygen administration varied beyond orders for 1 (#9) of 4 records reviewed of patients on oxygen in a total sample of 13 patients.

The agency failed to ensure the licensed practical nurse communicated an additional medication to the case manager 1 patient (#10) of a total sample of 13 records reviewed.

The agency failed to ensure care was coordinated with the patient's ESRD (dialysis) facility for 1 (#8) of 1 patient receiving dialysis in a total sample of 13 patients.

The skilled nurses failed to ensure the documented a patients oxygen saturations and level of activity when obtained for 1 ( #9) of 4 records reviewed of patients on oxygen and 1 (#4) of 1 skilled nursing home visits in a sample of 5 and 2 (#1, 13) of 2 patient record reviewed of patients with…

Skilled nursing failed to ensure clinical documentation were accurate and complete for 1 (#4) of 1 skilled nursing home visits and 1 (#13) of 2 record reviews of patients with intravenous site.

The agency failed to ensure the home health aide followed the plan of care for 1 patient (#5) of a total sample of 13 clinical records reviewed.