Ssm Health Businesses

The agency failed to: - Ensure that the individualized plan of care included all of the required components (574); - Ensure that drugs, services, and treatments are administered only as ordered by a physician (580); - Ensure that the relevant physicians (s) were promptly alerted to any changes in…

The agency failed to: - Provide services that were ordered by the physician as indicated in the plan of care (710); - Perform patient and caregiver education regarding wound care (714); and - Ensure communication with all physicians involved in the plan of care and other health care practitioners…

Complaint record review and interview the agency failed to document the complete investigation and resolution of complaints for two (Complaints #1 and #3) of three complaints reviewed.

The agency failed to ensure that the comprehensive assessment accurately reflected the patient's status and included the patient's current health, psychosocial, functional and cognitive status to support the need for skilled home health services in one (Record/Patient #5) of five cases.

The agency failed to ensure the comprehensive assessment included a complete and accurate review of the patient's medication regimen by the registered nurse (RN) in, but not limited to, two (Records/Patients #1 and #3) of five charts reviewed.

The agency failed to ensure that the plan of care (POC) was individualized and/or contained complete and accurate information for services and interventions in three (Records/Patients #1, #3 and #5) of five records reviewed.

The agency failed to ensure that only the most current medication orders were included on the plan of care (POC) in one (Record/Patient #1) of five records reviewed.

The agency failed to ensure prompt notification to the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered in two (Records/Patients #1 and #4) of five records reviewed.

The agency failed to ensure the integration of orders from all physicians involved in the plan of care (POC) to assure the coordination of all services and interventions provided to the patient in one (Record/Patient # 3) of five records reviewed.

The agency failed to ensure coordination of care between all disciplines assigned to care for the patient in two (Records/Patients #1 and #4) of five records reviewed.

The agency failed to ensure staff provided the patient/caregiver with ongoing education and training in, but not limited to, one of five records (Record/Patient #4).

The agency failed to ensure that the registered nurse (RN) followed the plan of care in two (Records/Patients #1 and #4) of five records reviewed related to wound and diabetic assessments.

The agency failed to ensure that patient and caregiver education was provided in one (Record/Patient #4) of five records reviewed.

The agency failed to ensure communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) regarding wound care and diabetic assessment/management in two (Records/Patients #1 and #4) of five records reviewed.