Trinity North Home Health LLC

The Skilled Nurse (SN) failed to follow the physicians orders in 11 (#1-#11) of 11 (#1-#11) clinical records reviewed by not monitoring vital signs, blood glucose levels or weights nor reporting out of range values to the physician.

The Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients medications in 3 (#2, #3, #11) of 11 (#1-#11) clinical records reviewed.

This element was not met in 7 (#2, #3, #4, #6, #7, #9, and #11) of 11 (#1-#11) clinical records reviewed.

The Agency failed to alert the Physician to changes in the patients condition which may have necessitated an alteration in the Plan of Care (POC) in 9 (#2, #3, #4, #6, #7, #8, #9, #10, #11) of 11 (#1-#11) Clinical Records reviewed.

The Agency failed to maintain documentation of clinical competencies for obtaining vital signs on patients in 2 of 2 Agency Staff interviewed.(staff member # 3 & #4).

The Governing Body failed to oversee the management of the agency in that the Agency's Policies and Procedures were not current clinical practice guidelines.

The Skilled Nurse (SN) failed to complete a Drug Regimen Review (DRR - review of medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions) to include all current and added medication the patient was taking in 1 (#1) of 7 (#1…

The Agency failed to provide the patient with complete and accurate written patient medication schedule / instructions in 3 (#3 - #5) of 3 (#3 - #5) home visits conducted.

The Agency failed to ensure Criminal History Record Checks and Arkansas Department of Health (ADH) Determination Letter were completed on all Home Health Aide (Aide) employees no less than one time every five years as required for continued employment.