Well Care Home Health of the Triad Inc

The skilled nurse failed to assess a new wound/do wound care for 1 of 1 discharged patient with a wound [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30 pm.

Staff interviews the skilled nurse failed to change an indwelling catheter as ordered by the physician in the plan of care for 1 of 1 discharged patient with an indwelling catheter [#1]. The findings included: The policy, Plan of Care [2/22] was provided by RN # 2 on 5/16/24 at approximately 4:30…

The agency failed to follow the physician's order for wound care for 1 of 3 charts [#1]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/28/20. A review of the Plan of Care for the certification period 8/22/21 to 10/20/21 revealed the following diagnoses: Pressure Ulcer of…

The agency failed to provide wound care based on a physician's order for 1 of 3 charts [#1]. The findings included: 1A.

Staff interviews the agency failed to communicate changes in a wound/onset of a new wound to the physician for 1 of 3 charts [#1]. The findings included: The policy, Coordination of Care [1/3/13], was provided by employee # 8 on 11/9/21. The policy stated, "...Timely and ongoing communication is…

Staff interviews the agency failed to document/record wound measurements weekly in accordance with agency policy for 3 of 3 charts [#1, 2 and 3]. The findings included: The policy, Wound Addendum [last revision date 7/18], was provided by employee # 8 on 11/9/21. The policy stated, "Wounds will be…

The agency failed to follow the plan of care [POC] related to notifying the physician when vital signs were outside the given parameters for 1 of 3 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 5/14/21 and an admitting diagnosis of Pressure-induced deep tissue…

The agency failed to document the existence and/or resolution of a complaint for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 5/14/21 and an admitting diagnosis of Pressure-induced deep tissue damage of right heel.

The agency failed to communicate with the physician missed visits for 2 of 5 patients (#1 and 3); and weights gain outside of defined parameters for 1 of 5 patients (#1).

The RN failed to provide supervision of the LPN for 2 of 5 patients (#1 and 5).