Initial Comments:
Based on the findings of an onsite unannounced complaint investigation completed December 19, 2023, Concordia Visiting Nurses was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. The survey was conducted from the Cabot parent location.
Plan of Correction:
484.75(b)(1) ELEMENT
Interdisciplinary assessment of the patient
Name - Component - 00
Ongoing interdisciplinary assessment of the patient;
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse (LPN) and registered nurse (RN) failed to assume responsibility for the patient and failed to ensure an ongoing interdisciplinary assessment of the patient was completed for one (1) of one (1) discharged record with an indwelling urinary catheter who required emergency services (CR1).
Review of facility policy on December 19, 2023, at 10:15 a.m. showed:
"POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... N. Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care. ... P. Serves as the primary liasison and coordinator of care when nursing and other services are provided. ... R. Meets with the interdisciplinary team routinely to ensure coordination of care."
"POSITION DESCRIPTION - LICENSED PRACTICAL NURSE ... POSITION SUMMARY ... The LPN collaborates patient care with the case managing RN, physician, and patient ... DUTIES AND RESPONSIBILITIES ... F. ... Conducts a comprehensive physical examination and nursing assessment of the patient at each skilled visit."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient's record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient's record."
"Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient's record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained."
Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient's admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, "Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month." The plan of care was signed by the RN on 10/19/2023.
Review of CR1's skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), " Has [urinary catheter] in place that SN [skilled nursing] to manage." CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During six (6) of seven (7) visits (10/24-11/24/2023) the LPN failed to document the amount of urine in the patient's urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 visits, the LPN replaced the patient's urinary catheter and simply documented the patient's urinary catheter was last changed on 10/24/2023 for example.
Review of CR1's emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., "Triage Presenting Complaint and Acuity Level: foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder."
There was nothing in the above visit notes to show the RN supervised the LPN over the 40-day episode (10/19 to 11/29) to ensure the patient's needs were met or if the LPN was following agency policy concerning urinary catheter care.
CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed the LPN failed to document how much urine was in patient's urinary catheter drainage bag from 10/24-11/24/2023 visits, or if urine was obtained when new urinary catheter was inserted on 10/24/2023 and 11/24/2023. EMP3 also confirmed no RN supervision for the entire episode when care was provided by the LPN.
Plan of Correction:How will the agency correct the deficiency?
- Ensure that all LPNs and RNs have a thorough understanding of the interdisciplinary assessment and documentation of urinary catheter patients' needs through re-education and monitoring.
- One-on-one education on urinary catheter change for a male patient will be completed with the LPN who completed the visit on 11/24/23 (double check the date).
Measures or systems the Agency will alter to ensure the problem does not occur:
- Re-education to the nursing staff regarding appropriate assessment and documentation of urinary catheter patients and coordination of care between RN and LPN.
- Re-education to the nursing staff regarding how to appropriately ensure that a catheter change was successful and how to address any unexpected outcomes.
- Revisions will be made to the genitourinary section in EMR to better reflect type of catheter present, status and amount of output before and after catheter change.
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 urinary catheter charts/week will be completed to verify that appropriate assessments including amount and description of output observed in catheter bag at each visit and coordination of care between disciplines are occurring until 100% compliance. Then 10 charts per quarter for four quarters will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinician (s) for education review and or individual remediation. Auditing to be completed by the Director of Compliance or designee and will begin on or after 1/22/2024.
484.75(c)(1) ELEMENT
Nursing services supervised by RN
Name - Component - 00
Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k).
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the registered nurse (RN) failed to supervise, monitor and evaluate the performance of the licensed practical nurse (LPN) regarding data collection to ensure the patient's needs were met as delegated by the RN for one (1) of one (1) discharge record with an indwelling urinary catheter who required emergency services (CR1).
Review of facility policy on December 19, 2023, at 10:15 a.m. showed:
"SUBJECT: Nursing Services Policy: IX-2 I. Policy Concordia Visiting Nurses provides nursing services to patients in need ... The qualified License Practical Nurse (LPN) ... may provide nursing services under the supervision of the registered nurse. A. Provider Care ... The RN is responsible for all aspects of the nursing process including: ... provision of skilled care ... observation of clinical signs and symptoms ... assignment and supervision of the LPN. ... The LPN may provide care under the guidance and supervision of the RN."
"POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... H. Supervises and periodically evaluates the care given by the LPN to his/her primary patients to ensure oversight I. Evaluates and manages LPNs ... who are providing services to his/her patients. ... Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient's record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient's record."
"Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient's record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained."
Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient's admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, "Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month." The plan of care was signed by the RN on 10/19/2023.
Review of CR1's skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), " Has [urinary catheter] in place that SN [skilled nursing] to manage." CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All of the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During these visits the LPN failed to document the amount of urine in the patient's urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 SN visits, the LPN replaced the patient's urinary catheter and simply documented the patient's urinary catheter was last changed on 10/24/2023. There was no documentation to show how much urine was in patient's urinary catheter drainage bag, and if urine was obtained when new urinary catheter was inserted.
There was nothing in the above visit notes to show the RN supervised the LPN over the 40-day episode (10/19 to 11/29) to ensure the patient's needs were met or if the LPN was following agency policy concerning urinary catheter care.
Review of CR1's emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., "Triage Presenting Complaint and Acuity Level: Foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder."
CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed there was no documented supervision by the RN for the entire episode. The patient was discharged by the RN on 12/19/2023.
Plan of Correction:How will the agency correct the deficiency?
- Education will be completed to ensure that all LPNs and RNs are knowledgeable regarding requirements of the duties of a RN to supervise, monitor, and evaluate the performance of the licensed practical nurse regarding data collection to ensure the patient's needs are met as delegated by the RN to prevent potential harm to the patient
- One-on-One re-education provided to the LPN's and RN who cared for the patient in question regarding appropriate LPN supervision and coordination of care to ensure that all of the patient's needs are being met.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education to nursing staff regarding requirements of LPN supervision including frequency of visits and to ensure the needs of the patient are being met by monitoring and evaluating the performance of the LPN
- Review of policy IX-2, Nursing Services
- Review of position descriptions for both RN and LPN with appropriate field nursing staff
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audits of 10 nursing charts/month x3 months will be completed to ensure appropriate RN supervision of LPNs and that the needs of the patient are being met and coordination of care is occurring until 100% compliance. Then 10 charts per quarter for four quarters will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation. Auditing to be completed by the Director of Compliance or designee and will begin on 1/22/2024.
Initial Comments:Based on the findings of an onsite unannounced complaint investigation completed December 19, 2023, Concordia Visiting Nurses was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.32(a) REQUIREMENT
SUPERVISION
Name - Component - 00
601.32(a) Supervision. The home
health agency provides skilled nursing
service by or under the supervision of
a registered nurse and in accordance
with the plan of treatment.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the registered nurse (RN) failed to supervise, monitor and evaluate the performance of the licensed practical nurse (LPN) regarding data collection to ensure the patient's needs were met as delegated by the RN for one (1) of one (1) discharge record with an indwelling urinary catheter who required emergency services (CR1).
Review of facility policy on December 19, 2023, at 10:15 a.m. showed:
"SUBJECT: Nursing Services Policy: IX-2 I. Policy Concordia Visiting Nurses provides nursing services to patients in need ... The qualified License Practical Nurse (LPN) ... may provide nursing services under the supervision of the registered nurse. A. Provider Care ... The RN is responsible for all aspects of the nursing process including: ... provision of skilled care ... observation of clinical signs and symptoms ... assignment and supervision of the LPN. ... The LPN may provide care under the guidance and supervision of the RN."
"POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... H. Supervises and periodically evaluates the care given by the LPN to his/her primary patients to ensure oversight I. Evaluates and manages LPNs ... who are providing services to his/her patients. ... Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient's record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient's record."
"Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient's record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained."
Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient's admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, "Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month." The plan of care was signed by the RN on 10/19/2023.
Review of CR1's skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), " Has [urinary catheter] in place that SN [skilled nursing] to manage." CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All of the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During these visits the LPN failed to document the amount of urine in the patient's urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 SN visits, the LPN replaced the patient's urinary catheter and simply documented the patient's urinary catheter was last changed on 10/24/2023. There was no documentation to show how much urine was in patient's urinary catheter drainage bag, and if urine was obtained when new urinary catheter was inserted.
There was nothing in the above visit notes to show the RN supervised the LPN over the 40-day episode (10/19 to 11/29) to ensure the patient's needs were met or if the LPN was following agency policy concerning urinary catheter care.
Review of CR1's emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., "Triage Presenting Complaint and Acuity Level: Foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder."
CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed there was no documented supervision by the RN for the entire episode. The patient was discharged by the RN on 12/19/2023.
Plan of Correction:How will the agency correct the deficiency?
- Education will be completed to ensure that all LPNs and RNs are knowledgeable regarding requirements of LPN supervision and coordination of care.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education to nursing staff regarding requirements of LPN supervision including frequency
- Review of policy IX-2, Nursing Services
- Review of position descriptions for both RN and LPN with appropriate field nursing staff
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Audits of 10 nursing charts/month will be completed to ensure appropriate RN supervision of LPNs is occurring and coordination of care is occurring until 100% compliance. Then 10 charts per quarter for four quarters will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation. Auditing to be completed by the Director of Compliance or designee and will begin 1/22/2024.
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the registered nurse (RN) failed to regularly reevaluate the patient's nursing needs for one (1) of one (1) discharge record with an indwelling urinary catheter who required emergency services (CR1).
Review of facility policy on December 19, 2023, at 10:15 a.m. showed:
"POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... N. Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care. ... P. Serves as the primary liasison and coordinator of care when nursing and other services are provided. ... R. Meets with the interdisciplinary team routinely to ensure coordination of care."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient's record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient's record."
"Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient's record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained."
Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient's admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, "Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month." The plan of care was signed by the RN on 10/19/2023.
Review of CR1's skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), " Has [urinary catheter] in place that SN [skilled nursing] to manage." CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During six (6) of seven (7) visits (10/24-11/24/2023) the LPN failed to document the amount of urine in the patient's urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 visits, the LPN replaced the patient's urinary catheter and simply documented the patient's urinary catheter was last changed on 10/24/2023 for example.
Review of CR1's emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., "Triage Presenting Complaint and Acuity Level: foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder."
There was nothing to show the RN regularly reevaluated the patient's nursing needs while the LPN was providing care over the 40-day episode (10/19 to 11/29) to ensure the patient's needs were met as evidenced by the LPN visit notes and resultant ER visit on 11/25/2023.
CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed the LPN failed to document how much urine was in patient's urinary catheter drainage bag from 10/24-11/24/2023 visits, or if urine was obtained when new urinary catheter was inserted on 10/24/2023 and 11/24/2023. EMP3 also confirmed no RN supervision for the entire episode when care was provided by the LPN.
Plan of Correction:How will the agency correct the deficiency?
- Education will be provided to ensure that all LPNs and RNs have a thorough understanding of the interdisciplinary assessment and documentation of urinary catheter patients' needs.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Re-education to nursing staff regarding appropriate assessment of urinary catheter patients and coordination of care between RN and LPN
- Re-education to RNs regarding need to regularly update care plan based on patient's needs
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 urinary catheter charts/week will be completed to verify that appropriate assessments including amount of output observed in catheter bag at each visit and coordination of care between disciplines are occurring until 100% compliance. Then 10 charts per quarter for four quarters will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation. Auditing to be completed by the Director of Compliance or designee and will begin 1/22/2024.
601.32(c) REQUIREMENT
DUTIES OF THE QUALIFIED LPN
Name - Component - 00
601.32(c) Duties of the Qualified
Licensed Practical Nurse. The
qualified licensed practical nurse:
(i) provides services in accordance
with agency policies,
(ii) prepares clinical and progress
notes,
(iii) assists the physician and/or
registered nurse in performing
specialized procedures,
(iv) prepares equipment and
materials for treatments observing
aseptic technique as required, and
(v) assists the patient in
learning appropriate self-care
techniques.
Observations:
Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse failed to provide services in accordance with agency policy for one (1) of one (1) discharged record with an indwelling urinary catheter who required emergency services (CR1).
Review of facility policy on December 19, 2023, at 10:15 a.m. showed:
"POSITION DESCRIPTION - LICENSED PRACTICAL NURSE ... POSITION SUMMARY ... The LPN collaborates patient care with the case managing RN, physician, and patient ... DUTIES AND RESPONSIBILITIES ... F. ... Conducts a comprehensive physical examination and nursing assessment of the patient at each skilled visit."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient's record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine."
"Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient's record."
"Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient's record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained."
Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient's admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, "Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month." The plan of care was signed by the RN on 10/19/2023.
Review of CR1's skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), " Has [urinary catheter] in place that SN [skilled nursing] to manage." CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During six (6) of seven (7) visits (10/24-11/24/2023) the LPN failed to document the amount of urine in the patient's urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 visits, the LPN replaced the patient's urinary catheter and simply documented the patient's urinary catheter was last changed on 10/24/2023 for example.
Review of CR1's emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., "Triage Presenting Complaint and Acuity Level: foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder."
CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed the LPN failed to document how much urine was in patient's urinary catheter drainage bag from 10/24-11/24/2023 visits, or if urine was obtained when new urinary catheter was inserted on 10/24/2023 and 11/24/2023.
Plan of Correction:How will the agency correct the deficiency?
- Education will be provided to ensure that all LPNs and RNs are knowledgeable regarding requirements of LPN supervision and coordination of care.
Measures or systems the Agency will alter to ensure the problem does not occur:
- Education to nursing staff regarding requirements of LPN supervision including frequency
- Review of policy IX-2, Nursing Services
- Review of position descriptions for both RN and LPN with appropriate field nursing staff
Plans to monitor the Agency's performance to ensure the problem does not occur:
- Weekly audits of 5 urinary catheter charts/week to verify that appropriate assessments including amount of output observed in catheter bag at each visit and coordination of care between disciplines are occurring until 100% compliance. Then 10 charts per quarter for four quarters will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation. Auditing to be completed by the Director of Compliance or designee and will begin 1/22/2024.
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