Mercy Hospital Ardmore, Inc.

The agency failed to ensure an Emergency Preparedness Communication Plan for the agency included updated current staff contact information for all patients and staff.

The agency failed to ensure a transfer/discharge summary contained necessary medical information at the time of patient transfer/discharge for two (Patients #1 and 6) of 11 patients.

The agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees.

The agency failed to ensure the initiation and review of a PIP through their QAPI Program 01/01/23 to 11/07/23 for all patients and employees.

The agency failed to ensure its infection control program included surveillance monitoring and reporting was included in QAPI program activities for all patients and staff.

The agency failed to ensure advance beneficiary notice was provided to one (Patient #9) of 11 patients.

The agency failed to ensure medication regimen changes were updated on the medication profile for one (Patient #5) of 11 patients.

The agency failed to ensure individualized patient POC included: 1. Identification of wound care sites for one (Patient #1) of 11 and; 2. Reoccurring catheter change intervention due date or last change date for one (Patient #3) of 11 patients.

The agency failed to ensure physician notification of patient reported inoperable (broken) blood glucose monitor for one (Patient #11) of 11 patients.

The agency failed to ensure: 1. SN conducted assessments of patients weight every visit for one (Patient #1) of 11 patients; 2. SN conducted reoccurring every month catheter change for one (Patient #3) of 11 patients; 3. SN visits were conducted for two (Patients #4 and 10) of 11 patients and; 4.…

The agency failed to ensure a completed discharge summary was provided for five (Patients #1 and 6) of 11 patients.

The agency failed to ensure: 1. home health aide visit frequency was followed as ordered on the plan of care for one (Patient #3) of 13 patients; 2. the skilled nurse notified the physician of blood pressure readings outside of ordered parameters for one (Patient #10) of thirteen patients.

The agency failed to ensure the initiation and review of PIPs through their QAPI Program for 186 current patients and all current employees.

The agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Patient #12) of 13 patients with home health aide services.