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Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education documentation, audit tools, Rules and Regulations of the Medical Staff, and policy and interview, it was determined the facility failed to:


1. Follow their own Plan of Correction for monitoring emergency equipment. Refer to A 093.

2. Follow their own Plan of Correction for ensuring medical records (MR) contained the correct consents and were signed by patient / caregivers. Refer to A 131.

3. Follow their own Plan of Correction for education to be provided to clinician's and medical staff. Refer to A 392.

4. Ensure the patients received all medications, treatments as ordered by the physician. Refer to A 392.

5. Follow their own Plan of Correction for ensuring nursing and medical staff were educated on accurate documentation and swing bed process. Refer to A 467.

6. Follow their own Plan of Correction for ensuring a home medication policy was in place and clinical staff were educated. Refer to A 500.

7. Follow their own Plan of Correction for ensuring the nursing and medical staff were provided education regarding dietitian consults. A 621.

8. Follow their own Plan of Correction for ensuring all registered nurse (RN) staff were inserviced on freedom of choice form. Refer to A 823.

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 286, A 131, A 392, A 467, A 500, A 621, and A 823 for findings.