Carter Healthcare of Oklahoma, LLC

PT staff failed to conduct initial evaluations timely as part of the comprehensive assessment for four (#2, #3, #4 and #7) of seven (#1-#7) records reviewed.

SN staff failed to promptly notify the physician of a patient fall with injuries and increased pain for one (#5) of seven (#1-#7) records reviewed.

SN staff failed to provide services and interventions as ordered in the POC for three (#2, #3 and #6) of seven (#1-#7) records reviewed.

SN staff failed to provide service as ordered in the POC for one (#2) of seven (#1-#7) records reviewed.

The PT failed to conduct the initial assessment within 48 hours of the referral as required for one (#7) of seven (#1-#7) records reviewed.

SN staff failed to review all medications the patient was currently using as part of the comprehensive assessment in order to identify possible side effects and drug interactions for one (#7) of seven (#1-#7) records reviewed.

The agency failed to ensure development of an agency specific Emergency Preparedness Program for 30 current patients and five employees.

The agency failed to document emergency drills from January 1, 2018 - January 31, 2019 for 68 current patients and all employees.

The agency failed to ensure the SN visit frequency was completed as ordered on the POC for one (Pt #6) of seven patients, Findings: Pt #6 A review of the POC dated 09/07/19 - 11/5/19 showed orders for a SN frequency of once a week for four weeks and then every other week for five weeks to begin…

The agency failed to ensure the initiation and conduction of PIPs through their QAPI Program for 30 current patients and five current employees.

The agency failed to ensure: 1) the POC included a pain parameter for one (Pt #5) of seven patients; 2) the plan of care included interventions related to the primary diagnosis for one (Pt #6) of seven patients.