Gold Horses LLC

The agency failed to investigate a complaint after receipt of allegations of abuse, neglect and exploitation (ANE) for one of four patients whose record was reviewed (Patient 2).

The Director of Nurses failed to ensure an appropriate health care professional performed a reassessment of a patient when there was a change in condition for one of four patients whose records were reviewed (Patient 2).

The agency failed to ensure skilled professionals completed the comprehensive assessment at discharge for one of four patients whose records were reviewed (Patients 2).

The agency failed to ensure the clinical record included all clinical notes for two of four patients whose records were reviewed (Patients 2 and 4).

The agency failed to ensure discharge and transfer summaries were completed and provided to the primary care practitioner or other health care professional for one of four patients whose records were reviewed (Patient 2).

The agency failed to ensure that procedures were performed only as ordered by the physician for two of two active patients (Patients 1 and 2) and one of one discharged patients (Patient 3) whose records were reviewed.