Ideal Nursing Services, Inc.

The agency's staff failed to document complete, patient-specific, comprehensive assessments that accurately reflected the patients' current health status consistent with the patients' immediate needs in one (1) of 10 clinical records (Patient #10).

The agency's staff failed to ensure that the clinical record contained accurate information in accordance with current clinical record documentation standards of practice in one (1) of 10 clinical records (Patient #2).

The agency's staff failed to conduct accurate medication reconciliation for in one (1) of 10 clinical records (Patient #1).

The agency's staff failed to ensure that patients' developed Plans of Care were individualized, accurate, specific to each patient's needs, and included all required elements in three (3) of ten (10) clinical records (Patients # 2, 6, and 10).

Agency staff failed to revise the Plan of Care to reflect all patient care orders, including verbal orders, in the Plan of Care for one (1) of ten (10) clinical records (Patient # 4).