Mercy Health Services Iowa Corporation

The agency failed to ensure the patients clinical record included accurate documentation of assessments and maintained pertinent current information in the patient record for 2 of 7 sampled patients (Patients # 4 and #6).

The agency: 1) Failed to ensure the agency skilled staff completed an individualized Plan of Care that contained accurate information.

The agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency.

The agency failed to ensure completion of the other follow- up (significant change in condition) comprehensive assessment at the time of a change in patient status/condition for 2 of 2 sampled patients requiring a significant change in condition assessment (Patients #1 and #8).

The agency failed to include an individualized assessment relating to the patient's current health status when completing comprehensive assessments for 9 of 17 sampled patients (Patients #6, #7, #8, #9, #12, #13, #14, #15 and #17).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care for 6 of 17 sampled patients (Patients #2, #5, #8, #9, #10, and #11).

The agency failed to update the Plan of Care with all new orders for 8 of 9 sampled patients with current episodes and interim or verbal physician orders completed after 6/17/19 when staff were instructed to update the Plan of Care with new orders (Patients #2, #3, #4, #6, #7, #8, #9, and #11).

The agency failed to provide medications, treatments or services only as ordered by the physician for 4 of 17 sampled patients (Patients #3, #5, #9 and #16).

The agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 2 of 17 sampled patients (Patients #12 and #16).

The agency failed to ensure patient care delivery was coordinated in a way to meet patient individualized needs for 2 of 2 sampled patients (Patients #11 and #14).

The agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary wound assessment at least weekly for 5 of 8 sampled patients with wounds (Patients #4, #7, #11, #13, and #17).

The agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer for 2 of 2 sampled patients with transfers (Patients #1 and #16).