Inspection Results » South Peninsula Hospital Long Term Care

  1. Health Inspection on October 26, 2018 [1]

    1. Isolated: Actual harm that is not immediate jeopardy
      • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-11-19)
    2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-11-23)
      • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-12-08)
    3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install (Corrected 2019-01-11)
      • Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Corrected 2018-11-19)
      • Provide and implement an infection prevention and control program. (Corrected 2018-11-19)
    4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-12-08)
      • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-12-08)
      • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-12-08)
      • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-11-21)
      • Keep all essential equipment working safely. (Corrected 2018-11-16)
      • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-12-08)
      • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-12-20)
    5. Widespread: No actual harm with potential for minimal harm
      • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2018-11-26)

To be part of the Medicare and Medicaid programs, nursing homes have to meet certain requirements set by Congress. The Centers for Medicare and Medicaid Services (CMS) has entered into an agreement with state governments to do health inspections and fire safety inspections of these nursing homes and investigate complaints about nursing home care. [2]

About The Inspection Process


References

  1. http://www.medicare.gov/NursingHomeCompare/About/Health-Inspections.html
  2. http://www.medicare.gov/NursingHomeCompare/About/Inspection-Results.html