Inspection Results » California Pacific Medical Center- Davies Campus Hospital

Health Inspection on September 12, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-12-19)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-12-19)
   • Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. (Corrected 2018-12-19)
   • 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 2018-12-19)
   • Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (Corrected 2018-12-19)

2. Pattern: 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 2018-12-19)
   • Provide and implement an infection prevention and control program. (Corrected 2018-12-19)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2018-12-19)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-12-19)