Inspection Results » Worcester Rehabilitation & Health Care Center

Health Inspection on September 5, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2018-11-14)
   • Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Corrected 2018-11-14)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-14)

2. Isolated: Actual harm that is not immediate jeopardy

   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-11-14)
   • Keep residents' personal and medical records private and confidential. (Corrected 2019-01-10)
   • 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 2018-11-14)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-02-01)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-14)

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

   • Implement a program that monitors antibiotic use. (Corrected 2018-11-14)

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

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-02-01)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-01-10)
   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2019-01-10)
   • Respond appropriately to all alleged violations. (Corrected 2018-11-14)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-11-14)
   • Provide and implement an infection prevention and control program. (Corrected 2019-02-01)
   • 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 2018-11-14)
   • Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. (Corrected 2018-11-14)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-14)

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

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2019-01-10)
   • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (Corrected 2018-11-14)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-11-14)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-01-10)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-14)
   • Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentÂ’s advance directives. (Corrected 2018-11-14)
   • Provide bedrooms that don't allow residents to see each other when privacy is needed. (Corrected 2018-11-14)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-11-14)
   • Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. (Corrected 2018-11-14)
   • Provide activities to meet all resident's needs. (Corrected 2018-11-14)
   • Provide or obtain dental services for each resident. (Corrected 2018-11-14)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-11-14)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-11-14)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-11-14)
   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2018-11-14)
   • Give the resident's representative the ability to exercise the resident's rights. (Corrected 2018-11-14)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-11-14)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. (Corrected 2018-11-14)
   • Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Corrected 2019-01-10)
   • Ensure that the resident and his/her doctor meet face-to-face at all required visits. (Corrected 2019-02-01)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-11-14)
   • Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (Corrected 2018-11-14)

6. Widespread: No actual harm with potential for minimal harm

   • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (Corrected 2018-11-14)

7. Pattern: No actual harm with potential for minimal harm

   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2018-11-14)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2019-02-01)