Inspection Results » Providence St Joseph Hospital

Health Inspection on April 19, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-05-14)

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

   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-05-14)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-05-14)
   • Provide and implement an infection prevention and control program. (Corrected 2018-05-14)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-05-14)
   • 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 2018-05-14)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-05-14)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-05-14)

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

   • Not hire anyone with a finding of abuse, neglect, exploitation, or theft. (Corrected 2018-05-14)
   • Assess the resident when there is a significant change in condition (Corrected 2018-05-14)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-05-14)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2018-05-14)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-05-14)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-05-14)
   • Ensure that the resident and his/her doctor meet face-to-face at all required visits. (Corrected 2018-05-14)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2018-05-14)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-14)