Inspection Results » Martha and Mary Health Service

Health Inspection on September 18, 2018 ^[1]

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

   • 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 2018-11-15)

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

   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-11-15)
   • 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 2018-11-15)
   • 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 2018-11-15)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-11-15)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-11-15)
   • Ensure that residents are fully informed and understand their health status, care and treatments. (Corrected 2018-11-15)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-15)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-11-15)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-15)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-15)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-11-15)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2018-11-15)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-11-15)
   • 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 2018-11-15)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-11-15)