cms_AK: 74
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
74 | WRANGELL MEDICAL CENTER LTC | 25015 | P.O. BOX 1081 | WRANGELL | AK | 99929 | 2018-04-30 | 865 | F | 0 | 1 | O8F911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the QAPI (Quality Assurance Performance Improvement), used to identify and implement change for improvement, and had identified areas that had been or should have been identified. Specifically , the QAPI committed failed to ensure: 1) the need for an updated facility assessment to include 1 resident #1 who needed specialized care; 2) identify late transmissions of MDS (material data set-a federal mandated assessment); 3) identify the lack of antibiotic stewardship program. (based on a census of 10). Without identifying or adequately addressing areas of quality deficiencies systematic correction could not be achieved and/or maintained. Failure to identify systemic processes for improvement had the potential to place all residents at risk for poor outcomes. Findings: Review of the QAPI Plan revised 4/2018, revealed .Improve the safety of the healthcare system and work processes; Identify indicators of quality related to structure, process and outcomes of patient care; .design or redesign care processes . Facility assessment Review of the facility assessment on 4/24-27/18, revealed the facility assessment had not identified Resident #1 who had a cardiac pacemaker who needed special monitoring equipment and care. Record review revealed Resident #1 had been admitted to the facility on [DATE] with an implanted cardiac pacemaker. During an interview on 4/27/18 at 2:58 pm, the Chief Nursing Officer (CNO) stated she did not know there was a Resident in the facility who had a pacemaker. The CNO stated the pacemaker should have been in the facility assessment to ensure special training or care required of staff. MDS Transmittals Record review from 4/24-27/18, revealed Resident #'s 1; 3; 5; 6; 9; and 10 had MDS assessments completed but not transmitted. Refer to Citation 640. During an interview on 4/27/18 at 9:29 am, the Quality Director (QD) revealed, she did not know the MDS assessments had not been submitted or that they should have be monitored for timely submission. Antibiotic Stewardship Record review on 4/25/18 at 10:00 am, revealed a draft antibiotic stewardship policy that was not implemented at the time of review. During an interview on 4/27/18 at 12:18 pm, the Infection Control Nurse stated the antibiotic stewardship policy was in draft and had not been implemented yet. Refer to Citation 881. | 2020-09-01 |