cms_GU: 34
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
34 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2016-09-29 | 354 | F | 0 | 1 | H7FJ11 | Based on observation, interviews and record review, the facility failed to designate a registered nurse as the director of nursing of the skilled nursing unit (SNU) on a full time basis as required. Finding includes: On 9/26/16 at 9:00 a.m. during the entrance conference, an administrative staff member (AA1) identified the associate administrator of nursing services (AANS1) as the director of nursing at the facility (skilled nursing unit) which was about 7 miles away from the hospital. On 9/27/16 at 10:00 a.m., the AANS1 introduced herself to the survey team as the SNU's director of nursing and provided her business card with an official title as the Associate Administrator of Nursing Services. Further interview revealed that she had oversight responsibility of nursing services at the acute hospital and at the skilled nursing unit. AANS1 added that she also oversaw the unit supervisor of the SNU because the unit supervisor (LN1) was new at her position. Review of facility documents however revealed the lack of documented evidence of the appointment. In addition, while a registered nurse, AANS1 was hospital-based and worked full-time at the hospital as an assistant administrator for hospital nursing services. In addition, review of the facility's brochure given to newly admitted residents to the SNU made reference about the SNU Inter-disciplinary team; however, the composition of the team did not identify a director of nursing (as member) but the SNU's unit supervisor which also had the title of SNU Hospital Supervisor of Nursing. Further, review of the facility's Daily Assignment sheet revealed the name SNU's unit supervisor listed as SNU Head Nurse. On 9/28/16 at 10:00 a.m., interview with the SNU's unit supervisor (LN1) revealed that she had several responsibilities since the former DON left the SNU. She added that some of her responsibilities included coordination and supervision of nursing services at the SNU, conducting weekly meetings with other members of the interdisciplinary team, creating staffing work schedules, and representing the SNU at the hospital's quality improvement meetings monthly. LN1 confirmed that she reported to the hospital's assistant administrator of nursing services since she assumed the position of the SNU's supervisor. She also stated she was not aware of who the designated DON for the SNU was, and denied that she was the designated DON. LN1 later confirmed that there has been no official appointment or designation of a DON for SNU. Review of the survey forms required to be completed and submitted by the facility further revealed the lack of identification of a DON as well as work hours by the DON at the SNU. The CMS Form-671 (Long Term Care Facility Application for Medicare and Medicaid) for example, revealed the lack of hours (zero hours) worked by the DON at the SNU after the form was revised and submitted to the survey team on 9/27/16. | 2020-09-01 |