cms_GU: 85
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
85 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2012-01-26 | 493 | E | 0 | 1 | J2NN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not have a governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, and did not ensure that the appointed administrator was responsible for management of the facility. Findings include: 1. The facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable for one of 10 sampled residents, (Resident 4) and one of 5 unsampled residents (Resident (11); and failed to provide necessary treatment to promote healing and prevent infection for one of 10 sampled residents (Resident 6) a resident who entered the facility with pressure ulcers. (Cross-refer to F314.) 2. The facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore as much normal bladder function as possible; 1. When the facility did not assess or refer a resident for bladder training or adaptive equipment resulting in accidental incontinence for one of 10 residents (Resident 2), and 2. When the facility did not prevent the development of UTIs for one of 10 residents (Resident 6). (Cross-refer to F315) 3. The facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels when the facility did not promptly provide necessary equipment or supplies to ensure that 1 of 10 residents (Resident 6) received adequate nutrition when her feeding tube leaked for six weeks resulting in an 18% weight loss; and Resident 2 did not receive follow up care for weight maintenance. (Cross-refer to F325) 4. The facility did not have an effective infection control program coordinated by a trained and qualified infection control practitioner who was allowed sufficient time and resources in infection control activities. (Cross-refer to F441.) 5. The administrative manual pertaining to the governing body noted that the facility must have a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the Skilled Nursing Unit. In addition, the purpose of the administrative manual was to identify the governing body of the Unit. The administrative manual however did not identify a responsible governing body or designated individuals with authority and control over the facility. Further review of facility documents revealed the lack of documented evidence that the duties and responsibilities of the governing body, and that of the appointed administrator responsible for the day-to-day operation of the facility, were delineated. On 1/25/12, for example, following a request for a copy of the job description of the facility administrator, a copy identified as draft was presented. | 2017-01-01 |