cms_PR: 23
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 490 | F | 0 | 1 | ZOYB11 | Based on an observational tour performed during recertification extended survey from 5/2 thru 5/4/17 from 8:00 am to 5:00 pm, accompanied by residents and staff interviews and review of policies, procedures and other administrative documents as well as clinical records reviewed, it was determined that the facility failed to ensure that all staff members have to perform their duties effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: 1. The facility failed to ensure that the QAPI and Infection Control programs work independently from each other with their own rules and planning methods that guarantee the quality of care that has to be provided to each resident and to ensure an environment free of infectious agents that cause cross contamination issues. a. According to administrative documents review such as: QAPI quarterly reports, the Infection Control planning methods and interviews performed to the Infection Control Preventionist (employee #7) on 5/4/17 at 10:00 am, the Infection Control indicators are included in the quarterly reports of QAPI program and no specific interventions are seen to work with the infection control issues that help to discontinue the deficient practices that were identified. The Administration failed to monitor that the activities that are performed for monitoring and tracking the infection control issues are different from the QAPI program activities. The facility has to ensure that each program has to define their mechanism of action establishing a solve problem method, to develop a specific plan of corrective actions, to provide evidence of a written plan of action and perform monitoring surveillance to guarantee compliance with state and federal rules and regulations. 2. The facility failed to ensure that the Nursing Supervisor and other nurses in leadership positions ensure that the nursing staff performs accurate skin assessment in a manner that the written documentation in the clinical records shows the residents real problems and that their interventions are performed according to the interventions that were written in the plan of care. During clinical records review performed from 5/2 to 5/4/17 it was identified that there is no correlation between the nurses' notes documentation with the plan of care. 3. The facility failed to ensure that the interdisciplinary staff performs an accurate pain assessment to each resident according to the Pain Management Protocol. They have to ensure that an ongoing mechanism is established in compliance with the Pain Management Protocol and other professional guidelines that are in compliance with the state and federal regulations. 4. The facility failed to perform monitoring activities where the staffing from housekeeping, physical environment and Safety Officer perform their routine tours for identifying issues that can affect the sanitary and comfortable environment that the residents needs to ensure quality of life and quality of care. 5. The facility failed to establish an ongoing mechanism to ensure that each professional complies with the state law requirements related to providing actualized credentials documents. | 2020-09-01 |