Plan of Correction 2011

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Plan of Correction 2011

Plan of Correction 2011

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  • 1. Plan of Correction 2011
  • 2. Environmental
    F465: The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
    F465: Cracked or uneven surfaces may harbor bacteria.
    Toilet assist bars in the bathroom in resident room E7 were observed to be loose. The bars could be rocked.
  • 3. Environmental
    All staff is to monitor items altering the toilet prior to use (commode, assist rails, toilet risers, etc.)
    Housekeeping please help by checking the items when cleaning the restrooms.
    West Wing shower room tiles were cracked and flooring had gouges in the linoleum. (Report these items on the maintenance log immediately)
  • 4. Environmental
  • 5. Environmental
  • 6. Environmental
  • 7. Call Lights
    7 out of 10 residents stated that staff shut off their call lights and told them they would return in a few minutes, but did not return for a while.
    W113 call light illuminated in the hallway, but no audible alarm sounded on at the nurses station to indicate the light was on.
  • 8. Call Light
    All staff to answer call lights
    Do not turn off call light until you meet the residents needs.
    Call light systems volume to remain on high at all times.
    If a call light is not functioning it must be repaired immediately or the resident is to be placed on 15min checks.
  • 9. CODE RED
    Fire Drill/Actual Fire “CODE RED”
    Remove those in danger
    Alarm pull station and send someone to report to report to the charge nurse
    Conceal close the door
    Extinguish get the4 nearest extinguisher, feel the door for hear, if cool enter and extinguish fire.
  • 10. CODE RED
    Nothing is to be placed in front of a fire extinguisher or pull station at any time!
  • 11. Fluid Restriction
    F327 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.
  • 12. Fluid Restrictions
    No one is to give a resident fluids unless approved by the charge nurse.
    Resident will have a blue colored wrist band on to indicate restriction.
    Door Name Tag Identifier with cup will be on name tag.
    Fluid restricted residents will have blue color records for ADL, Food Acceptance, and Fluid Intake Records.
  • 13. Nurses Only
    Always use nursing interventions and allow the resident time to adjust to the facility befor treating with anti-psychotics.
    Antipsychotic Medications may never be ordered PRN and must always have a diagnosis.
  • 14. Nurses Only
    Dialysis facilities and Long Term Care Facilities must coordinate lab draws.
    All residents on dialysis are tracked closely in the lab tracker book.
    Clarify with physician and Dialysis to eliminate duplicate labs being drawn.
    Detroit Bio will not draw labs for dialysis residents unless order states, “To be drawn by Detroit Bio.”
  • 15. Nurses Only
    Quinolone Antibiotics must be administered 2hours before or 6 hours after iron, aluminum, magnesium, calcium
    Pharmacy will call with all alerts
    Stickers are placed on ATB med card to warn staff of possible interaction
    All MAR’s are equipped with a pink sheet to warn nurses to check interactions
  • 16. Nurses Only
    Milk of Mag
  • 17. Nurses Only
    Review Transcription of orders Policy
    All medication orders must state: The medication name, dosage, route, time, frequency, diagnosis.
    On admission if there is a medication change it must be charted in the Nurses Notes.
    Review physician order sheets and medication sheets from the hospital closely.