HENDRICKS COMMUNITY HOSPITAL

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Provide safe and appropriate respiratory care for a resident when needed.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Have a Compliance and Ethics Program.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Provide and implement an infection prevention and control program.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Provide and implement an infection prevention and control program.

Respond appropriately to all alleged violations.

Provide safe, appropriate pain management for a resident who requires such services.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Make sure that a working call system is available in each resident's bathroom and bathing area.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Provide care by qualified persons according to each resident's written plan of care.

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Have a program that investigates, controls and keeps infection from spreading.

Operate and provide services according to Federal, State, and local laws and professional standards.