Surrey Place St Lukes Hospital Skilled Nursing
SURREY PLACE ST LUKES HOSPITAL SKILLED NURSING in CHESTERFIELD, MO — inspection on August 1, 2024.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F726)
3.
Failed to include infection control services, such as surveillance and antibiotic use, as well as the facility employing an Infection Preventionist (IP) who was responsible for overseeing the infection control program. (Refer to
Review of the facility's Medication Orders Policy, reviewed February 2021, showed:
-Policy: Medication Orders shall be clear and accurate.
Practitioners with delineated clinical privileges shall be able to give orders.
Written patient medication orders for treatment shall be dated, timed and signed by the prescriber.
All other medication orders will be entered into the hospital computer system via CPOE.
Orders entered by a non-physician, shall be countersigned by the ordering physician;
-Process for Accepting a Telephone Order: The hospital minimizes the use of verbal and telephone medication orders.
Only authorized prescribers can give telephone orders;
-Telephone orders are permitted.
When taking a telephone order, the listener will type the order into CPOE.
The listener will read the entire transcribed order back to the prescriber, including the patient's name and will use words instead of abbreviations.
The prescriber will countersign the telephone order;
Telephone orders are not to be taken for anti-neoplastic agents, except to discontinue or hold the antineoplastic agent. A telephone order that seems inconsistent with the patient's problem will be questioned/clarified before the order is implemented;
-Preprinted and electronic standing orders, order sets, and protocols for medication orders include the following Processes for use: Review and approval of standing orders and protocols by the medical staff and the hospital's nursing and pharmacy leadership;
-Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines;
265414
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 265414 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Surrey Place St Lukes Hospital Skilled Nursing 14701 Olive Blvd Chesterfield, MO 63017
During an interview on 08/01/24 at 2:23 PM, the Administrator was asked specifically why the infection control program was not included in the Facility Assessment and why there was no mention of the IP.
The Administrator stated she has not seen other examples of a written Facility Assessment mention that they provide infection control surveillance and employ an IP to oversee the program.
46592
265414
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 265414 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Surrey Place St Lukes Hospital Skilled Nursing 14701 Olive Blvd Chesterfield, MO 63017
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.