Fort Bayard Medical Center

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Ensure that residents are fully informed and understand their health status, care and treatments.

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

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

Provide and implement an infection prevention and control program.

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

Post nurse staffing information every day.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Provide enough food/fluids to maintain a resident's health.

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

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

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

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Plan the resident's discharge to meet the resident's goals and needs.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

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

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

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

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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.

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

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Implement a program that monitors antibiotic use.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide or obtain dental services for each resident.

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.

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 each resident must receive and the facility must provide necessary behavioral health care and services.

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

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.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.