WESTERN MD HOSPITAL CENTER

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

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

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

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

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’s drug regimen must be free from unnecessary drugs.

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

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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

Provide care and assistance to perform activities of daily living for any resident who is unable.

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.

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

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Respond appropriately to all alleged violations.

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

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.

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

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.

Prepare residents for a safe transfer or discharge from the nursing home.

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

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

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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

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

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