Plan of Correction 2011

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.

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)

Environmental

Environmental

Environmental

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.

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.

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.

CODE RED

•Nothing is to be placed in front of a fire extinguisher or pull station at any time!

Fluid Restriction

• F327 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

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.

No Fluids

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.

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.”

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

Nurses Only

• Cipro• Levaquin• Tequin• Noroxin• Trovan• Zagam• Avelox

• Calcium• Magnesium• Mylanta• Milk of Mag• Iron

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.