LAURELBROOK SANITARIUM - DAYTON, TN

Complaint Deficiency

• Proper stairway enclosures and vertical shafts
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Offer other nutritional food to each resident who will not eat the food served
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Actual harm
  • Scope: Some
• A two-hour-resistant firewall in common walls
  • Harm: Actual harm
  • Scope: Many
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• A separate and independent backup electrical power source
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Review or revise the resident's care plan after any major change in a resident's physical or mental health
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper backup exit lighting
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Actual harm
  • Scope: Some
• Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
  • Harm: Actual harm
  • Scope: Few
• Provide special eating equipment and utensils for each resident who needs them
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide proof that all residents' personal money which is deposited with the nursing home, is secure
  • Harm: Actual harm
  • Scope: Many
• Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Check and assess each resident's assessment at least every 3 months
  • Harm: Actual harm
  • Scope: Many
• Emergency lighting that can last at least 1 1/2 hours
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Corridors that are separated from common areas by walls constructed to limit the passage of smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Fire-resistant room wall surfaces
  • Harm: Actual harm
  • Scope: Many
• Provide bedrooms that hold no more than 4 residents per room
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Emergency lighting that can last at least 1 1/2 hours
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give or get quality lab services/tests in a timely manner to meet the needs of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have an adequate water supply for the sprinkler system
  • Harm: Actual harm
  • Scope: Many
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Tell the resident completely about his or her health status, care and treatments
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Try to resolve each resident's complaints quickly
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give the resident the right to receive visitors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Protect each resident from all abuse, physical punishment, and being separated from others
  • Harm: Actual harm
  • Scope: Some
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Actual harm
  • Scope: Many
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident receives an accurate assessment by a qualified health professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Actual harm
  • Scope: Some
• Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that special or therapeutic diets are ordered by the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Give or get specialized rehabilitative services per the patient's assessment or plan of care
  • Harm: Actual harm
  • Scope: Few
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Be administered in an acceptable way that maintains the well-being of each resident
  • Harm: Actual harm
  • Scope: Many
• 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility
  • Harm: Actual harm
  • Scope: Many
• Make sure medically necessary lab services/tests are ordered by the attending physician
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep complete, dated lab records in the resident's file
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Actual harm
  • Scope: Many

Quality Measures