JACKIE WITHROW HOSPITAL - BECKLEY, WV

Staff Information

Complaint Deficiency

• 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: Few
• Hire sufficient dietary support personnel
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Approved construction type or materials
  • Harm: Actual harm
  • Scope: Some
• Exit stairways and towers that are smoke proof
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
  • Harm: Potential for minimal harm
  • Scope: Some
• 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: Many
• Properly constructed piped-in oxygen systems
  • Harm: Actual harm
  • Scope: Some
• Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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
• Provide special eating equipment and utensils for each resident who needs them
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Potential for minimal harm
  • Scope: Many
• Exits that are accessible at all times
  • Harm: Potential for minimal harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Potential for minimal harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Many
• 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
• 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Potential for minimal harm
  • Scope: Some
• 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
• 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: Many
• Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
  • Harm: Potential for minimal harm
  • Scope: Many
• Reasonably accommodate the needs and preferences of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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
• 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: Some
• Post nurse staffing information/data on a daily basis
  • Harm: Potential for minimal harm
  • Scope: Many
• A two-hour-resistant firewall in common walls
  • Harm: Potential for minimal harm
  • Scope: Some
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Potential for minimal harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Many
• Protected exits that allow the resident to escape the building
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly located and lighted Exit signs
  • Harm: Potential for minimal harm
  • Scope: Many
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Potential for minimal harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Potential for minimal harm
  • Scope: Many
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Potential for minimal harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Many
• A two-hour-resistant firewall in common walls
  • Harm: Potential for minimal harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Potential for minimal harm
  • Scope: Many
• Proper stairway enclosures and vertical shafts
  • Harm: Potential for minimal harm
  • Scope: Many
• 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: Many
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly located and lighted Exit signs
  • Harm: Potential for minimal harm
  • Scope: Some
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved automatic sprinkler system connected to the fire alarm system
  • 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: Many
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Some
• Properly installed electrical wiring and equipment
  • Harm: Potential for minimal harm
  • Scope: Some
• Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
  • Harm: Potential for minimal harm
  • Scope: Many
• 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
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Potential for minimal harm
  • Scope: Many
• Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed
  • Harm: Potential for minimal harm
  • Scope: Many
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Some
• Provide housekeeping and maintenance services
  • 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
• 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
• Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
  • Harm: Minimal harm or potential for actual harm
  • 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: Some
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that a working call system is available in each resident's room or bathroom and bathing area
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure there is a pest control program to prevent/deal with mice, insects, or other pests
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some

Quality Measures