SIBLEY MEM HOSP RENAISSANCE - WASHINGTON, DC

Quality Measures

Complaint Deficiency

• 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: Few
• Signs that state that exit doors are to be kept closed
  • 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
• Provide housekeeping and maintenance services
  • 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
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • 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: Few
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Operate and provide services according to Federal, State, and local laws and professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • 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
• Corridor and hallway doors that block smoke
  • 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
• 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
• Provide housekeeping and maintenance services
  • 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: 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
• Provide necessary care and services to maintain the highest well being of each resident
  • 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: Few
• Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • 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: Few
• Operate and provide services according to Federal, State, and local laws and professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • 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: Minimal harm or potential for actual harm
  • Scope: Few
• 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: 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
• 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
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
  • 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: 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
• Keep all essential equipment working safely
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few

Staff Information