PEMISCOT COUNTY MEMORIAL HOSPITAL MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
08/06/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
08/06/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/06/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
08/06/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
08/06/2009	post nurse staffing information.	Widespread	Potential for minimal harm
08/06/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
08/06/2009	Choose a doctor to be the medical director.	Widespread	Potential for minimal harm
08/06/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
08/06/2009	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
08/06/2009	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
08/21/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Let residents talk to and get information from agencies acting on their behalf.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/21/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Make sure that residents are well nourished.	Widespread	Minimal harm or potential for actual harm
08/21/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
08/21/2008	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
08/21/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
08/21/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Minimal harm or potential for actual harm
08/21/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
08/21/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
08/21/2008	Choose a doctor to be the medical director.	Widespread	Potential for minimal harm
08/21/2008	Keep complete, dated lab records in the resident's file.	Isolated	Minimal harm or potential for actual harm
08/21/2008	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
08/21/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Potential for minimal harm
08/21/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
08/21/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/21/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
08/21/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
08/21/2008	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
08/30/2007	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
08/30/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
08/30/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Pattern	Minimal harm or potential for actual harm
08/30/2007	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
08/30/2007	an automatic smoke detection system in all hallways.	Pattern	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death