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Summary of Findings San Ramon Hospital, Inc.: Infirmary

The document summarizes findings from a monitoring visit to San Ramon Hospital's infirmary. It identifies numerous deficiencies requiring correction, including inadequate nursing personnel, missing policies and documentation, lack of committee meetings and reports, and needed equipment. The hospital must submit additional documentation and hire more nurses to meet standards. Physical plant issues like the need for a PWD toilet and cadaver holding area are also noted. Full compliance will require addressing all findings.

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Karenina Victoria
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88 views2 pages

Summary of Findings San Ramon Hospital, Inc.: Infirmary

The document summarizes findings from a monitoring visit to San Ramon Hospital's infirmary. It identifies numerous deficiencies requiring correction, including inadequate nursing personnel, missing policies and documentation, lack of committee meetings and reports, and needed equipment. The hospital must submit additional documentation and hire more nurses to meet standards. Physical plant issues like the need for a PWD toilet and cadaver holding area are also noted. Full compliance will require addressing all findings.

Uploaded by

Karenina Victoria
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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SUMMARY OF FINDINGS

INFIRMARY
SAN RAMON HOSPITAL, INC.
38 Gen. Ordoñez St., Rancho 4, Marikina City

Date of Monitoring: July 24, 2018 FULL COMPLIANCE DATE: _____________________


Date Prepared: August 20, 2018 Evaluated by: _______________________________

VIOLATION: Inadequate personnel complement in the nursing service

FINDINGS:
 Submit policy addressing patient’s rights and proof of posted patient’s rights
 Photo of posted list of services at ER/OPD
 Proof of completely accomplished patient’s chart (with Partograph and Newborn record if applicable,
complete history and Physical Examination)
 Policy on medicine administration
 Proof of Clinical Practice Guidelines (CPG) (Top 5 cases of Admissions/Consultations)
 PRC license of Nurse Gapasin
 Submit incident report on Patient Asuncion re: medication record (ibuprofen on order but mefenamic acid was
given)
 Proof of discharge plan
 Photo of updated organizational chart, Vision, Mission, Goals
 Proof of Administrative Policies, Nursing Procedure Manuals
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging
Waste Management
Patient Safety
Infection Control
Emergency and Disaster Preparedness
CQI
Grievance
Selections and Promotions
 Proof of Annual accomplishment report
 Policies for Dietary, Linen/Laundry, Security of Patients.
 Valid Memorandum of Agreement with Waste Management Service, Ambulance, Security
 Policy for hiring, credentialing, and privileging of staff
 Presence of annual plan for training activities
 Proof of orientation conducted to new personnel
 Proof of Job descriptions with conforme
 Policy on record storage, safekeeping, maintenance, retention and disposal
 Policy of filing and retrieval of charts
 Policy to protect records and charts against loss, destruction, tampering and unauthorized used.
 Management plans addressing:
a. Safety
b. Security
c. Disposal and Control of Hazardous Wastes
d. Emergency and Disaster Preparedness
 Proof of preventive maintenance of equipment, presence of operating manuals of medical equipment
 Presence of sentinel event reporting system
 Proof of water analysis results (last 6 months)
 Certificate of Training (in-house) or MOA of personnel in-charge of maintenance of equipment
 Proof of designation of Infection Control Physician and Infection Control Nurse
 Policy for the prevention of hospital associated infections (use of PPEs, isolation precautions, and hand
washing)
 Policy for prevention and treatment of needle-stick injuries
 Policy for cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments, supplies
 Presence of policies in reporting of notifiable diseases
 Presence of Quality Improvement Program and proof of implementation
 Presence of Customer Satisfaction Survey and analysis
PROGRAMS
 Policy on generic prescribing
 Designation of HEMS Coordinator
 Newborn Screening for Hearing logbook
PERSONNEL
 Copy of the following:
- Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
- Medical records officer – Contract, trainings, ICD-10 trainings and Records Management Training
- Billing/Cashier – Contract, trainings
- Building maintenance/Utility worker - Contract, trainings
- Laundry Worker – contract
- Driver – driver’s license, contract
- Cook - contract
- Security guard – contract or MOA
- Nurse Supervisor – Diploma, valid PRC license, contract, Master’s Degree in Nursing or at least 9 units.
- NURSES – to hire additional 6 fulltime RNs (plus 3 reliever-optional) (currently 3 RNs are employed)
Nurse’s Name Diploma Valid PRC Contract/MOA

PHYSICAL PLANT REQUIREMENT


 Provision of PWD toilet
 No Kitchen – To submit MOA
 Provision of cadaver holding area
 Oxygen tanks with straps/anchor
 Provide area for storing oxygen and remove oxygen units at the hallway.
EQUIPMENT/INSTRUMENT
Submit photo and official receipt of the following:
ADMINISTRATIVE SERVICE KITCHEN
 Ambulance – MOA with ACECOR expired  No kitchen - Provide MOA
 Generator set housing
EMERGENCY ROOM DELIVERY ROOM
 Defibrillator  Oxygen tank with strap
LABOR ROOM CADAVER HOLDING AREA
 Oxygen unit with strap  Bed or stretcher for cadaver
NURSING UNIT/WARD  Epinephrine
 O2 tank  Morphine SO4 10mg/ampule
E-CART CONTENTS  Noradrenaline 2mg/ampule
 Amiodarone  Sodium bicarbonate 50mEq/ampule
 Atropine  Verapamil
 Benzodiazepine(diazepam)
 Diphenhydramine 250mg/ampule
 Dobutamine
 Dopamine

MONITORED BY:
Dr. Karen Lito
Cynthia Aldo
Abby

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