| 38 |
GUAM MEMORIAL HOSPITAL AUTHORITY |
655000 |
499 NORTH SABANA DRIVE |
BARRIGADA |
GU |
96913 |
2016-09-29 |
490 |
F |
0 |
1 |
H7FJ11 |
Based on observation, interview and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to enable residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings include: 1. During the survey, a food services director was not hired by the facility to ensure oversight and supervision of dietary services. Interview with staff revealed that while two dietetic technicians were available to the facility to provide coverage for two days of the week on Monday and Wednesday, it was unclear as to whether the technicians fulfilled the position of food services director. In addition, there was no documentation available to indicate that the technicians had adequate training and experience; that a food services director position description (or its equivalent) had been developed, and whether the dietetic technicians met the requirements. Further, while the facility had the services of a registered dietitian one day a week on Saturdays, there was no documentation that there was regularly scheduled consultations between the dietetic technicians and the registered dietitian to ensure effective communication; and that the needs of residents were being assessed and identified, and dietary outcomes were being met. (Cross-refer to F325 and F363.) 2. There was no indication that the facility had used its resources to ensure that vital appliances used in the kitchen to cook, prepare, and store food were in good operating condition. The kitchen's dishwashing machine, for example, had been out of order according to dietary staff, since the beginning of the year because of a broken booster pump. Review on 9/28/16 of the departmental requisition (dated 3/28/16) for the replacement of the dishwasher revealed that it was unprocessed and was returned (to Admin5) because of incomplete documentation and the amount of money requested that required additional information. During an interview on 9/28/16, an administrative staff member for hospital food services (Admin5) explained the many delays in procurement including the lack of bids received from vendors and her lack of familiarity with the requisition process and other requirements. In a letter dated 9/20/16, however, according to Admin5, a response from the supply management administrator revealed that the requisition was again returned (unprocessed) because of incomplete information on requisition and to prepare Scope of Work/Services and submit for FY2017. In the same interview, Admin 5 added that because of the impending fiscal year ending (on 9/30/16), the revised requisition will unlikely be acted upon until after the start of the fiscal year (YEAR) resulting in further delay. Admin5 added that the lack of funding was a major issue. Review of facility records revealed the lack of involvement by facility administrative staff in the requisition process so that procurement of a replacement dishwasher could be expedited. Review of a supplemental attachment dated 3/16/16 to the initial departmental requisition made revealed that the current dishwasher had exceeded (its) functional life and the booster heater is irreparable. The attachment noted further that the facility had been cited by Public Health because it (dishwasher) does not work properly. Repeat citations could force SNU (the facility) to close their kitchen. The delay in getting a replacement dishwasher had also resulted in residents of the facility being served meals using disposable food containers and plates and Styrofoam cups, and using plastic forks, spoons, and knives to eat over a extended period of time. In a separate interview on 9/28/16, MS1 stated that the dishwasher may have been broken in (MONTH) (YEAR), and remained out of order since. (Cross-refer to F241 and F456.) 3. Review of the personnel record revealed that the job description of the recreation therapy coordinator lacked documentation of training and experience to prepare and enable her to effectively coordinate the facility's activity program, supervise recreational technicians, and ensure that activities provided to residents were meaningful and met the residents' needs. 4. Review of facility documents including the organizational chart revealed that the facility (the skilled nursing distinct part) was a unit under the assistant administrator of nursing service, which was also under the associate administrator for clinical services. Further document review however revealed that the facility did not have an appointed facility administrator, as required under 483.75(d). While facility staff interviewed during the survey identified the hospital CEO as the administrator of the facility, the position description (of the hospital CEO) did not include specific duties and responsibilities for the facility, including ensuring that the facility was administered in a manner that allowed it to use its resources effectively and efficiently to enable residents to maintain their highest practicable level of physical, mental, and psychosocial well-being; and participation in quality assessment and performance improvement activities. 5. The facility did not have any documentation to indicate that an appointment was made to designate the director of nursing service. (Cross-refer to F354) |
2020-09-01 |