Intermountain Health Holy Rosary Hospital

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Provide safe, appropriate pain management for a resident who requires such services.

Implement a program that monitors antibiotic use.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Ensure that residents are fully informed and understand their health status, care and treatments.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Provide and implement an infection prevention and control program.

Ensure each resident receives an accurate assessment.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

Provide care or services that was trauma informed and/or culturally competent.