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San Lorenzo Hospital Health Management

The document summarizes a monitoring visit to San Lorenzo Hospital's infirmary. It found the nursing staff was inadequately sized and identified other areas of non-compliance including lacking policies on patient rights, incomplete documentation of required committees, and a need to designate infection control staff. It also noted deficiencies in personnel records and contracts, and missing medical equipment in the emergency room that needed to be obtained and documented. The hospital was asked to address these issues and submit further documentation to achieve full compliance.

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Karenina Victoria
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160 views2 pages

San Lorenzo Hospital Health Management

The document summarizes a monitoring visit to San Lorenzo Hospital's infirmary. It found the nursing staff was inadequately sized and identified other areas of non-compliance including lacking policies on patient rights, incomplete documentation of required committees, and a need to designate infection control staff. It also noted deficiencies in personnel records and contracts, and missing medical equipment in the emergency room that needed to be obtained and documented. The hospital was asked to address these issues and submit further documentation to achieve full compliance.

Uploaded by

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

INFIRMARY
SAN LORENZO HOSPITAL HEALTH MGT. CO, INC (DEPARO)
24 Susano Rd., Brgy. 170 Zone 15, Deparo, Caloocan City 1420

Date of Monitoring: May 22, 2018 FULL COMPLIANCE DATE: _____________________

Date Prepared: August 22, 2018

VIOLATION: Inadequate personnel complement in the nursing service

LACKING COMPLIANCE:
 Submit policy addressing patient’s rights:
5. Right to care and security of personal belongings
6. Right to freedom from restraint
7. Right to freedom from abuse, mistreatment, etc.
 Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging   
Waste Management   x
Patient Safety   
Infection Control   x
Emergency and Disaster Preparedness   
CQI   x
Grievance   
Selections and Promotions   x
 Proof of designation of Infection Control Physician and Infection Control Nurse
PROGRAMS
 Designation of HEMS Coordinator
PERSONNEL
 Copy of the following:
- Medical records officer – Contract, trainings, ICD-10 trainings and Records Management Training
PHYSICIANS NURSES – to hire 4 fulltime nurses (plus 3 reliever-optional)
(Currently, 5 RNs are employed)

Doctor’s Name Diploma Valid PRC Contract/ Nurse’s Name Diploma Valid PRC Contract/MOA
MOA
Dr. Pascual x   Michelle Quintas x  x
Dr. Bautista x   Sherwin Go   
Rechely Medeza   
May Ann Ruiz x  x
Irene Santiago   
x
x
x
x
PHYSICAL PLANT REQUIREMENT
 No Kitchen – To provide MOA

EQUIPMENT/INSTRUMENT
Submit photo and official receipt of the following:

EMERGENCY ROOM
 Delivery set (2sets) - primigravid
- Metzenbaum scissors straight
- Mayo scissors straight
- Kelly hemostatic forceps
- Needle holder
- Tissue forceps

E-CART CONTENTS BASIC ER SUPPLIES


 Anti-rabies vaccine – passive  Sharps container(puncture-proof)
 Amiodarone  Splinting devices
 Aspirin USP grade 325mg/tablet
 Atropine
 Benzodiazepine(diazepam)
 Morphine SO4 10mg/ampule
 Phenobarbital 30mg/ml IV or 30mg tablet
 Pyridoxine 1g/ampule
 Tramadol

MONITORED BY:

Dr. Karen
Lito
Abby
Aldo

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