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Deficiency Records for Hendricks Community Hospital
View the most recent health deficiencies and inspection results for Hendricks Community Hospital. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Hendricks Community Hospital. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2025-04-30 | 2025-06-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2025-04-30 | 2025-06-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-04-30 | 2025-06-25 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-04-30 | 2025-06-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-04-30 | 2025-06-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2025-04-30 | 2025-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-30 | 2025-06-25 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-04-30 | 2025-06-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2025-04-30 | 2025-05-30 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2025-04-30 | 2025-05-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2025-04-30 | 2025-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-04-30 | 2025-05-21 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2025-04-30 | 2025-05-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-30 | 2024-07-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-30 | 2024-07-31 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-05-30 | 2024-07-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-30 | 2024-07-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-30 | 2024-07-31 | N |
| Have a Compliance and Ethics Program. | Health | 2024-05-30 | 2024-07-31 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-30 | 2024-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-30 | 2024-07-31 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-30 | 2024-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-19 | 2023-07-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-19 | 2023-07-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-19 | 2023-07-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-07-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-19 | 2023-07-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-19 | 2023-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-19 | 2023-07-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-05-30 | Not Fixed | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-19 | Not Fixed | N |