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