LTC Assgnt 3

Design Failure Mode and Effect Analysis Report 1

Assignment 3

HCAD 635

University of Maryland Global Campus

Introduction

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Design Failure Mode and Effect Analysis Report 2

Design Failure and Effects Analysis (DFMEA) is a structured way to identify and address

potential problems, or failures and their resulting effects on the system or process before an

adverse event occurs (CMS, 2020). For this assignment, I chose to research an Alzheimer’s Adult

Day Center and a Dementia Unit in a Skilled Nursing Facility located in Hawaii. Each facility

will help guide a walk through the DFMEA tool.

Aspect A: Introduction, State Residence, and Physical Plant Summaries

Identify the two types of secured units that you will research.

1. Alzheimer’s Adult Day Center.

2. Dementia Unit in a Skilled Nursing Facility.

Select a state residence to apply to your LTC settings.

 Hawaii.

Describe the following elements for each of the physical plants' descriptions: Number of

licensed beds or square footage of each LTC facility/setting.

1. Windward Senior Day Care Center has two adult day care centers located in Kailua,

Hawaii. The organization has licensed to care for a total of 69 full-time adult participants.

The center located at 77 North Kainalu Drive is 10,080 sq ft.

2. Oahu Care Facility is a dementia care facility in Honolulu, HI. Oahu Care Facility has a

capacity of 82 secure memory care units. The center located at 1808 S Beretania St is

10,660 sq ft.

The number of LTC residents served, or potential average daily census, of each LTC

facility/setting.

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Design Failure Mode and Effect Analysis Report 3

1. Windward - 34 residents.

2. Oahu – 74 residents.

Type of locking devices, secured devices, or means of egress used in each LTC

facility/setting.

1. Windward – fire exits and walkways, and windows, locked gate.

2. Oahu – Stairs, walkways, windows, and fire exits.

Other key physical plant description items for each LTC facility/setting.

1. Windward – Stand-alone facility, single floor, possibly a basement. Small outdoor

courtyard. 3-4 exits.

2. Oahu – Stand-alone facility, 3 floors possibly a basement, no outdoor space. 5-6 outside

doors (not including resident rooms) 1 garage entrance/exit.

Select one of the settings that you researched in Aspect A: Conduct a DFMEA drill, and

include at least two failure points for one of your selected LTC facility/settings from Aspect

A.

 Windward Senior Day Care Center o Process: Medication administration

 Failure #1 Delay in distribution of medication Causes:

 Poor staff rotation  Time constraints  Poor communication between staff and resident  Medication check process not in place.  Insufficient drug delivery system

o Severity: Risk of bleeding, risk of adverse drug event, high severe effect. 10 (On a scale of 1-10, with 1 being less severe and 10 being most serve).

o Probability: 3 (On a scale of 1-10, with 1 being less likely to occur and 10 being very likely to occur).

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Design Failure Mode and Effect Analysis Report 4

o Detection: 2 (On a scale of 1-10, with 1 being likely to detect and 10 being very unlikely to detect)

o facility/setting harm: Lower facility’s reputation, malpractice claims, and potential criminal charges.

 Recommendation  Medication profiles should be created for

each resident and reviewed on a monthly basis.

o Process: Wound Care  Failure #2 Improper wound care documentation

Causes:  Knowledge deficit  Lack of supporting staff training  Inefficient documentation process  Time constraints

o Severity: Risk of bleeding. 5 (On a scale of 1-10, with 1 being less severe and 10 being most serve).

o Probability. 3 (On a scale of 1-10, with 1 being less likely to occur and 10 being very likely to occur).

o Detection. 6 (On a scale of 1-10, with 1 being likely to detect and 10 being very unlikely to detect)

o facility/setting harm: wound-related lawsuits  Recommendation

 Weekly audits of wound care documentation will help minimize discrepancies.

Process Failure Causes Facility Effect

Severit y

Probabilit y

Design Control

Likelihoo d of detection

Recommendatio n

Action Taken

Medication administratio

Delay in distribution

•Poor staff rotation

malpractic e claims,

10 3 Preventio n

2 Medication profiles should

Medication profiles keep

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Design Failure Mode and Effect Analysis Report 5

n of medication •Time constraints •Poor communicatio n between staff and resident •Medication check process not in place. •Insufficient drug delivery system

and potential criminal charges. Required Medicatio n dosage missed.

be created for each resident and reviewed on a monthly basis. Additional employee medication training.

administratio n times/days in order.

Wound Care Improper wound care documentatio n

•Knowledge deficit •Lack of supporting staff training •Inefficient documentatio n process •Time constraints

wound- related lawsuits. Wound- related injuries due to poor wound care.

5 3 Preventio n

6 Weekly audits of wound care documentation.

This will help minimize any discrepancies .

Work Cited

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Design Failure Mode and Effect Analysis Report 6

Centers for Medicare & Medicaid Services. (2020). Guidance for performing failure mode and effects analysis with performance improvement projects.

Home. (n.d.). Windward Senior Day Care Center. Retrieved July 1, 2022, from http://www.windwardseniordaycarecenter.org/

Welcome. (2013, May 22). Oahu Care Facility. http://oahucarefacility.com/

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