| 101 |
ELLEN SAGAR NURSING CENTER |
425012 |
1817 JONESVILLE HIGHWAY |
UNION |
SC |
29379 |
2017-08-16 |
225 |
G |
1 |
0 |
MGP911 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. RN #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because the resident had been up in wheelchair without a foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract. |
2020-09-01 |