cms_SC: 10264
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10264 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 514 | E | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 verified these blanks. Review of multiple Medication Flowsheets revealed that narcotic medications had been initialed as having been given when there was no documentation to corroborate this in the Narcotic and Hypnotic Record. There were also instances of medications being signed out on the Narcotic and Hypnotic Record, which were not documented on the Medication Flowsheet as having been given to the resident. The following documentation was reviewed and verified by Registered Nurse (RN) #2 on 10/17/2010. Review of Resident A's October 2010 Medication Flowsheet revealed an order dated 09/11/2010 that stated "[MEDICATION NAME] ([MEDICATION NAME])- Schedule IV Tablet; 0.5 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 4hrs PRN)". This was initialed on the front of the Medication Flowsheet as having been given on 10/10/2010 at 6:30 PM. On the back of the flowsheet, was an entry dated 10/10/10 that stated that [MEDICATION NAME] 0.5 mg had been given at 6:30 PM for agitation. However, the narcotic log documented that [MEDICATION NAME] 0.5 mg had only been signed out at 2 PM on 10/10/2010. There was nothing on the Medication Flowsheet to indicate the resident received any [MEDICATION NAME] at 2 PM. There was another separate entry that revealed that [MEDICATION NAME] 0.5 mg had been initialed as having been given on the Medication Flowsheet for 10/03/2010 at 9 PM, however, the Narcotic and Hypnotic Record did not have an entry for that date and time. Review of the Narcotic and Hypnotic Log for Resident A revealed "[MEDICATION NAME] 0.5 mg, Take 1 Tab by mouth every 4 hours as needed". Further review revealed that [MEDICATION NAME] 0.5 mg had been signed out on the log on 10/07/2010 at 9 AM and 10/15/2010 at 4:45 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Another order for Resident A, dated 09/21/2010, was listed on the Medication Flowsheet as "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab (tablet); Oral TID- Three Times A Day". The scheduled times were listed as 9 AM, 1 PM, and 9 PM. Review of the Medication Flowsheet revealed initials in the 10/06/2010, 9 PM square. However, review of the Narcotic and Hypnotic Record revealed that the medication had not been signed out for that date and time. There was another order dated 9/13/10 that stated "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab; Oral PRN-As Needed". Review of the Narcotic and Hypnotic Record revealed that the medication had been signed out on 10/03/2010 at 1700 but this had not been documented as having been given on the Medication Flowsheet. Review of Resident B's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record revealed that [MEDICATION NAME] 1 mg had been signed out on 10/11/2010 at 10 AM, 10/13/2010 at 9:30 AM, and on 10/16/2010 at 9 PM. However, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Review of Resident C's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for "[MEDICATION NAME] 10 mg Tablet SUB (Substitute) FOR: AMBIEN" revealed that the medication had been signed out on 10/16/2010 at 9 PM, however, the Medication Flowsheet was blank for that date and time. Review of Resident D's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for the medication revealed [MEDICATION NAME] 0.5 mg had been signed out on 10/3/2010 at 9 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at this time. Review of Resident E's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the resident's Narcotic and Hypnotic Record for "[MEDICATION NAME](one) W(ith) APAP 7.5-500 mg Tablet, Take 1 Tab by mouth every 4-6 hours as needed" revealed that the medication had been signed out on 10/9/2010 at 9 PM and on 10/11/2010 at 9 PM. The Medication Flowsheet, however, was blank and did not document any [MEDICATION NAME] as having been given for these dates. Review of Resident F's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Further review revealed another entry for "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III Tablet; 10-500 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 6hrs PRN)". Review of the Narcotic and Hypnotic Record for the medication revealed that the medication had been signed out on 10/09/2010 at 8 AM, 1:30 PM, and 5 PM only. The Medication Flowsheet for the PRN Hydocodone-[MEDICATION NAME] was blank and did not indicate a 5 PM dose had been given on this date. The nurse had initialed the medication as having been given on the routine (Three Times Daily) entry for 10/09/2010 at 9 AM, 1 PM, and 9 PM; however, there was no 9 PM entry on the narcotic log. Further review revealed this same medication had been signed out on the narcotic log on 10/11/2010 at 9AM, 1 PM, 5 PM, and 9 PM; however, there was no documentation on the Medication Flowsheet that a PRN dose had been given at 5 PM. | 2014-02-01 |