| 120 |
ELLEN SAGAR NURSING CENTER |
425012 |
1817 JONESVILLE HIGHWAY |
UNION |
SC |
29379 |
2019-11-10 |
656 |
D |
0 |
1 |
NAMT11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement the care plan for pressure ulcer risk and activities of daily living care for one of 20 sampled residents reviewed (Resident #37). The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. On 11/09/19 at 9:28 AM, Licensed Practical Nurse (LPN) #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated that someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. |
2020-09-01 |