cms_SC
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45 rows where "inspection_date" is on date 2016-04-21
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Suggested facets: facility_name, facility_id, address, city, zip, scope_severity, complaint, standard, eventid, filedate, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4557 | 4557 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 156 | D | 0 | 1 | UKCX11 | Based on record review and interview, the facility failed to issue notices of Medicare non-coverage and/or liability notices in a timely manner to 2 of the 3 sampled residents reviewed. Residents #59 and #99 did not receive the required 48 hour notice of Medicare non-coverage. The findings included: During a review of notification of Medicare non-coverage and liability notices on 4-21-16 at 3:40 PM, the Business Office Manager verified the following: (I) Resident #99's end of service date was noted as 1/4/16. The CMS (Centers for Medicare and Medicaid Services) -NOMNC Notice of Medicare Non-Coverage and the Medicare Determination on Continued Stay-Skilled Nursing Facility (liability notice) were signed on 01/04/16, indicating the receipt of notification. (2) Resident #59's end of service date was noted as 3/4/16. The CMS -NOMNC Notice of Medicare Non-Coverage was signed but left undated. A letter was sent to the family indicating that the notice was given via telephone on 3/3/16. The Medicare Determination on Continued Stay-Skilled Nursing Facility (liability notice) also indicated that notice was given via telephone on 3/3/16. | 2019-11-01 |
| 4558 | 4558 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 159 | D | 0 | 1 | UKCX11 | Based on review of Resident Trust records and interview, the facility failed to ensure that two of two residents reviewed for resident funds received quarterly statements and had access to their monies on the weekends. Residents #103 and #49 were unaware of the availability of Resident Trust monies on weekends. Quarterly statements were sent to family members instead of to these residents who were cognitively intact. One of 1 resident reviewed did not have authorization for specific deductions made from the Resident Trust account (Resident #103). In addition, based on review of Resident Trust records and interview, there was no evidence that 3 of 4 Medicaid recipients with balances over $2000 were notified of potential loss of eligibility. The findings included: During an interview on 4/18/2016 at 2:48 PM, Resident #103 was asked, Can you get your money when you need it, including on weekends? The resident responded, It's hard to get money on weekends. The office is closed. When asked the same question on 4/18/2016 at 3:36 PM, Resident #49 stated that monies were not available on the weekends. Review of the admission packet on 4-20-16 revealed no notification of accessibility to funds. During an interview on 4-21-16 at 3:42 PM, the Business Office Manager (BOM) stated that money was kept on the East Wing for weekend use. They know they can get money on the weekend. When asked how residents had been notified, s/he responded, Resident Council. Review of the prior 6 months (11-15 through 4-16) Resident Council minutes revealed that availability of funds on weekends had not been listed as a topic of discussion. Residents #49 and #103 were not listed in attendance. During further interviews on 4/18/2016 at 3:36 PM, Resident #49 was asked, Does the facility let you know how much money you have in your account? Resident #49 stated, I don't get a quarterly statement but if you ask, they'll tell you. During review of Resident #49's and #103's accounts with the BOM on 4-21-16 at 5 PM, s/he confirmed that the last 3 quarter… | 2019-11-01 |
| 4559 | 4559 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 160 | B | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Trust account and interview, the facility failed to convey the personal funds and a final accounting upon death within 30 days to the named executor or probate jurisdiction administering the individuals' estates for 2 of 3 expired residents. One of the three sampled residents (Resident #149) reviewed had funds which were not released within 30 days. One of the 3 sampled residents reviewed (Resident #24) had a cash balance issued to an unauthorized family member. The findings included: A closed record review of personal funds was conducted on [DATE] at 3:42 PM with the Business Office Manager (BOM). Review of the Admit/Discharge Report for [DATE] through [DATE] revealed that Resident #149 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $394.36 issued via check #1164 to close the trust account on [DATE]. The date of issue was verified by the BOM. Review of the Admit)Discharge Report revealed that Resident #24 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $38.00 issued via cash ticket #245 to CASH TO RESIDENT which closed the trust account on [DATE]. Review of the Resident Trust Petty Cash Withdrawal Sheet with the BOM revealed that an individual signed receipt for the $38 remaining in the account. The BOM was unable to provide evidence that the monies were received by a named executor or a person authorized by the court. | 2019-11-01 |
| 4560 | 4560 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 241 | E | 0 | 1 | UKCX11 | Based on observation and interview the facility failed to offer or provide glasses for residents during the meal service at both breakfast and lunch. Residents were served milk or liquid supplements in cartons or cans. Observations were made on one unit during meal time and the Nutrition Services Director confirmed this was the facility practice unless requested by a resident. The findings included: During observation of the noon meal on B Hall on 4-18-16 at 12:37 PM, no glasses were provided on trays for residents who were served milk in cartons or supplements in cans. Certified Nursing Assistants did not offer glasses as residents were served. During observation of the breakfast meal on B Hall on 4-19-16 at 8:39 AM, no glasses were provided on trays for residents who were served milk in cartons or supplements in cans. The same was observed on C hall at 8:52 AM. On 04/18/2016 at 11:56 AM, during the lunch observation, a Certified Nursing Assistant (CNA) opened a milk carton for a resident. There was no glass provided and the CNA did not offer to obtain one for the resident. During an interview on 4/20/2016 at approximately 2:00 PM, when asked if glasses were offered for milk, the Nutrition Services Director (NSD) stated; We will provide glasses if the resident requests. | 2019-11-01 |
| 4561 | 4561 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 250 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to identify and address the needs of 1 of 4 sampled residents reviewed for social services. There was no evidence of social service intervention for Resident #41 related to refusal of medication and wound care interventions. There was no evidence of provision of needed counseling services regarding behavior and/or health care choices that could potentially result in adverse consequences. The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Interview on 4/18/2016 at 12:06 PM with Licensed Practical Nurse (LPN) #6 revealed that Resident #41 was admitted with Stage 4 pressure ulcers on the left lateral ischium and the right ischium. Review of the 3-15-16 Quarterly Minimum Data Set Assessment at 10:12 AM on 4-20-16 revealed that the resident had a Brief Interview for Mental Status score of 15, indicating s/he was cognitively intact. S/he required extensive assistance for bed mobility and transfers. No MDS Assessments on file noted refusal/rejection of care. Record review on 4-20-16 at 9:50 AM revealed that the resident was being treated at the hospital at the Advanced Wound Healing & Hyperbaric Center. Review of the 4-8-16 report revealed that Resident #41 had recently resolved an unstageable necrotic pressure ulcer on the left lateral ankle and an area of suspected deep tissue injury (pressure ulcer) on the right medial great toe. The resident was noted as insensate in these areas-unable to feel pain. The Stage 4 pressure ulcer on the left lateral ischium had muscle exposed and measured 9 X 17 X 2 centimeters (cm). The Stage 4 pressure ulcer on the right ischium had muscle, bone, and joint exposed and measured 8 X 10.9 X 2.1 cm. Both ischial ulcers had tunneling and undermining. Wound care orders for 3-18-16 and 4-8-16 included Prevalon Boots to be worn at all times-bilateral and limit time in wheelchair to 1 h(ou)r BID (twice daily) maximum. Multiple obse… | 2019-11-01 |
| 4562 | 4562 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 279 | E | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop care plans for 2 of 3 sampled residents reviewed with limited range of motion (ROM) and existing contractures to prevent further decline. Care plans for Residents #51 and #52 did not address contractures with measurable goals and specific interventions to prevent further decline. In addition, based on observation, record review and interview, the facility failed to develop a care plan for 1 of 1 sampled resident reviewed for refusal of care and services. The care plan for Resident #41 did not address refusal of medication and wound care. The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Interview on 4/18/2016 at 12:06 PM with Licensed Practical Nurse (LPN) #6 revealed that Resident #41 was admitted with Stage 4 pressure ulcers on the left lateral ischium and the right ischium. Review of the 3-15-16 Quarterly Minimum Data Set (MDS) Assessment at 10:12 AM on 4-20-16 revealed that the resident had a Brief Interview for Mental Status score of 15, indicating s/he was cognitively intact. S/he required extensive assistance for bed mobility and transfers. No MDS Assessments on file noted refusal/rejection of care. Record review on 4-20-16 at 9:50 AM revealed that the resident was being treated at the hospital at the Advanced Wound Healing & Hyperbaric Center. Review of the 4-8-16 report revealed that Resident #41 had recently resolved an unstageable necrotic pressure ulcer on the left lateral ankle and an area of suspected deep tissue injury (pressure ulcer) on the right medial great toe. The resident was noted as insensate in these areas-unable to feel pain. The Stage 4 pressure ulcer on the left lateral ischium had muscle exposed and measured 9 X 17 X 2 centimeters (cm). The Stage 4 pressure ulcer on the right ischium had muscle, bone, and joint exposed and measured 8 X 10.9 X 2.1 cm. Both ischial ulcers had tunneling and undermining… | 2019-11-01 |
| 4563 | 4563 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 282 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the care plan was followed to minimize injury related to falls for one of two sampled residents reviewed for falls. Resident #51 did not have floor mats in place for 2 of the 4 days of the survey. The facility also failed to ensure that the care plan was followed related to prevention of pressure sores for one of three sampled residents reviewed for pressure ulcers. Heel protectors were not in place as ordered and care planned for Resident #51. The findings included: The facility admitted Resident #51 with [DIAGNOSES REDACTED]. Review of the 4-5-16 Quarterly Minimum Data Set Assessment at 2:28 PM on 4-20-16 revealed that Resident #51 had impaired ROM on 1 side, both upper and lower extremities, and was totally dependent for bed mobility. Record review on 4-20-16 at 12:49 PM revealed physician's orders [REDACTED].at all times and Bilateral heel protectors at all times. Review of the Care Plan at 3:05 PM on 4-20-16 revealed that it addressed potential for skin breakdown and included an intervention to apply bilateral heel protectors at all times. Problems also included that the resident had a history of [REDACTED]. Multiple observations on 4-18-16 (at 11:09 AM, 2:04 PM, 4:09 PM, and 5:15 PM) and 4-19-16 (at 8:17 AM, 9:32 AM, and 3:30 PM) revealed Resident #51 in bed with no floor mats in place. Multiple observations on 4-18-16 (at 11:09 AM, 2:04 PM, 4:09 PM, and 5:15 PM), 4-19-16 (at 8:17 AM, 9:32 AM, and 3:30 PM), and 4-20-16 (at 9:18 AM and 4 PM) revealed Resident #51 in bed with no heel protectors in place. None were visible in the resident's room. During an interview on 4-20-16 at 9:18 AM, when asked about the floor mats, Certified Nursing Assistant (CNA) #4 stated, They were probably cleaning them. During an interview on 4-20-16 at 4:32 PM, when asked how the CNAs knew what care was to be provided, the Assistant Director of Nurses referred to a reference list kept at … | 2019-11-01 |
| 4564 | 4564 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 309 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to assure that the physician orders [REDACTED]. Resident #37 received fluids in excess of the amounts calculated for dietary to provide for 2 meals. In addition, 2 of 2 residents sampled (#52 & #102) were not assessed to rule out pain or other causal factors prior to administration of an antipsychotic medication. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. A record review on 4/21/2016 at approximately 2:00 PM for resident #37 revealed physician orders [REDACTED]. A review of the I & O Records from 2/1/2016 to 4/20/2016 revealed 7 days where total fluid exceeded 1200 cc for the day. On 4/20/16 at approximately 11:30 am, a review of the Fluid Restriction Worksheet located in Medical Administration Record (MAR) had been completed on and signed on 6/17/15 by the Nutrition Services Director (NSD) and the Registered Dietitian (RD) which had entries made for 1200 cc total daily fluid restriction; 600 cc from nutrition services and 600 cc from nursing. The Fluid Restriction Worksheet further stated; The following fluids will be provided via nutrition services: Breakfast, 4 oz skim milk, total 120cc; Snack Nepro 210 cc, total 210 cc, Lunch 4oz water; total 120 cc, and Dinner 5 oz water; total 150cc. On 04/20/2016 at 12:30 PM an observation of resident #37 lunch tray served revealed resident received an 8 ounce cup of water on his/her tray and the tray ticket on tray with printed instructions: Water-4 ounces . On 04/21/2016 at 8:31 AM, an observation of the breakfast tray, revealed resident received an 8 ounce carton of skim milk on his/her tray and the tray ticket with printed instructions: Skim Milk-1/2 cup An interview on 4/20/16 at 11:15 AM with the NSD regarding the process for residents with fluid restrictions ordered, s/he said a Fluid Restriction Worksheet is calculated by Registered Dietitian (RD) after reviewing with the nursing … | 2019-11-01 |
| 4565 | 4565 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 314 | E | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide care and services to promote the prevention of pressure ulcer development and/or promote the healing of existing pressure ulcers for 3 of 3 sampled residents reviewed for pressure ulcers. Prevalon boots were not applied as ordered for Resident #52. Resident #51 had no heel protectors in place as ordered. Wound care orders were not initiated for Resident #41 and there was no evidence of refusal of care with interventions implemented for same. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Review of Wound Treatment & Progress Records at 2;18 PM on 4-19-20 revealed that the resident had a history of [REDACTED]. Record review on 4-19-16 at 2:24 PM revealed physician's orders [REDACTED]. Review of the 2-2-16 Annual Minimum Data Set (MDS) Assessment on 4-21-16 at 10:55 AM revealed that the resident was totally dependent for bed mobility. Multiple observations on 4-18-16 (at 12:26 PM, 2:03 PM, and 3:52 PM) and 4-19-16 (at 8:15 AM, 9:15 AM, and 2:45 PM) revealed Resident #52 without the Prevalon Boots in place as ordered. None were visible in the resident's room. During an observation on 4-19-16 at 2:45 PM, Licensed Practical Nurse (LPN) #5 confirmed that the Prevalon Boots were not in place and verified the order that they were to be on at all times. Scars were observed on feet and ankles. LPN #5 checked the closet, but was unable to locate the Prevalon boots in the resident's room. The LPN confirmed that the physician's orders [REDACTED]. Further record review revealed that the facility had assessed the resident with potential for skin breakdown related to incontinence and impaired mobility. Care Plan interventions included bilateral prevalon boots at all times under a problem related to ADL's (Activities of Daily Living)/Vision/Dental. The facility admitted Resident #51 with [DIAGNOSES REDACTED]. Record review on 4-20-16 at 12… | 2019-11-01 |
| 4566 | 4566 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 318 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that 2 of 3 sampled residents reviewed with limited range of motion (ROM) and existing contractures were provided services to prevent further decline. Resident #52 was not positioned to prevent further contractures and no handrolls were observed in place as ordered. Resident #51 had no evidence of provision of ROM or use of hand rolls to prevent further decline. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Multiple observations on 4-18-16 (at 12:26 PM, 2:03 PM, and 3:52 PM) and 4-19-16 (at 8:15 AM, 9:15 AM, and 3 PM), revealed Resident #52 with contractures of the neck, left arm and hand, and bilateral knees. No handroll, splint or positioning devices were observed in place to address the contractures. Review of the 2-2-16 Annual Minimum Data Set (MDS) Assessment on 4-21-16 at 10:55 AM revealed that Resident #52 had impaired ROM on both sides, both upper and lower extremities. On 4-19-16 at 2:45 PM, Licensed Practical Nurse (LPN) #5 and the surveyor observed Resident #52 in bed with no positioning pillows between the resident's severely contracted legs or positioning pillows/devices to prevent further contractures of the knees, arm, or hands. The LPN stated that the resident was not positioned correctly and immediately addressed it with Certified Nursing Assistant (CNA) #4 who was in attendance. Record review on 4-19-16 at 2:24 PM revealed physician's orders [REDACTED]. During an observation on 4-19-16 at 3 PM, CNA #4 and LPN #5 verified that handrolls were not in place. Upon investigation, the CNA found one in the back of the top drawer of the bedside stand and one on the top shelf of the closet. The LPN confirmed that the physician's orders [REDACTED]. Further record review revealed that the Care Plan addressed pain related to contractures, but there was no care plan developed with specific goals and interventions for con… | 2019-11-01 |
| 4567 | 4567 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 323 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F323 Based on record review and interview, the facility failed to provide interventions to prevent accidents and minimize potential injury to one of two sampled residents reviewed for falls. Resident #51 did not have floor mats in place for 2 of the 4 days of the survey. The findings included: The facility admitted Resident #51 with [DIAGNOSES REDACTED]. Review of the 4-5-16 Quarterly Minimum Data Set Assessment at 2:28 PM on 4-20-16 revealed that Resident #51 had impaired ROM on 1 side, both upper and lower extremities. Record review on 4-20-16 at 12:49 PM revealed physician's orders [REDACTED].at all times. Multiple observations on 4-18-16 (at 11:09 AM, 2:04 PM, 4:09 PM, and 5:15 PM) and 4-19-16 (at 8:17 AM, 9:32 AM, and 3:30 PM) revealed Resident #51 in bed with no floor mats in place. During an interview on 4-20-16 at 9:18 AM, when asked about the floor mats, Certified Nursing Assistant (CNA) #4 stated, They were probably cleaning them. During an interview on 4-20-16 at 4:32 PM, when asked how the CNAs knew what care was to be provided, the Assistant Director of Nurses referred to a reference list kept at the nursing station. Review of the list revealed instructions for floor mats x 2. During an interview on 4-20-16, the Director of Nurses agreed that alternate mats should be replaced when the resident's are removed for cleaning | 2019-11-01 |
| 4568 | 4568 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 329 | D | 0 | 1 | UKCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that an assessment to determine the underlying cause of behavior was completed and non-pharmacological interventions were attempted prior to administration of antipsychotic medication for one of 5 sampled residents reviewed for unnecessary medication. Resident #52 exhibited verbal behavior and was placed on daily [MEDICATION NAME] without attempts at non-pharmacological interventions to assess/determine the root cause. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Review of the 2-2-16 Annual Minimum Data Set (MDS) Assessment on 4-21-16 at 10:55 AM revealed that Resident #52 had unclear speech, rarely or never understood/understands, and had exhibited no behaviors in the 7 day look-back period. Review of MDS Assessments completed on 10-26-15, 11-11-16, 11-23-16, 12-28-16, and 2-2-16 revealed the resident had not been coded as receiving any psychoactive medications. Observation on 4-18-16 at 12:26 PM revealed Resident #52 with multiple severe contractures of extremities seated in a reclining gerichair in the day room. Periodically the resident would exhibit a pained expression/grimace and would yell out without evidence of external stimulation. S/he would also yell out when coughing. Staff in the room failed to address the behavior. Review of 2-16, 3-16, and 4-16 Nurse's Notes and Behavior/Intervention Monthly Flow Records on 4-19-16 at 3:15 PM revealed no documented behaviors until 4-14-16. Review of Nurse's Notes on 4-21-16 at 11:12 AM revealed entries at 9 AM and 9:30 AM on 4-14-16 when the resident was yelling out inappropriately + refusing care and (with) profanity. The physician saw Resident #52 and wrote an order for [REDACTED]. There was no evidence of assessment to determine the underlying cause of the behavior or attempts to implement any interventions prior to administration of the antipsychotic drug. Although the resident was … | 2019-11-01 |
| 4569 | 4569 | SAINT MATTHEWS HEALTH CARE, LLC | 425170 | 601 DANTZLER STREET | SAINT MATTHEWS | SC | 29135 | 2016-04-21 | 372 | D | 0 | 1 | UKCX11 | Based on observation, interview, and review of the Food Code 2013, the facility failed to assure that one of one outdoor oil refuse storage unit was placed on a surface that was constructed of nonabsorbent material. The outdoor oil refuse storage unit was stored directly on a grass surface. The findings included: Observation on 4/20/2016 at 12:12 PM revealed the outdoor refuse storage unit for oil was located directly upon a grass surface. On 4/21/2016 at approximately 4:00 pm, an interview with the Dietary Manager revealed that s/he was aware of the placement of the unit. The Dietary Manager stated that the Maintenance department in the facility made arrangements for the placement of the unit. The Food Code 2013 states: 5-501.11 Outdoor Storage Surface. An outdoor storage surface for REFUSE, recyclables, and returnables shall be constructed of nonabsorbent material such as concrete or asphalt and shall be SMOOTH, durable, and sloped to drain. | 2019-11-01 |
| 4702 | 4702 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 157 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Notification, Physician or Responsible Party, the facility failed to notify the physician of Resident #100 refusing [MEDICAL TREATMENT] and fingerstick blood sugars not done as ordered for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility failed to notify the physician of the unavailability of ordered medications for Resident #8. The facility further failed to notify the physician of missed doses of medications for Resident #186 for 2 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review on 4/20/2016 at approximately 10:49 AM of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Further review on 4/20/2016 at approximately 10:49 AM of the MAR for (MONTH) (YEAR) revealed K-Phos No 2 tablet 350-700 mg to be administered at 9:00 AM on 2/15/2016, 2/16/2016, 2/17/2016, 2/18/2016 and 2/19/2016 was not given. The 1:00 PM dose of this medication was not administered on 2/16/2016, 2/17/2016, 2/18/2016 and 2/19/2016. The 5:00 PM dose was not administered for 2/17/2016, 2/18/2016 and 2/19/2016. The 9:00 PM dose on 2/19/2017 was not administered. During even further review of the MARs on 4/20/2016 at approximately 10:55 AM revealed a MAR indicated [REDACTED]. Review on 4/20/2016 at approximately 2:00 PM of the nurses notes dated 2/06/2016 and 2/8/2016 states,[MEDICATION NAME] 1 mg, not available from pharmacy. The nurses notes dated 2/15/2016 states the K-Phos No 2 Tablet is not available from pharmacy. On 2/16/2016 the nurses note states, pharmacy will fill, and not available from pharmacy. On 2/17/2016 and 2/18/2016 the nurses note states, medication not available. On 2/19/2017 the nurses note states, not available, will call pharmacy again. Further review of the nurses notes on 4/20/2016 at approximately 2:00 PM revealed a note on 3/7/… | 2019-09-01 |
| 4703 | 4703 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 224 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to protect residents from abuse for one of one resident's (#178) coerced without an investigation or report to state agencies. One of one residents (resident #69) with misappropriation of funds, without a thorough investigation and 2 residents with allegations of abuse that were not reported to state agency. The findings included: During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for aski… | 2019-09-01 |
| 4704 | 4704 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 226 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct an investigation and report allegations of abuse for 1 of 1 residents the facility identified a concern with (resident # 178). The facility failed to report and provide a thorough investigation of 2 of 2 random allegations of abuse reported to them by the surveyor. The findings included: Cross refer to F 224. Preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not included an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of… | 2019-09-01 |
| 4705 | 4705 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 248 | D | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interview and review of activity attendance sheets, the facility failed to provide an ongoing program of activities designed to meet the interests, and the physical, mental and psychosocial well being for Resident #2 for 1 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observations made on the first 2 days of the survey, 4/11/2016 and 4/12/2016 revealed the resident in his/her room with no activities to meet his/her interest. Review on 4/22/2016 at approximately 3:15 PM of the Activity - Admission Evaluation revealed current activity interest for Resident #2 that includes games such as cards, word trivia and bingo. He/she also enjoys puzzles, exercise groups, television sports and music. He/she enjoys reading, Spiritual and Religious activities with groups and enjoys trips, gardening, and going out of doors. He/she also enjoys pets and socializing. No documentation could be found where Resident #2 was offered any of the activities of his/her interest or encouraged to attend any activities at all. Review on 4/22/2016 at approximately 5:00 PM of the Comprehensive Plan of Care did not include activities of any kind for Resident #2. Review on 4/22/2016 at approximately 5:00 PM of the activity attendance sheets included the dates from 1/29/2016 through 2/3/2016 but none from the current admission for Resident #2. During an interview on 4/22/2016 at approximately 5:10 PM with the Activity Director he/she stated, he/she has not attended any out of room activities since the readmission. We are doing in room activities for this resident. The activity director could not provide documentation for any in room activities. | 2019-09-01 |
| 4706 | 4706 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 279 | D | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a Comprehensive Plan of Care with goals and interventions for an ongoing program of activities to meet the interest, and the physical, mental and psychosocial well being of each resident. Resident #2 was not provided activities of interest for 1 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observations made on the first 2 days of the survey, 4/11/2016 and 4/12/2016 revealed Resident in his/her room with no activities to meet his/her interest. Review on 4/22/2016 at approximately 3:15 PM of the Activity - Admission Evaluation revealed current activity interest for Resident #2 that includes games such as cards, word trivia and bingo. He/she also enjoys puzzles, exercise groups, television sports and music. He/she enjoys reading, Spiritual and Religious activities with groups. He/she enjoys trips, gardening, and going out of doors. He/she also enjoys pets and socializing. No documentation could be found where Resident #2 was offered any of the activities of his/her interest or encouraged to attend any activities at all. Review on 4/22/2016 at approximately 5:00 PM of the Comprehensive Plan of Care did not include activities of any kind for Resident #2. During an interview on 4/22/2016 at approximately 5:30 PM with the Care Plan Coordinator/Director of Nursing in training, verified that the Comprehensive Plan of Care did not include activities for Resident #2. | 2019-09-01 |
| 4707 | 4707 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 280 | D | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to afford the opportunity to the resident and/or responsible party to participate in the care plan process for 2 of 3 residents reviewed for care plan participation.(Residents #211 & #197) The findings included: The facility admitted Resident #211 with [DIAGNOSES REDACTED]. During an individual interview with Resident #211, on 4/19/16 at 1:58 PM, he/she stated a care plan meeting was conducted and he/she was not invited which made the resident feet left out. During an interview with the Care Plan Coordinator (CPC) on 4/23/16 at 11:49 AM, the CPC stated a 72 hour meeting had been scheduled and the resident's parents did not want him/her in attendance. On 4/23/16 at 11:59 AM, during an interview with Social Services (SS), SS stated during a 72 hour meeting items such as discharge planning, applying for Medicaid and insurance is discussed. SS further stated the resident's parents did not want the resident to attend this meeting. No documentation could be provided related to the parents wishes for the resident not to attend the meeting. During the survey process, a policy was not provided related to invitation to care plan meetings and the care plan process. The facility admitted Resident #197 with [DIAGNOSES REDACTED]. During an interview on 4/18/2016, Resident # 197 reported that he/she was not included in decisions concerning his/her medications, therapy or other treatments. Resident #197 also reported at that time that he/she had not been invited to attend or participate in a Care Planning Conference. During an interview on 4/23/2016 at approximately 10:46 AM with the Care Plan Coordinator/Director of Nursing in training, he/she stated, if a resident is short term they are included in a care plan conference along with the family. The meeting is arranged by the receptionist and the meeting is called a 72 hour meeting. No documentation could be found that Resident #197 nor his/her family… | 2019-09-01 |
| 4708 | 4708 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 282 | D | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to follow the Comprehensive Plan of Care related to ensuring a 1200 milliliter daily fluid restriction was followed. The facility further failed to monitor the input and output for Resident #100 for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review on 4/19/2016 at approximately 7:00 PM of the physician telephone orders revealed an order dated 2/22/2016 which read, Fluid restriction 1200 milliliters (mls), daily for End Stage [MEDICAL CONDITION]. During an interview on 4/19/2016 at approximately 7:00 PM Licensed Practical Nurse # 1 confirmed that the fluid restriction was not being followed per the physician's orders [REDACTED].#100 was taking in more than the ordered 1200 mls daily. Review on 4/20/2016 at approximately 4:05 PM of the Comprehensive Plan of Care dated 2/23/2016 and revised on 3/20/2016 and included interventions to encourage to follow fluid restriction as ordered 1200 mls daily. Also included on the care plan was an intervention to, Monitor intake and output. No documentation could be found to ensure the fluid restriction was being followed nor documentation for the correct input and output. | 2019-09-01 |
| 4709 | 4709 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 309 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Encouraging and Restricting Fluids, the facility failed to ensure a 1200 milliliter daily fluid restriction was followed per a physician's order. The facility further failed to monitor the input and output for Resident #100 for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review on 4/19/2016 at approximately 7:00 PM of the physician telephone orders revealed an order dated 2/22/2016 which read, Fluid restriction 1200 milliliters (mls), daily for End Stage [MEDICAL CONDITION]. During an interview on 4/19/2016 at approximately 7:00 PM Licensed Practical Nurse # 1 confirmed that the fluid restriction was not being followed per the physician's order and confirmed that Resident #100 was taking in more that the ordered 1200 mls daily. Review on 4/19/2016 at approximately 7:08 PM of the Medication Administration Record [REDACTED]. The fluid intake on 4/5/2016 was 1650 mls, 4/6/2016 the intake was 1650, on 4/7/2016 the intake was 1320 and on 4/10/2016 the fluid intake was 1400 mls. Further review on 4/19/2016 at approximately 7:08 PM revealed a MAR for (MONTH) (YEAR). On 3/28/2016 the intake of fluid was recorded as 3060 mls and 1740 mls on 3/29/2016. The MAR for (MONTH) revealed on 2/24/2016 the intake of fluid was 1625 mls and on 2/25/2016 the intake of fluid was 2050 mls. No measurements of urine could be found in the medical record for Resident #100, just continent episodes. Review on 4/20/2016 at approximately 7:15 PM of the guidelines for fluid restrictions of 1200 mls per day revealed breakfast 240 mls, Lunch 240 mls and Supper 240 mls. During medication administration Resident #100 could consume 150 mls with the 7 to 3 shift, 120 mls with the 3 to 11 shift and 120 mls with the 11 to 7 shift. The guidelines also stated that the resident may have 3 ounces/90 mls of fluids per shi… | 2019-09-01 |
| 4710 | 4710 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 323 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide supervision for the safety of the residents. Resident #178 was visited in the middle of the night by someone s/he did not know, and instructed to sign a paper. The resident was told to not tell anyone about the paper and not to tell ayone about the visit. The findings included: Cross refer to F224- Prevention, investigation and reporting abuse/neglect and misappropriation of funds. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was o… | 2019-09-01 |
| 4711 | 4711 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 328 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure residents received the proper treatment and care for 3 of 3 residents reviewed for respiratory services. (Resident #5, Resident #117, and Resident #160) The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED].in the evening every Sun . Observation on 4/18/16 at approximately 11:00 AM revealed the oxygen concentrator was in use. Further observation revealed that the filter on the left side of the concentrator was missing, and the filter on the right side of the oxygen concentrator was heavily soiled with a white-colored substance on the surface of the filter. Further observations on 4/19/16 at approximately 4:00 PM and 4/20/16 at approximately 10:30 AM revealed the same findings. Review of the Medication Administration Record [REDACTED]. The Director of Nursing in Training confirmed these findings with the surveyor on 4/23/16 at approximately 11:00 AM. The surveyor informed the staff member that these findings were first observed upon entry to the facility on [DATE]. The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observation on 4/18/16 at approximately 1:00 PM revealed Resident #117 resting in bed with the oxygen concentrator in use. Further observation revealed the filters on both sides of the oxygen concentrator were heavily soiled with a white-colored substance. Additional observations on 4/19/16 at approximately 11:00 AM and 4/20/16 at approximately 10:30 AM revealed the same findings. The Director of Nursing in Training confirmed these findings with the surveyor on 4/23/16 at approximately 11:00 AM. The surveyor informed the staff member that these findings were first observed upon entry to the facility on [DATE]. The facility admitted Resident #160 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDA… | 2019-09-01 |
| 4712 | 4712 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 332 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policies titled Administering Medications, Insulin Pen Delivery Device for Diabetes Care and Crushing Medications, the facility failed to maintain a medication error rate of less than 5 percent. There were 6 errors out of 26 opportunities for error resulting in a medication error rate of 23.07%. The findings included: Error #1 The facility admitted Resident #116 with [DIAGNOSES REDACTED]. On 4/21/16 at approximately 10:45 AM, during medication administration to Resident #116, Registered Nurse(RN)#1 was observed to administer [MEDICATION NAME] 800 milligrams(mgs). Record review revealed [MEDICATION NAME] was to be administered four times a day 9 AM, 1 PM, 5 PM and 9 PM. Resident #116 received the medication 1 hour and 45 minutes past the standard time frame of administration. Error #2 The facility admitted Resident #56 with [DIAGNOSES REDACTED]. On 4/21/16 at 11:17 AM, during medication administration to Resident #56, RN#3 administered Humalog 5 units via [MEDICATION NAME]. Prior to administration, RN#3 was asked was there anything to be done to the pen prior to administration in which he/she answered no. Prior to the administration of the insulin, RN #3 did not prime the pen nor did he/she leave the pen needle in for 6-10 seconds as required. Error #3-6 The facility admitted Resident #186 with [DIAGNOSES REDACTED]. On 4/22/16 at 9:02 AM, during medication administration to Resident #186, Licensed Practical Nurse #4 crushed the am medications to be administered which included [MEDICATION NAME] 5 mg delayed release, [MEDICATION NAME] Succ. ER 200 mg, [MEDICATION NAME] 67 mg and Dilitiazem ER 180 mg. Prior to crushing the medications, LPN#4 stated due to the resident having Dementia, all medications were crushed. Review of the facility policy titled Administering Medications revealed under item #4 the following: Medications must be administered within one (1) hour of their… | 2019-09-01 |
| 4713 | 4713 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 333 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policies titled Administering Medications, Insulin Pen Delivery Device for Diabetes Care and Crushing Medications, the facility failed to ensure that it was free of significant medication errors. There was six significant medication errors out of 26 opportunities for error observed during medication pass. The findings included: The facility admitted Resident #116 with [DIAGNOSES REDACTED]. On 4/21/16 at approximately 10:45 AM, during medication administration to Resident #116, Registered Nurse(RN)#1 was observed to administer [MEDICATION NAME] 800 milligrams(mgs). Record review revealed [MEDICATION NAME] was to be administered four times a day 9 AM, 1 PM, 5 PM and 9 PM . Resident #116 received the medication 1 hour and 45 minutes past the standard time frame of administration. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. On 4/21/16 at 11:17 AM, during medication administration to Resident #56, RN#3 administered Humalog 5 units via [MEDICATION NAME]. Prior to administration, RN#3 was asked was there anything to be done to the pen prior to administration in which he/she answered no. Prior to the administration of the insulin, RN #3 did not prime the pen nor did he/she leave the pen needle in for 6-10 seconds as required. The facility admitted Resident #186 with [DIAGNOSES REDACTED]. On 4/22/16 at 9:02 AM, during medication administration to Resident #186, Licensed Practical Nurse #4 crushed the am medications to be administered which included [MEDICATION NAME] 5 mg delayed release, [MEDICATION NAME] Succ. ER 200 mg, [MEDICATION NAME] 67 mg and Dilitiazem ER 180 mg. Prior to crushing the medications, LPN#4 stated due to the resident having Dementia, all medications were crushed. Review of the facility policy titled Administering Medications revealed under item #4 the following: Medications must be administered within one (1) hour of their prescribed time, … | 2019-09-01 |
| 4714 | 4714 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 371 | F | 0 | 1 | 1ROG11 | Based on observations, interviews and review of the facility policy titled, Temperature Regulations Made Practical and Infection Control Policy and Procedure, for the Dietary Department, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen and has the potential to effect all residents eating meals prepared in the facility kitchen. The findings included: During initial tour of the kitchen on 4/18/2016 at approximately 8:50 AM revealed the following: 1. The robo coupe was soiled with dried food and debris. 2. The stand mixer was covered and confirmed not used had a pink thin liquid in the bottom of the bowl. 3. The ice machine had a grease build up on the front, outside of the machine. 4. A large amount of cut-up chicken was observed in the stainless steel sink with a trickle of water running from the faucet. The chicken was thawed, laying directly in the sink, there was an odor coming from the chicken and a light brown color was noted on the lean portion of the chicken. During an interview on 4/18/2016 at approximately 8:50 AM with the Dietary Manager he/she stated that the chicken was removed from the freezer at around 8:00 AM. This surveyor asked for a temperature of the raw meat and it was taken by the Dietary Manager and was 69 degrees. The thawed chicken was removed from the sink and discarded in the trash. All of the above findings were confirmed at this time by the Dietary Manager. During initial tour on 4/18/2016 at approximately 9:15 AM of the nutrition room on the 100 hall revealed a bottle of Uti-Stat Cranberry supplement had expired on 1/2016. During an interview with Licensed Practical Nurse #5 verified the findings. Review of the facility policy titled, Temperature Regulations Made Practical, on 4/18/2016 at approximately 10:30 AM states under, Time and Temperature Principle, The failure to adequately control food temperatures is the one of two factors most commonly implicated in outbreaks of foodborne illness. The second most frequently implicated is … | 2019-09-01 |
| 4715 | 4715 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 425 | E | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility agreement with the Pharmacy, and the Consultant Pharmacy Services Agreement, the Pharmacy failed to ensure medications ordered by the physician were available and accessible for Residents #8 in a timely manner for 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review on 4/20/2016 at approximately 10:49 AM of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Further review on 4/20/2016 at approximately 10:49 AM of the MAR for (MONTH) (YEAR) revealed K-Phos No 2 tablet 350-700 mg to be administered at 9:00 AM on 2/15/2016, 2/16/2016, 2/17/2016, 2/18/2016 and 2/19/2016 was not given. The 1:00 PM dose of this medication was not administered on 2/16/2016, 2/17/2016, 2/18/2016 and 2/19/2016. The 5:00 PM dose was not administered for 2/17/2016, 2/18/2016 and 2/19/2016. The 9:00 PM dose on 2/19/2017 was not administered. During even further review of the MARs on 4/20/2016 at approximately 10:55 AM revealed a MAR indicated [REDACTED]. Review on 4/20/2016 at approximately 2:00 PM of the nurses notes dated 2/06/2016 and 2/8/2016 states,Alprazolam 1 mg, not available from pharmacy. The nurses notes dated 2/15/2016 states the K-Phos No 2 Tablet is not available from pharmacy. On 2/16/2016 the nurses note states, pharmacy will fill, and not available from pharmacy. On 2/17/2016 and 2/18/2016 the nurses note states, medication not available. On 2/19/2017 the nurses note states, not available, will call pharmacy again. Further review of the nurses notes on 4/20/2016 at approximately 2:00 PM reveled a note on 3/7/2016 that states, Cymbalta not available, request refill, The nurses note on 3/22/2016 states, Daily Vitamin Tablet - medication not available from pharmacy. No documentation could be found in Resident #8's medical record to ensure the physician was notified o… | 2019-09-01 |
| 4716 | 4716 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 431 | E | 0 | 1 | 1ROG11 | Based on record review, observation, interview and review of the facility policy titled Storage of Medications, the facility failed to maintain appropriate refrigerator temperatures on 2 of 2 units. In addition, the facility failed to secure the medication keys for the medication cart and medication room for 1 of 2 units. The findings included: Observation of the 100 Unit medication refrigerator on 4/22/16 at 6:50 PM revealed a temperature of 28 degrees Fahrenheit. At the time of the observation, Licensed Practical Nurse (LPN)#2 stated the correct temperature should be between 36-41 degrees. He/she stated they were unaware of the facility procedure if the refrigerator range was incorrect. At the time of the observation, no liquid medication was frozen. A recheck on 4/23/16 of the refrigerator revealed the temperature was 32 degrees Fahrenheit. On 4/22/16 at 2:24 PM, the 200 Unit refrigerator temperature reading was 32 degrees. At the time of the observation, no liquid medications were frozen. A recheck of the refrigerator on 4/22/16 at 6:55 PM revealed the a temperature reading of 36 degrees and on 4/23/16 at 10:49 AM a reading of 41 degrees. Review of the refrigerator log sheet for the 100 Unit revealed on 4/19/16 at 6 AM a temperature reading was 33 degrees; 7 PM-34 degrees; 4/20/16 at 6 AM-34 degrees; 7 PM-33 degrees; 4/21/16 at 6 AM-32 degrees; and 6 PM 33 degrees; and 4/22/16 at 12 PM 33 degrees. Review of the refrigerator log sheet for the 200 Unit revealed on 4/21/16 a temperature reading of 35 degrees and on 4/22/16 at 6:30 PM a temperature reading of 31 degrees. On 4/22/16 at 11:45 AM, Registered Nurse(RN) #2 was asked to unlock the Unit 2, medication cart 2. RN #2 reached into an unlocked desk drawer and obtained the medication keys which unlocked the medication room, the pixus room and the Unit 2, medication cart 2. At the time of the observation, RN #2 stated keeping the keys in an unlocked drawer was not the normal procedure. He/she continued by stating the keys were not on his/her person, so he/she … | 2019-09-01 |
| 4717 | 4717 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 490 | L | 0 | 1 | 1ROG11 | Based on review of facility files and interviews, the facility failed to Administer in a way to maintain safety of residents named in allegations of abuse/neglect misappropriation of funds. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds Cross Refer to F226: Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property. Cross refer to F323: Supervision to prevent accidents/incidents. Supervision not provided to prevent unknown person entering facility and resident's rooms when sleeping. | 2019-09-01 |
| 4718 | 4718 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 496 | D | 0 | 1 | 1ROG11 | Based on record review and interview, the facility failed to ensure registry verification was done prior to hire for 1 of 10 Certified Nurses Aides (CNA) reviewed for registry verification. (CNA #3) The findings included: Review of employee files during the Extended Survey revealed that the hire date for CNA #3 was 2/13/15. Further review of the employee file revealed that the facility had not obtained registry verification for CNA #3 until 2/16/15. This information was confirmed by Administrative Staff #1 on 4/28/16. | 2019-09-01 |
| 4719 | 4719 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 497 | E | 0 | 1 | 1ROG11 | Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required 12 hours of in-service training per year based on employment date. The findings included: A review of nurse aide in-service education during the Extended Survey on 4/28/16 revealed the facility was unable to provide documentation of nurse aide in-service training prior to 1/1/16. Administrative Staff #1 confirmed this finding and confirmed that the information provided related to in-service training failed to verify that the facility's CNAs received the required 12 hours of training based on hire date. | 2019-09-01 |
| 4720 | 4720 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 500 | D | 0 | 1 | 1ROG11 | Based on record review and interview during the Extended Survey, the facility failed to have outside resources for all needed areas. The findings included: Record review during the Extended Survey revealed a Dental contract and AMS Ambulance contract had not been signed. During an interview with the Administrator on 4/28/16 at 4:43 PM, he/she could not provide signed contract agreements for the above entities. | 2019-09-01 |
| 4721 | 4721 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 516 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain the safety and confidentiality of resident records and failed to safeguard clinical record information against unauthorized use. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds related to Resident #178. Cross refer to F226-Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property related to Resident #178. Cross refer to F-323 Supervision to prevent accidents/incidents related to Resident #178. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The administrator went to the resident (#178) and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The Administrator was asked by the surveyor, what… | 2019-09-01 |
| 4722 | 4722 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 519 | D | 0 | 1 | 1ROG11 | Based on record review and interview during the Extended Survey, the facility failed to have a written transfer agreement with one or more hospitals. The findings included: Record review on the Extended Survey on 4/28/16 revealed no transfer agreement with one or more hospitals. During an interview on 4/28/16 at 4:43 PM, the Administrator confirmed the facility did not have a written transfer agreement with a hospital. | 2019-09-01 |
| 4723 | 4723 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 520 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to identify quality deficiencies related to prevention of abuse/neglect, proper implementation of abuse/neglect policies, provision of supervision to ensure resident safety, and provision of medical record security. Failure of the Quality Assurance (QA) Committee to identify and implement action plans related to these quality deficiencies resulted in Immediate Jeopardy for Resident #69 and Resident #178. The findings included: Based on record reviews and interviews, the facility failed to identify concerns related to prevention of abuse/neglect, provision of supervision to ensure resident safety, and provision of medical record security. During an interview on 4/28/16, the Administrator and Director of Nursing stated and confirmed that the QA Committee had not identified and had not implemented action plans related to the concerns identified for Resident #69 and Resident #178. Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable on 4/28/16 at 2:05 PM, and the Immediate Jeopardy at F-224, F-226, F-323, F490, F516 and F-520 was removed but the citations remained at a lower scope and severity. The A[NAME] included the following: A[NAME]: It has been alleged in the context of the pending survey process that the Facility's respo… | 2019-09-01 |
| 5115 | 5115 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 309 | D | 0 | 1 | 7ZPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to adjust medication administration times for 1 of 1 sampled residents reviewed for [MEDICAL TREATMENT]. Resident #56 did not receive 9 AM medications on [MEDICAL TREATMENT] days. The findings included: The facility admitted Resident #56 with [DIAGNOSES REDACTED]. On 04/21/2016 at 10:53 AM, review of the Medication Administration Record [REDACTED]. According to the MAR indicated [REDACTED]= away from home. Further review of the MAR indicated [REDACTED]. Review of the nursing documentation revealed no explanation as to why these medications were held. When asked about the coding on the MAR indicated [REDACTED]. During an interview with the Administrator on 04/21/16 at 4:20 PM, s/he stated, We always reschedule medications for [MEDICAL TREATMENT] residents but missed this one totally. | 2019-05-01 |
| 5116 | 5116 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 333 | E | 0 | 1 | 7ZPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to administer the correct amount of insulin ordered by the physician for 1 of 1 residents reviewed for insulin administration. Resident #56 did not receive the correct amount of physician ordered insulin during medication administration. The findings included: The facility admitted Resident #56 with [DIAGNOSES REDACTED]. On 4/18/16 at 11:28 AM, an observation with Licensed Practical Nurse (LPN) #1 of the A-Hall medication cart revealed 1 vial of Humalog 100 unit insulin (Lot Number C 7C) with an open date of 3/4/16. Following the observation, LPN #1 verified Resident #56's vial of insulin was used after the manufactures recommendations and facility policy of 28 days. On 4/18/16 at 1:00 PM, review of Resident #56's Medication Administration Record [REDACTED]. Review of the Humalog manufactures recommendations under 16.2 Storage and Handling revealed, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the facility medication cart instruction sheet under Injectable Medications under Insulin Vials revealed, All vials should be dated when opened and discarded 28 days after opening. Review of the facility policy 5.3 Storage and Expiration Dating of Drugs, Biological's, Syringes and Needles revealed under 3.) The Facility should ensure that drugs and biological's that: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. Also, 3.1 stated, Once any drug or biological package is open, the Facility should follow manufacture/supplier guidel… | 2019-05-01 |
| 5117 | 5117 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 371 | F | 0 | 1 | 7ZPI11 | Based on observation, interview, and review of facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 2 kitchens with the potential to affect 31 of 31 residents with ordered diets by failing to dispose of expired food in the refrigerator, dry pans, and wear hair restraints. The findings included: On 4-18-16 at approximately 10:44 AM during initial tour of the main kitchen with the Assistant Executive Director, an observation of the main kitchen walk-in refrigerator revealed 7 turkey sandwiches with a use by date of 4/16. Also, an open bulk package of prosciutto meat dated 2/2 which was discolored gray and brown. Furthermore in the food preparation area 2 staff were not wearing hair restraints. Following the observation, the Assistant Executive Director verified the sandwiches and prosciutto were expired and indicated all expired items should have been removed. On 4-19-16 at 11:20 AM, an observation in the main kitchen of the food service line and food preparation area revealed that 2 staff did not have on a hair restraint and 2 staff did not have on a facial hair restraint. Also, 6 pans above the food service line were stacked wet. On 4-20-16 at 1:00 PM, an observation in the main kitchen with the Certified Dietary Manager (CDM) revealed 3 staff without a facial hair restraint and 1 staff without a hair restraint while food was being prepared and served. Following the observation, the CDM verified the findings of staff not wearing hair restraints. On 4-20-16 at 2:00 PM, an interview with the CDM indicated that expired food should be removed from the refrigerator, pans should be air dried prior to stacking, and s/he expected that all hair be restrained in the food preparation and serving area. Review of the facility policy Hair Restraints revealed under policy (3) Associates who have hair that cannot be covered with a single hairnet will wear two (one for the front and one for the back). All hair must be covered also. | 2019-05-01 |
| 5118 | 5118 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 431 | D | 0 | 1 | 7ZPI11 | Based on observation, interview, and review of facility policy, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 3 medication carts. Insulin was on the medication cart after the discard date. The finding included: On 4/18/16 at 11:28 AM, an observation with Licensed Practical Nurse ( LPN) #1 of the A-Hall medication cart revealed 1 vial of Humalog 100 unit insulin (Lot Number C 7C) with an open date of 3/4/16. Following the observation, LPN #1 verified the vial of insulin was being used past the manufactures recommendations and facility policy of 28 days. Review of the Humalog manufactures recommendations under 16.2 Storage and Handling revealed, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the facility medication cart instruction sheet reveals under Injectable Medications under Insulin Vials revealed, All vials should be dated when opened and discarded 28 days after opening. Review of the facility policy 5.3 Storage and Expiration Dating of Drugs, Biological's, Syringes and Needles revealed under 3.) The Facility should ensure that drugs and biological's that: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. Also, 3.1 stated, Once any drug or biological package is open, the Facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications. | 2019-05-01 |
| 5119 | 5119 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 441 | E | 0 | 1 | 7ZPI11 | Based on record review and interview, the facility failed to track and/or trend infectious organisms for 3 of 3 months reviewed for surveillance of infections. The findings included: On 04/20/2016 at 8:50 AM, review of the infection surveillance logs for January-March, (YEAR) revealed no documentation of the causative organisms for infections. On 04/21/2016 at 8:36 AM, review of the Infection Control Policy Manual revealed the South Carolina 2013 List of Reportable Conditions was the most recent list in the manual. On 04/21/2016 at 2:32 PM, Registered Nurse (RN) #1 confirmed there was no documentation of organisms in the surveillance logs. The RN stated if any resident had a culture, it would be located in the resident's record but confirmed that the organisms were not documented anywhere else. When asked how tracking and trending of transmittable organisms could be performed without documentation of the organism, the RN stated, I see what you mean. | 2019-05-01 |
| 5120 | 5120 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 463 | E | 0 | 1 | 7ZPI11 | Based on observation, interview, and record review, the facility failed to maintain a fully operational resident call system for 6 residents on 2 of 3 halls. The findings included: During initial tour on 04/18/16 at approximately 11:30 AM, the call lights in rooms 183A, 183B, and 190 were found non-functional. The signal lights outside of the residents' room doors did not light and the auditory signal at the nursing station did not sound. During an interview on 4/18/16 at 12:40 PM, the Executive Director verified the call lights in rooms 183A, 183B, and 190 were non-functional. On 4/18/16 at 1:19 PM, the Executive Director stated, We got an error message that I have never seen before. The Executive Director further stated the entire system was being re-booted. On 04/18/2016 at 12:21 PM, the call lights for beds 169-2, 165-2, and 163-2 were found to be non-functional. On 04/18/2016 at 12:38 PM, the Assistant Executive Director confirmed the call lights were not functioning. The Assistant Director also stated maintenance was currently working on the call lights in room 183 that were non-functional. On 04/18/2016 at 1:20 PM, Licensed Practical Nurse (LPN) #1 stated s/he was not aware there were call lights that were not functioning on Hall A and stated that no residents had complained of call lights not being answered. On 04/18/2016 at 1:24 PM, CNA (Certified Nursing Assistant) #1 stated some residents had complained about how long it took for call lights to be answered but didn't recall specific residents. The CNA stated the complaints had been less than a week ago. In addition, the CNA stated s/he works on all 3 halls and was not aware that some of the call lights were not functioning. On 04/18/2016 at 1:24 PM, CNA #2 stated s/he also worked on Hall A and denied that any residents had complained of call lights not functioning or not being answered. The CNA further stated s/he was not aware that some of the call lights were not functioning. On 04/18/2016 at 1:25 PM, CNA #3 from Hall A stated the only complaints s/h… | 2019-05-01 |
| 5121 | 5121 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2016-04-21 | 502 | E | 0 | 1 | 7ZPI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy, the facility failed to follow a procedure to ensure that expired laboratory supplies were removed from medication storage in 1 of 3 medication carts. The findings included: On [DATE] at 11:28 AM, an observation with Licensed Practical Nurse ( LPN) #1 of the A-Hall medication cart revealed 1 bottle containing (4) Quintet Blood Glucose test strips (Lot # 1601) with a stamped expiration date of ,[DATE]. Following the observation, LPN #1 verified the test strips were expired and being used past the manufactures recommendations and facility policy. Review of the Quintet Blood Glucose strip manufactures recommendations on the bottle revealed instructions, Discard when expired or 3 months after opening. Review of the facility policy 5.3 Storage and Expiration Dating of Drugs, Biological's, Syringes and Needles revealed under 3.) The Facility should ensure that drugs and biological's that: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier. | 2019-05-01 |
| 5156 | 5156 | MAGNOLIA PLACE - SPARTANBURG | 425175 | 8020 WHITE AVENUE | SPARTANBURG | SC | 29303 | 2016-04-21 | 281 | J | 1 | 0 | 77LK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, Resident #1's critical PT ([MEDICATION NAME])/INR (international normalizing ratio) was called by the lab to Registered Nurse #1 on 01/25/2016. RN #1 failed to address the critical PT/INR, Resident #1 received her/his previously ordered dose of [MEDICATION NAME] on 1/25 and 1/26/2016. On 1/27/2016 Resident #1 had a nosebleed and was admitted to the hospital with [REDACTED]. 1 of 5 residents reviewed with orders for [MEDICATION NAME]. The failure of the facility staff to address the critical PT/INR and the resident continued to receive the anticoagulant subsequently leading to a hospitalization resulted in the findings of Immediate Jeopardy at Past Noncompliance existing in the facility on 1/26/16. The facility implemented a plan of correction and the Immediate Jeopardy was removed on 2/2/16. The findings included: Cross refer to F-333 as it relates to a significant medication error. A critical PT/INR for Resident #1 was not addressed by the facility licensed staff on 1/25/2016. Resident #1 continued to received her/his previously ordered [MEDICATION NAME] on 1/25 and 1/26/2016. S/he was admitted to the hospital following a nosebleed on 1/27/2016 with an INR of 10.6. Review of the Geriatric Dosage Handbook 12th Edition 2007, pg. 1179, revealed: Dosing of [MEDICATION NAME] ([MEDICATION NAME]) must be individualized according to patient response to the drug as indicated by the INR . Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) coded her/him as having a BIMS (brief interview of mental status) of 15. Review of the most recent Quarterly MDS dated [DATE] coded her/him as having a BIMS of 09. Her current [DIAGNOSES REDACTED]. She required extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene; one person assist with locomotion on and off the unit; extensi… | 2019-04-01 |
| 5157 | 5157 | MAGNOLIA PLACE - SPARTANBURG | 425175 | 8020 WHITE AVENUE | SPARTANBURG | SC | 29303 | 2016-04-21 | 333 | J | 1 | 0 | 77LK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview Resident #1's critical PT ([MEDICATION NAME])/INR (international normalizing ratio) was called by the lab to Registered Nurse #1 on 01/25/2016. RN #1 failed to address the critical PT/INR, Resident #1 received her/his previously ordered dose of [MEDICATION NAME] on 1/25 and 1/26/2016. On 1/27/2016 Resident #1 had a nosebleed and was admitted to the hospital with [REDACTED]. 1 of 5 residents reviewed with orders for [MEDICATION NAME]. The failure of the facility assure staff acted upon a critical lab value and to assure a resident is free from significant medication errors, Resident #1 continued to receive an anticoagulant with a critically high PT/INR lab value, resulted in the findings of Immediate Jeopardy at Past Noncompliance existing in the facility on 1/26/16. The facility implemented a plan of correction and the Immediate Jeopardy was removed on 2/2/16. The findings included: Review of the facility investigation revealed a Five-Day Follow-Up Report faxed to the State Agency dated 2/4/2016 that included the following summary of the investigation: Resident #1 had a PT/INR drawn, as ordered, on the morning of 1/25/2016 with critical results. These results were called to Registered Nurse (RN) #1 at approximately 11 AM on the same morning. RN #1 notified Nurse Practitioner (who was in the facility at the time), but did not give details regarding the patient, type of lab, or lab value when reporting. NP was completing patient dictation at the time that the nurse states s/he notified her/him. RN #1 failed to follow up with ensuring that the provider addressed the critical result as well as the order for [MEDICATION NAME] and any need for administration of Vitamin K. Standard procedure for critical lab results with the contracted lab includes both verbal (via phone call) and faxed hard copy results are sent to the facility. The lab company did notify the nurse (RN #1) of the critical value. Subsequently, … | 2019-04-01 |
| 5158 | 5158 | MAGNOLIA PLACE - SPARTANBURG | 425175 | 8020 WHITE AVENUE | SPARTANBURG | SC | 29303 | 2016-04-21 | 514 | D | 1 | 0 | 77LK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, the facility failed to maintain clinical records that were readily accessible and systematically organized for 1 of 9 residents reviewed. Resident #19 failed to have readily accessible documentation related to her/his change in condition and admission to the hospital on [DATE]. The findings included: Resident #19 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the clinical record for Resident #19 revealed a Clinical Progress Note written by Activities dated 4/11/16 at 11:38 AM that stated, Neighbor sent out to hospital on [DATE] . and was not a bed hold. Further review of the clinical record revealed a note by the nursing staff dated 4/4/16 at 3:23 PM that stated, Resident confused and agitated. Trying to get up, talking to people that are not there. Notified Nurse Practitioner . new TO (telephone order) rec'd (received) for ua (urinalysis) with c&s (culture and sensitivity). This review failed to show a rationale for why or when the resident was sent to the hospital on [DATE]. In an interview with the surveyor on 4/18/16 at approximately 3:00 PM the Director of Nursing (DON) was asked to provided additional information about Resident #19's hospital admission on 4/4/16. S/he stated that s/he had assessed the resident and found her/him to be confused, not at her/his baseline. S/he stated that Resident #19's husband was in the facility and agreed the was not her/his usual self. The Director of Nursing stated s/he would need to look for the SBAR and her/his note to the hospital. The information was found after the DON looked through several large stacks of resident information in her/his office. | 2019-04-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );