cms_SC
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38 rows where "inspection_date" is on date 2016-04-28
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4932 | 4932 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 155 | D | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy entitled Advance Directives, the facility failed to incorporate choices regarding advance directives into treatment, care and services for 1 of 1 sampled resident reviewed for choices. Resident #119 had discrepancies in advance directives on the medical record. The findings included: The facility admitted Resident #119 with [DIAGNOSES REDACTED]. Review of the [DATE] admission History and Physical on [DATE] at 3:06 PM revealed that the resident was alert and say he (she) would not want CPR (cardiopulmonary resuscitation). Review of the Admission Body of Orders at 3:20 PM on [DATE] revealed the Code Status: Full Code. A [DATE] 3:10 PM Social Services Interdisciplinary Note reviewed at 4:40 PM stated, The resident is a DNR (Do Not Resuscitate) by his (her) choice. At 4:45 PM, review of the Medication Administration Record [REDACTED]. No Physician's Order could be located to reflect the resident's choice in advance directives. During an interview at 6:09 PM on [DATE], when asked about the code status of Resident #119, Registered Nurse #1 referred to the physician's orders and stated, full code. When the resident's request documented on the History and Physical was brought to her/his attention, s/he confirmed the information and reviewed the record for an updated order. The nurse was unable to locate a physician's order for DNR status. Social Services stated s/he had spoken with the resident and that s/he wanted to be a DNR. S/he had placed the completed form in the physician's box to be signed. The facility policy entitled Advance Directives states: On Admission, the attending Physician will discuss the desired code status with the resident and include this information in his History and Physical. If resident desires to have No CPR, MD will write order for this. During an interview on [DATE], the attending physician stated, I should have written the order. | 2019-07-01 |
| 4933 | 4933 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 156 | E | 0 | 1 | YC7O11 | Based on record review and interview, the facility failed to issue notices of Medicare non-coverage and/or liability notices to 3 of the 3 sampled residents reviewed (Residents #97, #23, and #8). One of 3 sampled residents reviewed did not receive the required 48 hour notice of Medicare non-coverage (Resident #8). The findings included: During a review of notification of Medicare non-coverage and liability notices on 4-28-16 at 2 PM, the MDS (Minimum Data Set) Coordinator verified the following: (1) Resident #8's end of service date was noted as 2/4/16. The CMS (Centers for Medicare and Medicaid Services) -NOMNC Notice of Medicare Non-Coverage was signed on 02/03/16, indicating the receipt of notification. (2) Resident #97, #23, and #8 were not issued liability notices (CMS -Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or one of the 5 CMS approved notices of non-coverage). | 2019-07-01 |
| 4934 | 4934 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 167 | C | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that the results of the most recent survey was readily available to residents and visitors for 3 of 4 days of the survey. The findings included. Upon entrance to the facility on [DATE], a sign was noted in the lobby indicating the location of survey results at the nursing station. Observations throughout the first 3 days of the survey revealed no named document or notebook visible at the nursing station. During an interview at 6 PM on 4-27-16 at the nursing station, Licensed Practical Nurse #2 was unaware of the location of the survey results. The[NAME] Secretary stated, There's a sign posted that it's at the nurse's station. It's kept back here. S/he indicated the cabinet countertop against the wall behind the nursing station. The[NAME] Secretary and Director of Nurses confirmed that the notebook was not readily accessible to residents or visitors wishing to examine survey results without having to ask a staff person. | 2019-07-01 |
| 4935 | 4935 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 241 | E | 0 | 1 | YC7O11 | Based on observation, interview, and review of the Environmental Services Policy & Procedure entitled Patient Room Cleaning-Daily Cleaning Service, the facility failed to ensure that residents' privacy was respected on 1 of 2 units (2600). Housekeeping staff failed to knock on resident room doors and request permission prior to entering. In addition, the facility also failed to promote dignity during the dining experience on 2 of 2 units. No glasses were provided for residents served drinks in cartons and cans. The findings included During a private resident interview with the door closed on 4-25-16 at 12:03 PM, housekeeping staff entered Resident #119's room without knocking and awaiting permission. S/he proceeded to dry mop the entire floor without speaking, pushing the mop under the resident's and surveyor's feet so s/he could accomplish the task. While conducting an observation in Resident #41's room on 4-25-16 at 12:20 PM, the housekeeper again entered the room without knocking and awaiting permission. During an interview at 1:45 PM on 4-27-16, Registered Nurse #1 stated, All staff should knock prior to entering resident rooms. Review of the Environmental Services Policy & Procedure entitled Patient Room Cleaning-Daily Cleaning Service at 2:55 PM on 4-27-16 revealed directions to 3. Announce: Knock on the door and, announce yourself housekeeping, once permission is granted to enter the room, do so with a smile . During observation of the noon meal Unit 2600 on 4-25-16, no glasses were provided on trays for residents who were served milk in cartons or other drinks in cans. Certified Nursing Assistants did not offer glasses as residents were served. During observation of the breakfast meals on Units 2400 and 2600 on 4-26-16 at 8:15 AM and on 4-27-16 at 7:45 AM, no glasses were provided on trays for residents who were served milk in cartons. Certified Nursing Assistants did not offer glasses as residents were served. Observation on the 2400 unit during lunch on 04/25/16 revealed residents were given drinks with… | 2019-07-01 |
| 4936 | 4936 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 309 | E | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure continuity of care by ensuring ongoing communication with the [MEDICAL TREATMENT] center and failed to monitor the effectiveness of pain medication for one of one sampled resident reviewed for [MEDICAL TREATMENT]. (Resident #27) Also, based on observation, record review, and interview, the facility failed to follow wound care interventions for one of one sampled resident reviewed for positioning. Resident #119 was not assisted to keep [MEDICAL CONDITION] legs elevated for 2 of 4 days of the survey. The findings included: The facility admitted Resident #119 with [DIAGNOSES REDACTED]. A wound care followup dated 4-22-16 noted the resident with improving [MEDICAL CONDITION] and venous congestion of the extremities. Lower extremity wounds included densely adherent eschar over the entirety of the dorsum of the patient's right foot,the distal aspect of the great toe and the dorsum of the second toe (of the right foot). There remains a dense eschar to the posterolaterel aspect of the left lower extremity . The hope is that we continue good wound care, pressure relief and elevation that should debridement become necessary, we will have minimized the amount of debridement that the patient has to undergo and potentially spare him (her) with sequelae of regressive therapy for these extremities. Review of the 4-24-16 and 4-26-16 Physician's Progress Notes on 4-26-18 at 3:06 PM revealed the resident with Brawny [MEDICAL CONDITION]. Review of the Care Plan on 4-26-16 revealed that interventions included to Elevate legs when sitting or sleeping. Review of the CNA (Certified Nursing Assistant) Care Plan/Kardex revealed no instructions to keep the resident's legs elevated. Multiple observations on 4-25-16 (at 12:03 PM, 12:17 PM, 2:14 PM, and 3:55 PM) revealed Resident #119 sitting in an upright bedside chair. Bilateral lower extremities were very [MEDICAL CONDITION], wrapped with soiled dress… | 2019-07-01 |
| 4937 | 4937 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 314 | D | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow procedures to prevent infection and promote the prevention of pressure ulcer development for one of three sampled residents reviewed for pressure ulcers. During wound treatment, Licensed Practical Nurse (LPN) #1 failed to cleanse the scissor before cutting foam dressing to apply directly to the sacral wound for Resident #21. Medline boots were not observed in place as ordered for Resident #21. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 4-27-16 at 8:07 AM revealed that pressure ulcers to the right heel, right medial foot, and right lateral malleolus had just healed on 4-20-16 and there was a physician's orders [REDACTED].>Medline boots at all times. Review of a 4-20-16 Operative/Procedure Report for sacral debridement revealed that the physician also evaluated the right foot and The patient should continue to have Medline boots for heel offloading. Review of the Treatment Administration Record (TAR) on 4-27-16 at 8:40 AM revealed that, although listed on the form, it was noted as FYI in the Hour column to indicate completion time. There were no initials to indicate this order was being carried out or that the resident was being monitored for placement of the boots. Nurse's Notes did not document placement of Medline boots for pressure ulcer prevention. Review of the Care Plan at 4:15 PM on 4-27-16 revealed interventions for the pressure ulcers to the right foot included Administer Medications/Treatments as ordered, but was not individualized to specific modalities. Review of the CNA (Certified Nursing Assistant)Care Plan/Kardex revealed no reference to boot application. Multiple observations on 4-25-16 (at 12:30 PM, 2:07 PM, 4 PM) and 4-26-16 (8:38 AM) revealed the resident without the Medline boots on as ordered. During an interview on 4-27-16 at 10:47 AM, Registered Nurse #1 reviewed the TAR and confirmed that nurses w… | 2019-07-01 |
| 4938 | 4938 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 329 | E | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 4 of 5 sampled residents reviewed for unnecessary medication had reason for administration documented and/or were monitored for effectiveness of PRN (as needed) medication (Residents #27, #113, #115, and #121), the facility failed to ensure that 1 of 5 sampled residents reviewed for unnecessary medication (Resident #115) had documented evidence of clinical need to increase the dosage of an antidepressant medication, and the facility failed to ensure that only those medications required to treat 3 of 5 residents' assessed conditions were being used. Residents #22, #41, and #113 were prescribed medication for which there was no evidence of clinical need. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review at 4:54 PM on 4-27-16 revealed physician's orders [REDACTED]. Continued review revealed no clinical indication for these medications to treat the resident's assessed condition. There were no laboratory reports to substantiate phosphorus or zinc deficiencies or reason for continued use. During an interview on 4-27-16 at 5:15 PM with management staff (Administrator, Director of Nursing, Nurse Consultant, Staff Development Coordinator), information was requested to provide clinical reasons for the use of the medication. On 4-28-16, Registered Nurse #1 stated they had reviewed the medical records and were unable to find any evidence of deficiencies. Record review on 4-28-16 at 9:27 AM revealed physician's orders [REDACTED]. One tablet (5 mg) every 6 hours for mild to moderate pain (1-6); 2 tablets (10 mg) every 6 hours as needed for severe pain (7-10). Review of the Medication Administration Records (MARs) revealed that between admission on 4-13-16 through 4-26-16, Resident #113 received thirty-two 10 mg doses and one 5 mg dose. Review of Progress Notes and MARs revealed that 13 of the 33 doses had no reason for administration a… | 2019-07-01 |
| 4939 | 4939 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 334 | E | 0 | 1 | YC7O11 | Based on record review and interview, the facility failed to ensure residents were provided with education regarding the flu shot and the pneumonia vaccine for 5 out of 5 residents reviewed for vaccination. Residents #23, #51, #41, #115, and #27 had no documentation of education for vaccination. The findings included: Review of facility record revealed Residents #23, #51, #41, and #27 had been admitted to the facility during the season when flu vaccinations were given (October - March). Review of record for all 4 residents revealed they had all declined the flu vaccination, however, there was no documentation they were given education regarding the shot. Review of facility record revealed Residents #23, #51, #41, #27, and #155 had all declined pneumonia vaccination, however, there was no documentation they were given education regarding the vaccination. In an interview on 04/28/16 at 10:30 AM, the Infection Control nurse confirmed Residents #23, #51, #41, and #27 were all admitted to the facility during the season when flu vaccinations were given and had all declined the vaccination and that Residents #23, #51, #41, #115, and #27 had all declined the pneumonia vaccination. The Infection Control nurse confirmed there was no documentation in facility records that the Residents had been provided with education regarding the flu vaccination or the pneumonia vaccination. | 2019-07-01 |
| 4940 | 4940 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 371 | F | 0 | 1 | YC7O11 | Based on observation, interview, and record review, the facility failed to ensure safe food in 1 or 1 kitchen by the presence of food items that had not been discarded after expiration date. The findings included: On 4/25/2016 at approximately 10:30 am, an observation of the walk in refrigerator revealed two bags of raw chicken dated 4/20 and a raw roast beef dated 4/18, a bag of shredded white cheese dated 2/15 and a bucket of pickles dated 9/23. During an interview on 4/25/2016 at approximately 11:00 AM, the Dietary Manager stated that chicken normally takes 3 days to thaw. The Dietary Manager stated h/she checks the coolers frequently and has asked staff to check refrigerators for out of date products daily and that foods should be discarded three days after they have been opened. A review of the NS 10.6 Food Expiration Dates Policy and Procedure, stated; 1. All perishable food/containers will be dated on the day it was Refrigerated foods will be prepared or thawed. refrigerated foods will be discarded after the following criteria have been met. 2. All perishable foods including cooked meats will be discarded within 48 hours of service unless frozen. | 2019-07-01 |
| 4941 | 4941 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 431 | E | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure all medications dispensed were documented as given for 2 out of 5 residents reviewed for unnecessary medications. As needed pain medications were documented as dispensed, but not administered for Residents #27 and #113. The findings included: Review of records for resident #27 revealed s/he received Hydrocodone as needed (PRN) for pain. Review of Resident #27's Pyxis medication dispensing record revealed 21 doses of PRN pain medication were dispensed from 04/18/16 through 04/26/16 and there was no record of administration for 7 doses. In an interview on 04/26/16 at 4:00 PM the facility Quality Assurance nurse confirmed all doses of medication which were dispensed should be recorded as given. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4-28-16 at 9:27 AM revealed physician's orders [REDACTED]. One tablet (5 mg) every 6 hours for mild to moderate pain (1-6); 2 tablets (10 mg) every 6 hours as needed for severe pain (7-10). Review of the Medication Administration Records (MARs) revealed that between admission on 4-13-16 through 4-26-16, there were thirty-two 10 mg doses and one 5 mg dose documented as given to Resident #113. Review of the (MONTH) (YEAR) Pyxis report on 4-28-16 revealed that 40 doses of Oxycodone had been removed from the Pyxis, leaving 7 doses (fourteen 5 mg tablets). During an interview on 4-28 at 10:35 AM, the Director of Nurses reviewed and verified the Pyxis data. | 2019-07-01 |
| 4942 | 4942 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 441 | D | 0 | 1 | YC7O11 | Based on observation and interview the facility failed to observe standard precautions related to providing care for residents identified as requiring contact precautions as part of their treatment plan. A Certified Nursing Assistant (CNA) was observed exiting a resident's room without washing hands with soap and water. In addition, the same CNA was noted to enter the resident's room with a breakfast tray without donning gown and gloves. Both observations were made in a resident room identified as Contact Precautions. Resident #27, was one of one resident reviewed on contact precautions. The findings included: Observation in the facility on 04/25/16 and 04/26/16 revealed Resident #27 was on contact precautions. In an interview on 04/26/16, the facility infection control nurse revealed Resident #27 was on contact precautions for MRSA. Observation at breakfast on 4/27/16 at 7:36 AM revealed a Certified Nursing Assistant (CNA) #3 entered Resident #27's room to bring in his/her lunch tray without donning a gown or gloves. In an interview on 04/26/16 at 7:40 AM, CNA #3 said she knew she was supposed to don a gown and gloves before entering Resident #27's room, but she forgot. In an interview on 04/26/16 at 10:40 AM the facility Infection Control Nurse confirmed the CNA should have donned gloves and a gown prior to entering Resident #27's room. Observation on 04/26/16 at 12:15 PM revealed CNA #3 went into the room of a resident whose door was marked indicating contact precautions. CNA #3 donned a gown and gloves and removed them upon leaving the room. CNA #3 then used hand sanitizer on the wall on her hands and did not wash her hands with soap and water prior to leaving the room. In an interview on 04/27/16 at 12:25 PM the facility Infection Control Nurse revealed the resident was on contact precautions due to Clostridium Difficile and stated CNA #3 should have washed her hands with soap and water prior to leaving the room. | 2019-07-01 |
| 5025 | 5025 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2016-04-28 | 157 | D | 0 | 1 | 9D8Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician or Hospice timely of changes in condition for Residents #3 and #160, 2 of 13 residents reviewed for notification of changes. Resident #3 had episodes of vomiting and refusal of meals, supplements and medications beginning 3/4/16 and Hospice was notified on 3/14/16. Resident #160 had a reaction after medications and the physician was not notified. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. At 9:12 on 4/27/2016, review of the Clinical Notes revealed episodes of vomiting, multiple refusals of supplements and medications documented beginning 3/4/16. There was no documentation that the physician was notified. Hospice was aware on 3/1/16 that the resident was refusing some meals but was not notified of continued refusal of meals or refusal of meds until 3/13/16. The documentation from Hospice provided by the facility stated no new concerns were voiced on 3/9/16. The DON reviewed the notes with the surveyor and confirmed that the hospice nurse was communicating with the nurse but it looks like they weren't discussing what was going on with the resident. At 1:07 PM on 04/27/2016, review of the Progress Notes revealed a note dated 4/26/16 by the Hospice Physician that stated the resident had a newly developed sacral wound since March. The note further stated the resident's intake was poor and she had continued weight loss in spite of supplements. There was no indication the physician was aware the resident was refusing and/or vomiting after the supplements. The facility admitted Resident #160 with [DIAGNOSES REDACTED]. At 2:48 PM on 04/28/2016, review of the Clinical Notes revealed a note timed and dated 4/6/16 that the resident had a reaction after receiving his IV (intravenous) and PO (by mouth) medications. The resident was noted to have a red itchy rash. There was no documentation the physician was notified. At 2:59 PM on 04/2… | 2019-06-01 |
| 5026 | 5026 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2016-04-28 | 309 | D | 0 | 1 | 9D8Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer medication as ordered for Resident #164, 1 of 5 residents reviewed for unnecessary medications. Resident #164 received 6 days of a medication that was ordered to be given for 7 days. In addition, the facility failed to communicate changes in status to Hospice and failed to administer treatments as ordered for Resident #3, 1 of 3 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #164 with [DIAGNOSES REDACTED]. At 10:45 AM on 04/28/2016, review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. The documentation indicated the medication was not available on 4/8/16. On 04/28/2016 at 3:07 PM, the Director of Nursing confirmed the resident only received 6 days of the [MEDICATION NAME] nebulizer treatment, not 7 as ordered. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. At 8:46 AM on 04/27/2016, review of the Physician order [REDACTED]. At 4:15 PM on 4/27/16, review of the Treatment Administration Record revealed one dose of [MEDICATION NAME] was not administered. Further review revealed the treatment was changed 3/20/16 when the [MEDICATION NAME] was supposed to be completed but no treatment was administered on 3/20/16. During an interview at 8:54 AM on 04/28/2016, the Director of Nursing (DON) confirmed one treatment with the [MEDICATION NAME] was not administered. At 9:12 AM on 4/28/16, the DON also confirmed there was no treatment done on 3/20/16. At 8:49 AM on 04/27/2016, review of the Wound Reviews revealed the resident had a Stage III pressure ulcer to the coccyx. The date of onset was noted as (MONTH) 29, (YEAR) as a Stage III measuring 7.0 x 5.5 cm with no depth. At 9:12 AM on 04/27/2016, review of the Clinical Notes revealed Body Audits dated 1/23, 1/25, 1/31, 2/8, 2/13 (pink heels and buttocks, on air mattress, treatment started with [MEDICATION NAME]), and 3/3/16. No do… | 2019-06-01 |
| 5027 | 5027 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2016-04-28 | 502 | D | 0 | 1 | 9D8Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain weekly hemoglobin and hematocrit laboratory tests as ordered for Resident #3, 1 of 3 residents reviewed for lab results completed. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. At 8:46 AM on 4/27/16, review of the (MONTH) (YEAR) Physician order [REDACTED]. At 1:15 PM on 04/27/2016, review of the laboratory studies in the record revealed an H&H was done 4/23, 4/2, 3/11, 3/4, 2/26, and 2/19/16. At 10:21 AM on 04/28/2016, the Director of Nursing stated that s/he was unable to locate any other H&H results and confirmed the test was not done every 7 days as ordered. | 2019-06-01 |
| 7445 | 7445 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 February 2016 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 3/7/2… | 2017-03-01 |
| 7446 | 7446 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7447 | 7447 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7448 | 7448 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7449 | 7449 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7450 | 7450 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7451 | 7451 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7452 | 7452 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 March 2016. On 3/28/2016 the intake of fluid was recorded as 3060 mls and 1740 mls on 3/29/2016. The MAR for February 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 shift … | 2017-03-01 |
| 7453 | 7453 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7454 | 7454 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7455 | 7455 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7456 | 7456 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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, … | 2017-03-01 |
| 7457 | 7457 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 … | 2017-03-01 |
| 7458 | 7458 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 February 2016 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 of… | 2017-03-01 |
| 7459 | 7459 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 … | 2017-03-01 |
| 7460 | 7460 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7461 | 7461 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7462 | 7462 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7463 | 7463 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7464 | 7464 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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… | 2017-03-01 |
| 7465 | 7465 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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. | 2017-03-01 |
| 7466 | 7466 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 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 (AOC) 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 AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to event… | 2017-03-01 |
| 8127 | 8127 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2016-04-28 | 309 | D | 0 | 1 | T9TE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview Resident #24's medical record did not contain Hospice Plan of Care nor any Discipline notes for visits made for 1 month. All notes were at the Hospice office. (1 of 1 Hospice record reviewed) The findings included: The facility admitted Resident # 24 with [DIAGNOSES REDACTED]. Record review on 4/26/15 revealed this resident to be on Hospice as of 3/24/16. There were no Hospice records included in the medical record. The DON (Director of Nursing) stated there was a separate book for each resident on Hospice with all the Hospice information included in that book. The resident's notebook only included the name of the Hospice Company and telephone number in the book. A nursing assessment and the CNA (Certified Nursing Assistants) signatures on dates for service were included. There was no plan of care provided to list care for the resident nor which disciplines would visit or how often visits would be made. There was no Hospice Physician's signature certifying Hospice care. Present when the DON verified the complete Hospice information was not in the resident's notebook were the Administrator and the MDS (Minimum Data Set) Coordinator. The DON called the Hospice Agency and by 4 PM 4/26/16 all the notes and Plan of care were placed into the Hospice Book. There were 2 sets of Chaplain notes included, dated 3/26/16 and 4/7/16. Four sets of RN (Registered Nurses) notes dated 3/28/16, 4/4/16, 4/10/16, and 4/18/16 were included, but there was still no Hospice Physician signature. | 2016-07-01 |
| 8128 | 8128 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2016-04-28 | 318 | D | 0 | 1 | T9TE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide adequate assessment and care planning related to Range of Motion/Contractures for Resident #35, 1 of 3 sampled residents reviewed for Range of Motion. Resident #35 has contractures to the left hand and elbow with no assessment or screenings to determine if the resident is maintaining her/his level of Range of Motion or having a decline in Range of Motion. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Record review of the Plan of Care on 4/27/2016 at 10:22 AM revealed a focus area/problem that indicated that the resident has contractures of left hand and elbow. The goal listed for this problem was that the resident would have no further contractures to the left hand or left elbow. The interventions/services listed on the Plan of Care for the resident's contractures were : left resting hand splint on day shift for 4-6 hours only remove splints on care rounds and check skin under splints for redness or breakdown; skin care post splint removal splint to left elbow 4-6 hours only on night shift daily The Plan of Care did not include any interventions for assessing, screening or monitoring of the resident's contractures. Record review of the physician's orders [REDACTED]. Left elbow and left hand splints were ordered for the resident on 6/12/2015. There were no additional orders for the resident's contractures. Record review of the Nurse's Notes from 2/1/2015-4/27/2015 on 4/27/2015 at 11:04 AM revealed no documentation that the resident's contractures were being assessed. Monthly nursing summaries identified that the resident had contractures, but did not indicate any type of Joint Mobility or Range of Motion assessments were being done. In addition, The Nurse's Notes and monthly summaries did not indicate if the resident was maintaining her/his current level of Range of Motion or if a decline in Range of Motion had occurred. Record review of … | 2016-07-01 |
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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 );