cms_SC
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45 rows where "inspection_date" is on date 2017-09-15
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4019 | 4019 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 155 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: [STATE], and review of the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. Residents #205 and #210 had advance directives signed by family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. It was determined on [DATE] at 11:45 AM that Immediate Jeopardy existed as of [DATE] for Resident #205 and on [DATE] for Resident #210 for F-155 which was identified at a scope and severity level of (J). The findings included: Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented … | 2020-09-01 |
| 4020 | 4020 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 156 | D | 1 | 1 | 4HVH11 | > Based on record review, interviews, and review of the facility policy entitled ABN (Advance Beneficiary Notice)-Medicare Part A Process Guideline, 2 of 3 residents reviewed for liability notices received no written notice of Medicare non-coverage (Residents #7 and #3), 1 of the 3 notices was not issued 2 days prior to the last covered Medicare Part A day (Resident #7), and 1 of the 3 (Resident #7) remained in the facility after denial of Medicare coverage, but received no liability notice (C[CONDITION] (Centers for Medicare and Medicaid Services) - NOMNC (Notice of Medicare Non-Coverage) or 1 of 5 C[CONDITION]-approved letters) as required. The findings included: During an interview on 9-8-17 at approximately 3 PM, Registered Nurse (RN) #4 reviewed 3 residents for Medicare non-coverage and liability notices. RN #4 confirmed the following: (1) Resident #7's last covered Part A day was on 5-3-17. Minimum Data Set (MDS) Coordinator #2 reviewed the MDS assessment and stated that the resident's Brief Interview for Mental Status (BI[CONDITION]) score was 15, indicating Resident #7 was cognitively intact. Review of the C[CONDITION] NOMNC revealed the family was notified via telephone of Medicare non-coverage on 5-3-17. There was no 2 day written notice given. There was no evidence that the resident was notified in writing of Medicare non-coverage as required. Although the resident had Part A days remaining and the resident stayed in the facility, no liability notice (C[CONDITION] or 1 of 5 C[CONDITION]-approved letters) was available for review. (2) Resident #3's last covered Part A day was on 5-17-17. MDS Coordinator #2 reviewed the MDS assessment and stated that the resident's BI[CONDITION] score was 13, indicating Resident #3 was cognitively intact. Review of the C[CONDITION] NOMNC revealed the family was notified via telephone of Medicare non-coverage on 5-15-17. There was no evidence that the resident was notified in writing of Medicare non-coverage as required. During an interview at the time of the review, RN #… | 2020-09-01 |
| 4021 | 4021 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 157 | G | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of Lippincott Procedures-Fall Management policy, the facility failed to notify the responsible party (RP) and/or the physician of changes in residents' conditions requiring potential physician intervention for 3 of 3 sampled residents reviewed for notification. Resident #156 had no evidence of physician or responsible party notification of a fall. Resident #42 had no evidence of the responsible party and/or the physician being notified of the following: a fall, a complaint of harm by a Certified Nursing Assistant (CNA), and the results of a urinalysis and the physician's decision not to treat the infection. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review of the Care Plan on 9/7/17 at 3pm revealed the resident fell on [DATE], 5/10/17, and 5/16/17. Review of the Nurse's Note on 9/7/17 at 3:10pm, revealed an entry on 5/6/17 that stated, S/p (status [REDACTED]. Further review of the Care Plan regarding falls revealed it had been updated with a handwritten entry that noted, 5/4/17 fall: no injuries. There was no evidence in the medical record that the responsible party or physician was notified of the fall. Further review revealed a Nurse's Note dated 5/18/17 that stated, Resident s/p fall on 5/15/17 with injury to forehead. Her (his) left eye is swollen but no pain. Neuro checks completed. There was no evidence in the record that the physician or responsible party was notified of the newly identified swollen eye and the injury to forehead. During an interview on 9/7/17 at 3pm, the DON verified there was no documentation in the record regarding notification of the responsible party or the physician of the fall on 5/4/17, or the injuries noted from the 5/15/17 fall. Review of the Lippincott Procedures- Fall Management policy provided by the facility on 9/9/17 at 3pm revealed that the procedures for a resident fall included: A post fall assessment, mon… | 2020-09-01 |
| 4022 | 4022 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 159 | C | 1 | 1 | 4HVH11 | > Based on record review and interview the facility failed to provide the residents/responsible parties quarterly statements for personal funds managed by the facility for 2 of 2 sampled residents reviewed for personal funds. Resident #42 and Resident #65 were not receiving quarterly statements for personal funds managed by the facility. The findings included: During an interview on 9/6/17 at 12:07pm, the responsible party for Resident #42 stated s/he hadn't gotten quarterly statements June of 2017. On 9/6/17 at 1pm, Resident #65 stated s/he had not received quarterly statements until this past June of 2017. During an interview on 9/8/17 at 2:30pm, the Business Office Manager (BOM) verified that the residents just started receiving their quarterly statements for March, April, and May 2017 in June. The BOM stated s/he received a lot of questions because the residents were not used to getting their statement notifications. S/he was unable to provide evidence that the residents received quarterly statements prior to June 2017. | 2020-09-01 |
| 4023 | 4023 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 160 | B | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to release funds within 30 days of death for 2 of 3 sampled residents reviewed for personal funds. Resident #121 and Resident #135 did not have their funds released within 30 days of their death. The findings included: On [DATE] at 2:45pm, review of records with the Business Office Manager revealed Resident #121 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. Further review revealed Resident #135 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. During an interview on [DATE] at 2pm, the facility administrator stated they did not have a policy, but followed Center for Medicaid/Medicare Services (C[CONDITION]) regulations. | 2020-09-01 |
| 4024 | 4024 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 164 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility document titled, Skills Competency Checklist Form: Treatment Nurse/Treatment Procedure Wound & Skin Checklist, the facility failed to ensure privacy during wound care for Resident #111 for 1 of 3 observed during wound care. The findings included: The facility admitted Resident #111 with [DIAGNOSES REDACTED]. An observation on 9/7/2017 at approximately 4:00 PM revealed wound care for Resident #111 performed without privacy being provided. Licensed Practical Nurse (LPN) #1 and LPN #5 knocked on the door for Resident #111 and waited for a response to enter. Resident #111 is unable to speak so LPN #1 stated his/her name and went into the room. This surveyor also knocked on the door and asked for permission to enter. This surveyor also requested permission to observe wound care and Resident #111 nodded that is was ok to observe. LPN #1 explained the procedure to Resident #111, closed the room door and proceeded to explain the procedure to the resident. The privacy curtain was pulled 1/2 way around the bed leaving an open area in view of the doorway. The resident room was a semi-private room and the roommate was in his/her bed. During wound care the roommate put on his/her call light for assistance and 2 Certified Nursing Assistants (CNAs) knocked on the door and LPN #5 yelled, patient care. The two CNAs and a nurse entered the room and walked over to Resident #111's roommate and proceeded with his/her care. Resident #111 was not afforded privacy during wound care. An interview on 9/8/2017 at approximately 4:45 PM with LPN #1 confirmed that Resident #111 had not been afforded privacy during would care. Review on 9/8/2017 at approximately 5:20 PM of the facility document titled, Skills Competency Checklist Form: Treatment Nurse/Treatment Procedure Wound & Skin Checklist, under #10 states, Protect patient/resident's dignity by providing privacy (such as curtain). The facility did not have a… | 2020-09-01 |
| 4025 | 4025 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 167 | C | 1 | 1 | 4HVH11 | > Based on observations and interviews, the facility failed to ensure results of the previous three years of survey results were readily available for resident/family and visitor review. The findings included: From 9-5-17 through 09/08/2017 at 6:28 PM, the survey results were observed in the front lobby, inside of a brown box located on the wall, to the left of the Reception Desk. The label on the brown box stated, Annual Survey Results. Inside the box was a notebook and the contents included survey results from the years 2016 and 2015. A sign was posted in a courtyard exit corridor as to the location of the survey results. This area was not readily accessible to residents or visitors unless entering the courtyard. There was no sign to indicate how to access 3 years of survey/complaint results upon request. The Administrator verified the survey results from the previous 3 years were not accessible and stated, They're in my office. S/he confirmed that the notebook contained survey results from the previous 2 years. On 9/8/2017 at approximately 6:45 PM, the Administrator placed the survey results from 2014 in the Annual Survey Result Book. | 2020-09-01 |
| 4026 | 4026 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 223 | G | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Abuse Identification and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to ensure the residents rights to be free from abuse for 1 of 3 sampled residents reviewed for abuse. The facility failed to provide an environment free from abuse. The staff failed to identify the incident as possible abuse. They failed to report the incident to administration and investigate the incident. Resident #42 stated the Certified Nursing Assistant (CNA) hurt her/his wrist during care and had requested the CNA not come back. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed a Nurse's Note dated 5/21/17 that stated Resident reports that CNA hurt her (his) wrist and made a verbal request for the CNA not to come back. There was no evidence of the staff identifying and reporting the allegation of abuse to administration. There was evidence that the CNA's assignment was changed. There was no evidence that the CNA was immediately suspended to protect all residents until the investigation of alleged abuse was completed. There was no evidence in the record that the responsible party was notified of the allegation of abuse, nor that the physician was made aware of the hurt wrist. Review of the facility [MEDICATION NAME] and Incident Log on 9/9/17 at 3pm revealed no evidence of the occurrence being investigated or reported. The facility policy for Abuse Identification on 9/9/17 at 4pm stated the following: 1. In attempting to identify a type of abuse or neglect, the following will be examined as to whether it is suspicious and may constitute abuse or neglect: Abuse Indicator includes complaints of pain with or without injury. 2. Any person hearing a complaint of any signs and symptoms of abuse or mistreatment should report it to the Administrator as soon … | 2020-09-01 |
| 4027 | 4027 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 225 | G | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Abuse Identification and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report and investigate an allegation of abuse to the State Agency for 1 of 3 sampled residents reviewed for abuse. The facility failed to investigate the report of alleged abuse and failed to report the initial allegation of abuse by Resident #42 within the two-hour timeframe to the state agency. Resident #42 stated the Certified Nursing Assistant (CNA) hurt her/his wrist during care and requested the CNA not come back. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed a Nurse's Note dated 5/21/17 that stated Resident reports that CNA hurt her (his) wrist and made a verbal request for the CNA not to come back. There was no evidence of the staff identifying and reporting the allegation of abuse to administration. There was evidence that the CNA's assignment was changed. There was no evidence that the CNA was immediately suspended to protect all residents until the investigation of alleged abuse was completed. There was no evidence in the record that the responsible party was notified of the allegation of abuse, nor that the physician was made aware of the hurt wrist. Review of the facility [MEDICATION NAME] and Incident Log on 9/9/17 at 3pm revealed no evidence of the occurrence being investigated or reported. The facility policy for Abuse Identification on 9/9/17 at 4pm stated the following: 1. In attempting to identify a type of abuse or neglect, the following will be examined as to whether it is suspicious and may constitute abuse or neglect: Abuse Indicator includes complaints of pain with or without injury. 2. Any person hearing a complaint of any signs and symptoms of abuse or mistreatment should report it to the Administrator as soon as possible… | 2020-09-01 |
| 4028 | 4028 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 241 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, the facility failed to ensure that residents were served beverages in non-disposable glasses and failed to ensure that residents were not given injections, medications and treatments in the dining room in front of other residents and during lunch service during 2 of 2 dining observations. The findings included: On 09/07/2017 at 5:25 PM the beverages for dinner were served in plastic cups in the [AGE]0 unit dining room. An interview with the nursing staff in the dining room, he/she said the dietary staff does not bring glasses so we serve (the beverages) in the plastic cups. When the dietary employee brought out glasses at approximately 5:45 PM the nursing staff then began to serve the beverages in glasses to the residents. On 09/07/2017 at approximately 6:00 PM an interview with the CDM (Certified Dietary Manager), he/she said that glasses are available and the dietary staff delivers the glasses to the dining rooms before meal service. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During Lunch meal observation in Summit Dining room on 9/5/17 at 12:29 PM, LPN #1 was observed injecting [MED] into abdomen and then administering nasal spray to Resident #23 while s/he was seated in dining room. Multiple alert and oriented residents as well as visitors were present in the Summit Dining room and observed both injection and nasal spray administration. LPN #1 was later observed entering Summit Dining room at approximately 1:05 PM with glucose monitor and supplies needed to perform Finger Stick Blood Glucose test. LPN #1 then proceeded to approach Resident #151 and used a lancet to puncture one of her/his fingertips, producing a blood sample that was used to complete a finger stick blood sugar test. Multiple alert and oriented residents as well as visitors were present in the Summit Dining room and observed the entire procedure. During interview on 9/7/17 at approximately 11:30 AM, Resident #23 was abl… | 2020-09-01 |
| 4029 | 4029 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 247 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and responsible party interviews, staff interviews, and medical record reviews, the facility failed to provide Resident #42, Resident #107, and Resident #257, or their responsible parties, with notification prior to being moved to another room. The facility failed to provide Resident #223 with notification prior to the arrival of a new roommate on three occasions. Three of 3 residents reviewed for Admissions/ Transfers/ Discharges and 1 of 3 residents reviewed for urinary tract infections did not have evidence in their medical records that either the Resident or their Responsible Party were notified prior to either a room change or the arrival of a new roommate. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. During a telephone interview on 9/6/17 at 12:18 PM, the Responsible Party (RP) for Resident #42 revealed that s/he was aware of room change that occurred upon return from the hospital on [DATE], but was not notified by the facility prior to room change that subsequently occurred on 8/25/17. During interview with Business Office Manager (BOM) on 9/7/17 at 11:05 AM, s/he revealed that Resident #42 was moved to room [ROOM NUMBER]B on [DATE] upon return from the hospital, and was again moved to room [ROOM NUMBER]P on 8/25/17. When LPN #3 was asked during interview on 9/7/17 at 12:20 PM who was responsible for notifying the resident/ responsible party when there is to be a room change, s/he replied that Social Services makes the notification and would be responsible for documenting the notification. S/he further elaborated a nurse would be the one to notify the resident and/or family if there was a clinical reason/ emergent reason and then document the room change/ notification, etc. During interview with Social Services #1 on 9/7/17 at 2:45 PM, s/he was asked who notifies families / residents of room changes when they occur. S/he replied, If planned room change, then social services wi… | 2020-09-01 |
| 4030 | 4030 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 248 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the Comprehensive assessment, the interests of and to support the physical, mental and psychosocial well being of Resident #[AGE] and #[AGE] for 2 of 2 residents reviewed for Activities. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 1:49 PM of the, Initial/Annual Activity Assessment Form, dated 7/25/2017 revealed current activity interests as exercising/walking, music, reading (books on tape, Spiritual/Religious activities, watching television, talking/conversing and sports (basketball and golf). Review on 9/9/2017 at approximately 2:00 PM of the, Group Attendance Record Form, for June 2017 revealed television on 6/6/2017 and a visitor on 6/14/2017 and 6/30/2017. No other activities were documented for Resident #[AGE] in June. Review on 9/9/2017 at approximately 2:00 PM of the, Group Attendance Record Form, for July 2017 revealed watching television on 7/6/2017, 7/7/2017 and 7/26/2017. Resident #[AGE] was read his/her mail on 7/28/2017. Further review on 9/9/2017 at approximately 2:10 PM of the, Group Attendance Record Form, for August 2017 revealed Resident #[AGE] actively participated in a social on 8/2/2017 and watched television on 8/4/2017, 8/16/2017 and 8/ 7. He/she had a visitor on 8/11/2017. No other activities were provided or documented as offered or encouraged for Resident #[AGE]. The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/8/2017 at approximately 8:25 AM of the, Activity Assessment Form, dated 6/12/2017 revealed current activity interests of music (Gospel, [AGE]'s, 70's and dance), reading (Bible Study), Spiritual/Religious activities, watching television (game shows) and gardening/plants (Roses). Review on 9/8/2017 at approximately 8:40 AM of the, Group Attendance Record Form, for… | 2020-09-01 |
| 4031 | 4031 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 250 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #[AGE]. No evidence in the medical record that Resident #[AGE] was provided social services from 10/14/2016 through 6/11/2017. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 2:28 PM of the, Social Services Progress Notes, revealed a note on 10/14/2016 and no other social service notes until 6/12/2017 for Resident #[AGE]. During an interview on 9/9/2017 at approximately 2:45 PM the Social Services Director stated, there was no social service staff from 10/14/2017 until 6/12/2017 so during that time from 10/14/2016 until 6/12/2017 (8 months) Resident #[AGE] did not received medically related social services. | 2020-09-01 |
| 4032 | 4032 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 258 | E | 1 | 1 | 4HVH11 | > Based on interview and review of Resident Council Meeting Minutes, the facility failed to maintain comfortable sound levels on 2 of 2 units. The findings included: During stage 1 of the standard survey on 9/5/17, sampled residents were interviewed concerning their perception of noise levels related to comfort. Residents #133, 65, 219, [AGE], and the family of Resident #1[AGE] each indicated there was a problem with the noise levels. Review of the facility's Resident Council Meeting Minutes on 9/9/17 at 10:20 am revealed in October of 2016, and in February and April of 2017, concerns by residents of discomfort related to the levels of noise. The activities director was interviewed on 9/9/17 at 9:56 AM, and s/he revealed that since s/he took over facilitating the Resident Council minutes, concerns were brought to the attention of staff and have been being addressed as they come to the attention of staff. There was no evidence that the facility has made an effort to resolve this concern related to noise. | 2020-09-01 |
| 4033 | 4033 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 278 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, Version 1.14, Chapter 3, the facility failed to accurately code Sections C and D on the Minimum Data Set (MDS) assessments for 1 of 1 sampled resident reviewed for hospice and 1 of 4 sampled residents reviewed for choices. Based on the incorrect coding, the mood interview was not attempted/conducted with Resident #178 and the Brief Interview for Mental Status (BI[CONDITION]) was not attempted/conducted with Resident #210. The findings included: The facility admitted Resident #210 with [DIAGNOSES REDACTED]. Closed record review on 9-9-17 at 12 PM revealed that the 5-11-17 Admission/5 Day Minimum Data Set (MDS) Section B was coded that Resident #210 had unclear speech, was sometimes understood and sometimes had the ability to understand others. Under Section C, Cognitive Patterns, the BI[CONDITION] interview was not attempted/conducted because the resident was noted as rarely/never understood. A staff assessment was conducted on Resident #210. The resident mood, preferences for customary routine and activities, and pain interviews were conducted. During an interview on 9-9-17 at 12:20 PM, MDS Coordinator #2 stated that Social Services was responsible for completion of the BI[CONDITION]. S/he reviewed Sections B and C of the MDS and verified the coding. MDS Coordinator #2 stated, The interview should have been attempted. Question #1 was coded wrong. The Resident Assessment Instrument (RAI) Manual, Version 1.14, page C-1, related to the BI[CONDITION], states: Steps for Assessment 1. Determine if the resident is rarely/never understood verbally or in writing. If rarely/never understood, skip to C0700 - C1000, Staff Assessment of Mental Status . Code 0, no: if the interview should not be attempted because the resident is rarely/never understood, cannot respond verbally or in writing, or an interpreter is needed but not available. Skip … | 2020-09-01 |
| 4034 | 4034 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 279 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop comprehensive care plans related to activities for Resident #[AGE], discharge plan and status of Adult Protective Services involvement for Resident #207, risk for mood fluctuations that require use of antidepressant and risk for grief adjustment related to sudden expiration of roommate and room change for Resident # 107 and discharge plan and Preadmission Screening and Resident Review (PASARR) level 2 services for Resident #55, for 1 of 2 reviewed for activities, 1 of 3 reviewed for hospitalization and 1 of 1 reviewed for PASARR Level 2 services, 1 of 3 reviewed for room change and 1 of 3 reviewed for Urinary Tract Infections. The findings included: Resident #55 was admitted with multiple diagnoses, including but not limited to [MEDICAL CONDITION]. Continued record review of Resident #55's care plan did not address or indicate the resident's discharge plan/goals, nor did it reference the mental illness per the Level 2 PASARR. During an interview with Social Services #3, on [DATE] at 11:16 AM, revealed knowledge of the serious mental illness and recommendations as well as the discharge plans and goals to not be on the resident's care plan. According to Social Services #3, the information about the resident's [DIAGNOSES REDACTED]. Resident #207 was admitted with multiple diagnoses, including but not limited to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Record review indicated a Summons, a Complaint and an Affidavit from [STATE] Department of Social Services, involving Resident #207's status as a vulnerable adult requiring state intervention. Record review revealed a social services note written on [DATE] that stated, Discharge plan for Resident is to remain at facility for short term placement. There were no further references to discharge planning in the social service progress notes. Continued record review of Resident #207's care plan did not address or reference the re… | 2020-09-01 |
| 4035 | 4035 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 280 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policies titled Care Plans and Occurrence Reduction Program, the facility failed to prepare, review and revise a comprehensive plan of care using an interdisciplinary team with inclusion of the resident in the plan of care for 10 of 20 residents reviewed for Care Plan participation and revision. Resident #156 and Resident #247 did not have the Care Plan updated with interventions to prevent recurrence of falls. Resident #156 did not have the Care Plan revised to reflect skin care treatment and interventions. Resident #210 did not have the Care Plan updated with a newly developed pressure ulcer. A Registered Nurse (RN) involved in the care of the Resident did not contribute to the Care Plan process for Resident #[AGE], Resident #90, and Resident #1[AGE]. A Certified Nurse's Assistant (CNA) was not involved in the Care Plan process for Resident #1[AGE]. Resident #22 had no evidence of participation in the Care Plan. Resident #178 had no evidence of hospice or family participation in the Care Plan. The findings included: The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 9/7/17 at 2pm and review of the facility Incident Log on 9/9/17 at 1:20pm revealed the resident fell on [DATE], 4/12/17, 7/30/17, 8/3/17, 8/7/17 and 9/3/17. Review of the facility Care Plans policy on 9/9/17 at 3pm stated, Care Plans will be updated by the nurses, Case Mix Directors, or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. Review of the Care Plan on 9/7/17 at 2pm, revealed a problem for Potential for injury from falls due to impaired balance and mobility related to history [MEDICAL CONDITION] right [MEDICAL CONDITION]. The falls that occurred on 7/30/17 and 8/3/17 were not reflected on the Care Plan, and there were no changes in fall prevention interventions. During an interview on 9/8/17 at 11:… | 2020-09-01 |
| 4036 | 4036 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 282 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow the developed care plan with regard to activities for Resident #[AGE], respiratory complications for Resident #207, interventions for a Urinary Tract Infection for Resident #257, fall interventions and dental services for Resident #42, for 1 of 2 residents reviewed for activities, 1 of 3 residents reviewed for hospitalization , 1 of 1 resident reviewed for Urinary Tract Infections, and 1 of 1 resident reviewed for accidents. The findings included: Resident #207 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. Record review of the resident's care plan on 9/7/17 at 9:00am, revealed the care plan's on page 3 of 10 describe care and services related to the resident's respiratory complications . The problem onset date was documented as 6/4/17, and stated, Potential for respiratory complications. (Handwritten) 8/14/17 - Q1 Conts to recover O2 as indicated Cont poc. The approaches to the Resident's potential for risk included, but aren't limited to, Provide O2 and inhalers as indicated. Notify MD of any respiratory complications. Continued review of the resident's medical record, revealed in the nurse's notes, no indication of respiratory distress or concern had been provided to the physician. Nurse's notes reviewed since admission revealed multiple notations of oxygen use/therapy with no indication of physician notification as outlined on the resident's care plan. The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 1:49 PM of the, Initial/Annual Activity Assessment Form, dated 7/25/2017 revealed current activity interests as exercising/walking, music, reading (books on tape, Spiritual/Religious activities, watching television, talking/conversing and sports (basketball and golf). Review on 9/9/2017 at approximately 2:00 PM of the, Group Attendance Record Form, for June 20… | 2020-09-01 |
| 4037 | 4037 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 309 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: [STATE], and review of the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. CPR was not initiated for Residents #205 and #210 when they were noted without vital signs. Advance directives were signed by the family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. In addition, based on observation, record review and interviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 5 of 5 residents reviewed for care and services. The facility failed to monitor Resident #257 for adverse effects and/or complications related to the administration of antibiotic therapy with failure to maintain contact isolation precautions on a consistent basis as ordered. The facility failed to monitor for mood fluctuations related to potential grief or adjustment issues related to unexpected roommate expiration and subsequent room change. The facility failed to ensure that Resident # 95's temperature was consistently monitored with antibiotic administration for active infection, with further failure to ensure that urology consultation was arranged as ordered by physician. The facility failed to ensure that Resident … | 2020-09-01 |
| 4038 | 4038 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 312 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to assist with activities of daily living (ADL) for 1 of 2 sampled residents reviewed for dental services. Resident #42 was observed over 3 days without assistance to insert dentures. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. During observations made by the surveyor on 9/5/17 at 1pm and 3pm, on 9/6/17 at 8:55am and 10:46am, on 9/7/17 at 8:56am, 11:26am, 1:30pm, 4pm, and 5:32pm, there were no dentures in place on the resident. During observation and interview on 9/7/16 at 11:26am, the resident was receiving therapy. When the surveyor asked the resident if s/he had dentures in place, s/he stated, No, but please put them in, just rinse them off with water first. The therapist stated s/he would put them in after therapy was completed. During observations later that day at 1:30pm, 4pm, and 5:32pm, the resident was not wearing dentures. Review of the Care Plan on 9/6/17 at 5:15pm, revealed a Care Plan that stated, Potential for acute oral/dental problems, with interventions to include, Assist resident with oral care as needed, and make sure resident has denture adhesive to prevent slipping. Further review of the Certified Nursing Assistant (CNA) Care Interventions Record form on 9/9/17 at 10am, stated the resident requires total care and has upper and lower dentures. During an interview on 9/6/17 at 12:10pm, the responsible party (RP) stated, They never put her (his) dentures in, and she (he) always put them in when she (he) comes and visits, and other family and church members come visit and notify me that the resident's dentures are not in place. | 2020-09-01 |
| 4039 | 4039 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 314 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, interviews and review of the facility form titled, Skill Competency Checklist Form: Treatment Nurse/Treatment Procedure Wound & Skin Checklist, the facility failed to ensure proper wound care during a dressing change and failed to ensure wound assessments were completed timely for Resident #[AGE]. The facility further failed to ensure Resident #210 did not acquire a pressure ulcer while in the facility. The facility additionally failed to ensure wound assessments, staging and measurements were completed for Resident #210. Resident #210 was admitted with a pressure ulcer and the facility failed to assess the wound for 7 days for 2 of 4 residents reviewed with Pressure Ulcers. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. An observation on on [DATE] at approximately 11:03 AM during wound care for Resident #[AGE], Licensed Practical Nurse (LPN) #1 washed his/her hands and applied gloves. LPN #5 proceeded to remove Resident #[AGE]'s brief. The soiled dressing had already been removed. LPN #1 cleansed the sacral wound with normal saline soaked gauze wiping upward from the lower buttocks toward the sacral wound. (LPN #1 failed to cleanse the wound bed inside out in a circular motion.) LPN #1 patted a dry 4 x 4 all over and around the wound and removed his/her gloves, washed his/her hands. LPN #1 applied clean gloves and proceeded to apply the [MED] in the wound bed that had been cut using scissors from his/her pocket that had not been cleaned prior to cutting the [MED]. LPN #1 then applied a foam dressing that had been dated and initialed. LPN #1 remover his/her gloves, washed his/her hands while the assistant, LPN #5 bagged the trash. LPN #1 then carried the soiled linen and trash to the soiled utility room, and washed his/her hands prior to charting the completed treatment. During an interview on [DATE] at approximately 5:15 PM with LPN #1, he/she confirmed the the… | 2020-09-01 |
| 4040 | 4040 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 323 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure: 1) Fall interventions were in place for 2 of 2 residents reviewed for falls, Residents #42 and #156 2) Fall interventions were not implemented to reduce the risk of falls 3) Dining room free of choking hazards; artificial and styrofoam based fruit had teeth marks and evidence of entire bites missing from the artificial fruits on display and 4) Unsecured medications in resident's rooms were accessible to mobile residents in 2 of 3 residents reviewed for accidents, in 1 of 4 dining rooms and a random observation. The findings included: During initial tour on 09/05/2017 at 11:05 AM, in the 500 unit dining room were 3 baskets on a stand, each basket contained artificial fruit; green and red artificial apples made of styrofoam. Multiple artificial apples had teeth marks and/or entire bites taken from the fruit and an area of white styrofoam remained in the absence of the red or green area where the bite mark had occurred. On 09/05/2017 at 11:49 PM this observation was verified by RN #5 who removed the apples and said: Thank you for telling me. During the Initial Tour on 09/05/2017 at 12:41 PM, a bottle of [MED] 5000 units containing 13 pills, a bottle of [MED] containing 15 pills, and a bottle of [MED], eye vitamin and mineral supplement, with approximately [AGE] pills were observed on the over bed table of Resident #133's room. 09/05/2017 at 12:58 PM a 32 ounces bottle of [MED], a wound cleanser, was observed on top of a dresser, and an 8 ounce a bottle of [MED] 0.12%, an oral rinse, was noted on the bathroom sink were also observed. Record review on 09/05/2017 at 5:50 PM revealed no Physician's Order for medication at the bedside and no assessment for self-administration. During an interview on 09/05/2017 at 6:01 PM the Director of Nursing (DON) stated s/he had not been aware of the medication in the resident's room. When asked how s/he would handle the situation, s/he stated, … | 2020-09-01 |
| 4041 | 4041 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 328 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an observation, interview and review of the facility policy titled, Medication Administration: Enteral Tubes, the facility failed to confirm placement of and flush a [MEDEQUIP] tube for Resident #178 prior to administering a medication via the tube. The facility further failed to ensure the correct tube feeding was infusing as ordered by the physician for Resident #178 for 1 of 1 resident observed with a [MEDEQUIP] tube. The findings included: The facility admitted Resident #178 with [DIAGNOSES REDACTED]. An observation on 9/7/2017 at approximately 11:45 AM, during wound care for Resident #178, Licensed Practical Nurse (LPN) #4 administered a pain medication via a [MEDEQUIP] tube without first checking for placement and flushing the [MEDEQUIP] tube with a physician ordered water flush. During an interview on 9/7/2017 at approximately 11:48 PM with LPN #4 it was verified that placement had not been checked and the water flush was not done for Resident #178 prior to administering a medication via a [MEDEQUIP] tube. Review on 9/7/2017 at approximately 1:48 PM of the facility policy titled, Medication Administration: Enteral Tubes, number 8 states, Enteral tubes will be flushed before administering medications with 15 mls (milliliters) of water, with 5 mls of water after each medication, and 15 mls at completion of the medication administration. Flushes may be changed due to physician's order. Under, Scope: Procedure & Key Points, number 5 states, Verify tube placement using the following procedures: Inject 15 - 20 cc's of air into the tube with the syringe and listen to stomach with stethoscope for distinct whooshing sound. Aspirate stomach contents with syringe. Observations made on all days of the survey revealed Resident #178 with a tube feeding of Glucerna 1.5 at 45 cc's infusing hourly with a water flush of 125 centimeters every 4 hours. Review on 9/8/2017 at approximately 5:28 PM of a physician's order for Resident #178 dated 7/… | 2020-09-01 |
| 4042 | 4042 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 329 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure that each resident's drug regimen be free from unnecessary medications for 2 of 5 residents reviewed for unnecessary medications. Resident #247 and Resident #22 received medication(s) without supportive [DIAGNOSES REDACTED]. The findings included Record review on 09/09/2017 at 2:09 PM revealed Physician's Orders for [MED] 50 milligram tablet to be given every night at hour of sleep. Medication Administration Record [REDACTED]. Additional review of medical record for Resident #247 revealed no identified [DIAGNOSES REDACTED]. The Consultant Pharmacist Drug Regimen Review form with entry dated 8/17/17 included inquiry to physician regarding [DIAGNOSES REDACTED].? dx (diagnosis) [MED] 50 hs (hour of sleep). Further review of monthly physician orders from admission through 8/1/2017 and telephone orders from admission through most recent telephone order at time of review dated of 9/1/17 revealed that there were no orders or clarifications initiated to identify the [DIAGNOSES REDACTED]. During an interview on 9/9/17 at 7:19 PM, the Director of Nursing verified that there was no response from physician regarding pharmacist request on 8/17/17 for identification of the [DIAGNOSES REDACTED]. No additional evidence was provided by facility during the remainder of both the standard and extended survey that was completed on 9/15/17. The facility admitted Resident #22 with diagnosed including: [DIAGNOSES REDACTED]. Record review on 09/06/2017 at 9:14 AM revealed Physician's Orders for Mag Oxide 400mg (milligrams) to be given 3 times daily, Zinc [MED] 220mg, [MEDICATION NAME] 325mg, Vitamin C 500mg, Vitamin B6 50mg, Vitamin E 1000 units, and [MED] 1000mg to be given daily. There was also an order for [REDACTED]. There were no laboratory reports to substantiate any deficiencies related to medications given or reason for continued use. During an interview on 09/07/2017 at approximately 5:00… | 2020-09-01 |
| 4043 | 4043 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 332 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews the facility failed to ensure that the medication error rate was maintained at less than 5 % (percent). There were 3 medication errors out of 25 opportunities for error resulting in a 12% error rate. These errors occurred when administering medications to Resident 108 who had [DIAGNOSES REDACTED]. (Error #1-Cross refer F441) The findings include: Error 1: During observation of medication pass on 9/6/27 at approximately 9:34 AM on the TCU (Transitional Care Unit), RN (Registered Nurse) # 2 performed a finger stick to the middle finger of the right hand of Resident 108 and used a glucometer to determine the blood glucose level. The reading was 1[AGE] and no [MED] was administer based on this result. A breakfast of juice, non-fat milk and cereal with spoon was on the residents bed side table. When RN # 2 returned to the medication cart he/she placed the glucometer in the cart without cleaning. When asked, he/she stated that the same glucometer was used for all residents needing finger sticks from that medication cart. He/she also stated that he/she had not wiped off the glucometer this time, but sometimes will use an alcohol prep pad to wipe off the glucometer because he/she did not like to use the messy Clorox wipes which are in the medication cart. After medication administration was completed and signed off by RN #2 on 9/6/17 at approximately 9:39 AM he/she stated all medications had been administered. During medication pass reconciliation on 9/6/17 at approximately 9:42 AM, a review of the September, 2017 physicians orders revealed that a finger stick had been ordered for 6:30 AM and 4:30 PM each day . On 9/6/17 at approximately 10:15 AM RN # 2 acknowledged that she had performed the finger stick and that the Residents MAR (medication administration record) stated it should be done at 6:30 AM and that 6:30 AM results of 132 had already been performed and recorded by the previous shift. R… | 2020-09-01 |
| 4044 | 4044 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 334 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of the facility policy titled, Influenza (Flu) Vaccinations for Healthcare Center Patients and Pneumococcal Vaccinations, the facility failed to ensure an informed consent was obtained for Resident #90 prior to receiving the Flu vaccine in 2016. Resident #90 has not been offered the Pneumonia Vaccine since 2015. The facility further failed to ensure Resident #82 was offered the Flu vaccine or received the education on the Flu vaccine for 2016 for 2 of 5 residents reviewed for Immunizations. The findings included: The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Review on 9/6/2017 at approximately 11:58 AM of the Immunization Summary Record Form for Resident #90 revealed documentation that Resident #90 received the Flu Vaccine on 10/8/2016 in the right thigh with Lot # 01 with an expiration date of 4/2017. No signed consent form could be found in the medical record for Resident #90 prior to receiving the Flu Vaccine in 2016. No documentation could be found to ensure that Resident #90 has been offered the Pneumonia Vaccine since 2015. Review on 9/6/2017 at approximately 12:48 PM of the revised document dated 1/20/2015, titled,Influenza (Flu) Vaccine Consent/Refusal Form, states, Permission to receive the vaccine will be obtained on admission, annually, with any significant changes, or as ordered by the physician, patient/resident or family. The order will remain valid and appear each October on the physician order sheet unless discontinued by the physician. Review on 9/6/2017 at approximately 1:00 PM of the facility policy tiled, Influenza (Flu) Vaccinations for Healthcare Center Patients, states, All patients who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with the vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefit… | 2020-09-01 |
| 4045 | 4045 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 366 | D | 1 | 1 | 4HVH11 | > Based on observation, interview and review of the facility's policy and procedures, the facility failed to ensure that an alternate option was offered to residents who refused lunch trays in 2 of 4 residents observed refusing meals in 1 of 2 dining observations. The findings included: During the dining observation of the residents receiving hall trays on 9/5/2017 at 1:13 PM, observed a resident on the 500 unit refusing lunch after the tray was placed in front of him/her, the CNA (Certified Nurse Assistant) asked the resident, Are you sure you do not want this? The resident shook his head no and waved his hand to indicate he did not want the tray. The CNA then removed the tray from the resident's bedside table and walked out of the room. During the dining observation on 9/5/2017 at approximately 1:30 PM, observed a resident on the [AGE]0 unit refusing his/her lunch after the meal tray was placed in front of him/her, the resident said: I am nauseous. The CNA then removed the tray from the resident's bedside table and walked out of the room. On 9/07/2017 at approximately 4:00 PM, the CDM (Certified Dietary Manager) is aware that residents shall be offered alternates when meals are refused and said that the Dietary Department maintains multiple options for residents who refuse meals. On 09/09/2017 at approximately 10:30 AM, RN #1, the Staff Educator said the all CNA Staff are trained during orientation about how to handle meal refusals. He/She said if resident refuses meal, an alternate should be offered, if the resident does not want alternate, the CNA should notify the nurse of the resident's meal refusal. Review of the form titled: Day 2 Nursing Orientation, .3.If they refuse a meal offer the resident an alternate, and if the resident continues to refuse, notify the nurse. | 2020-09-01 |
| 4046 | 4046 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 367 | D | 1 | 1 | 4HVH11 | > Based on observations, record review and interviews the Facility failed to ensure that Resident 30 received the correct mechanically altered diet as ordered by the physician in 1 of 4 dining room observations, The findings include: On 9/5/17 at approximately 12:54 PM during dining observation in the Killian (Hall [AGE]0) dining room Resident 30 was noticed not to be eating a slice of ham which had been served to him/her. The resident refused to let the Surveyor look at his/her diet slip. On 9/5/17 at approximately 1:02 PM a review of the September, 2017 physicians orders revealed that Resident 30 should be receiving chopped meats. On 9/5/17 at approximately 1:08 AM Certified Nursing Assistant # 1 and Registered Nurse # 1 acknowledged that Resident 30 had been incorrectly served sliced ham instead of the chopped ham as ordered by the physician. | 2020-09-01 |
| 4047 | 4047 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 371 | F | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility policy the facility failed to ensure: 1) Foods for storage are labeled and dated after removal from the original container. 2) Expired foods were removed from refrigeration units in the main kitchen, the satellite kitchens, and the supply room where the emergency food supply was located, 3) The dietary staff were wearing proper hair and beard protection during food preparation, 4)The dietary staff were not chewing gum and eating during food preparation and dishwashing, 5)The kitchen and the satellite kitchens walls and floors, and floor drains were free of dirt, debris and in good repair during food preparation, 6) The meat slicer, can opener, pans, pan lids, food storage bins in the main kitchen were clean and sanitary, 7) The Microwave oven, the steamtable units,the refrigerator and freezer units in the satellite kitchens were clean and sanitary, 8) The sanitizer solution was at the strength required for sanitizing pots and pans at 200 ppm (parts per million) in the three compartment sink of the main kitchen, 9) The sanitizing solution in the sanitizer buckets was at the required strength of 200 PPM for sanitizing work surfaces in the main kitchen, 10) The food temperature of baked fish on the serving line in 3 of 4 the satellite kitchens was 135 degrees or greater, 11) Food served to residents comes directly from the kitchen and that hands are washed in between feeding different residents 12) The walk-in freezer floor in the main kitchen is hazard free of ice buildup in one of one kitchen and 4 of 4 satellite kitchens. The findings include: During initial tour in the main kitchen, on 09/05/2017 at 10:38 AM, observed in the walk-in refrigerator multiple packages of sliced cheese, a plastic wrapped package of onions which had been opened and covered with plastic wrap and were not labeled or dated, the CDM (Certified Dietary Manager) removed and stated he would label the packages. O… | 2020-09-01 |
| 4048 | 4048 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 372 | D | 1 | 1 | 4HVH11 | > Based on observation, interview and record review, the facility failed to ensure the grease storage unit and area surrounding the outside grease storage receptacle was maintained and free from spillage in 1 of 1 grease storage receptacle. The findings included: On 09/05/2017 at 12:55 PM an observation was verified by the CDM (Certified Dietary Manager) that the grease storage container located outside building has buildup of grease and debris on top of the unit and spilled, black grease and debris build up on the concrete surface in front of the grease storage container. The Form titled, Cleaning Schedule Form-Monthly, Effective 9/01/2001, Reviewed: 08/03/2017, and Revised: 4/27/2016, states Dumpster Area: Sweep around dumpster area, Remove any excess items (i.e. broken equipment, chairs, debris, etc.) | 2020-09-01 |
| 4049 | 4049 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 386 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure telephone orders were signed by the physician per policy for Residents # 107, 257 and 207. Furthermore, the facility failed to provide evidence of physician assessment and intervention for a Urinary Tract Infection [MEDICAL CONDITION] for Resident #42. Residents # 107, 257, 207 and 42 were 1 of 3 residents reviewed for UTI, 1 of 5 residents reviewed for unnecessary mediations, 1 of 3 residents reviewed for hospitalization s and 1 of 3 residents reviewed for admission, transfer, discharge. The findings included: Resident #207 was admitted to the facility with multiple diagnoses, including but not limited to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of the physician's orders on 9/8/17 at approximately 1:00pm revealed multiple physician's telephone orders that were not signed by the physician. The dates for the unsigned orders were noted to be: 7/27/17, 7/14/17, 7/13/17 and 7/12/17. During an interview with the Vice President of Clinical Services on 9/9/17 at approximately 3:11pm, s/he stated some physicians sign and date the telephone orders and some will sign and not date. S/he showed the surveyor a wall file box, in the chart room, between the 500 and [AGE]0 unit that was filled with what was indicated as signed orders that needed to be filed. Review of the facility's policy, Physician Orders, on 9/8/17 at 5:30 p.m., revealed on page 2 of 3 that with regard to verbal and telephone orders, the order should be countersigned by the responsible physician within 48 hours for patients/residents in [STATE]. The facility admitted Resident #257 with [DIAGNOSES REDACTED]. Review of the medical record for Resident #257 on 9/8/17 revealed multiple telephone orders, including but not limited to those dated 8/17/17, 8/22/17, 8/28/17, 8/29/17, 8/31/17, and 9/5/17, that did not have corresponding signed originals with physician signature filed in medical record. Review of the Fa… | 2020-09-01 |
| 4050 | 4050 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 387 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the frequency of physician visits as required. Resident #22, Resident #42, Resident #156, Resident #95, Resident #[AGE], and Resident #207 did not have documented physician visits as required for 6 out of a total of 20 sampled residents reviewed. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed that the only Physician's Progress Notes in the medical record were on 12/16/16 and 8/24/17, after readmission from the hospital to the facility on [DATE]. No further evidence of physician visits were produced after requesting physician progress notes [REDACTED]. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 2pm revealed no evidence of physician visits on the chart. A request for medical records did not produce evidence of physician visits. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 9am revealed an unsigned progress note dated 7/22/16, a Physician's Progress Note dated 7/28/16 signed by an Advanced Practice Registered Nurse, and the progress note on the back of that note was dated 8/24/17. No further evidence of physician visits from 7/28/16 through 8/24/17 were produced after requesting physician progress notes [REDACTED]. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 2:30 PM of a form titled, Physician's Progress Notes, revealed the most recent note dated 11/02/2016. No other Physician's Progress Notes were found in t… | 2020-09-01 |
| 4051 | 4051 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 406 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide evidence of psychiatric intervention as outlined by the PASARR (Pre Admission Screening) and Level 2 recommendation for Resident #207, for 1 of 1 reviewed for PASARR. The findings included: Review of the resident's Social Service Progress Notes on 9/7/17 at 8:46am revealed no indication of the resident's PASARR status, with corresponding recommendations nor interventions until 7/5/17, 7 days after admission. On 7/5/17 a progress note was entered and mentioned the resident's anxiousness and tearfulness related to the [DIAGNOSES REDACTED]. (Resident #55) agreed to eval. This writer will notify Psych staff and continue to observe and assess. Review of the physician telephone orders revealed a verbal order written and signed on 7/10/17, Psychiatry Evaluation for stabilization of anxious/irritable mood. Continued review of the resident's medical record revealed [REDACTED]. Social Services #1 and #3 were asked about the document and neither could determine its origin. It was found by Social Services #3 that the family of Resident #55 had transported the resident to a psychiatry follow up, as there was no evidence the appointment had taken place. With regard to the written order on 7/10/17 for the psychiatry evaluation, Social Services #3 stated the consultation happened and the follow up would be soon. There was no evidence of the psychiatry evaluation in the resident's medical record and the chart had not been thinned. During an interview with Social Services #1 on 9/9/17 at 11:59am stated she could not locate the progress note the correspondence with the psychiatric evaluation or visit that was to have occurred in July of 2017. S/he stated that the psychiatrist emails the progress notes to Social Services #3.During an interview with Social Services #3 on 9/9/17 at approximately 12:30pm, it was discussed that Resident #55 was to be evaluated by the psychiatrist every 2-3 weeks. … | 2020-09-01 |
| 4052 | 4052 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 428 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure that both the consultant pharmacist report any irregularities to attending physician and director of nursing and that reported irregularities are acted upon timely for two of five residents reviewed for unnecessary medications. The physician failed to review and address pharmacy recommendations requesting identification of supportive [DIAGNOSES REDACTED].#247. Additionally, the Pharmacist failed to identify irregularity in medication regimen related to diagnoses for Resident #22. The findings included Record review on 09/09/2017 at 2:09 PM revealed physician's orders [REDACTED]. Medication Administration Record [REDACTED]. Additional review of medical record for Resident #247 revealed no identified [DIAGNOSES REDACTED]. The Consultant Pharmacist Drug Regimen Review form with entry dated 8/17/17 included inquiry to physician regarding [DIAGNOSES REDACTED].? dx (diagnosis) [MED] 50 hs (hour of sleep). Further review of monthly physician orders [REDACTED]. During an interview on 9/9/17 at 7:19 PM, the Director of Nursing verified that there was no response from physician regarding pharmacist request on 8/17/17 for identification of the [DIAGNOSES REDACTED]. No additional evidence was provided by facility during the remainder of both the standard and extended survey that was completed on 9/15/17. Resident #22 was admitted to the facility with diagnosed including: [DIAGNOSES REDACTED]. Record review on 09/06/2017 at 9:14 AM revealed physician's orders [REDACTED]. There was also an order [REDACTED]. Review of the Pharmacy Consultation Report on 09/07/2017 at approximately 2:00 PM revealed no reason for continued use. The pharmacist failed to identify this irregularity. Review of the facility's policy titled Consultant Pharmacist Service Provider Requirements reads, Reviewing the medication regimen of each patient/resident at least monthly, utilizing federally-mandated standards … | 2020-09-01 |
| 4053 | 4053 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 431 | D | 1 | 1 | 4HVH11 | > Based on observations, record reviews and interviews the Facility and Consultant Pharmacist failed to assure that expired medications were kept separate from other stored medications in 1 of 2 medication rooms. The finding include: On 9/5/17 at approximately 11:22 AM during inspection of the TCU (Transitional Care Unit) Medication room (Halls 100, 200, 300) the following expired medications were found on the top shelf of the upper right cabinet. -one 1,000 ml (milliliter) unopened bottle of Sterile Water for Inhalation, USP (United States Pharmacopoeia) by Airlife Lot ZI- 21 expiration 2013-01. -one 1,000 ml unopened bottle of Sterile Water for Inhalation, USP by Airlife Lot ZI- 23 exp 2013-01. This finding was confirmed on 9/5/17 at approximately 11:33 AM by LPN (Licensed Practical Nurse) # 1 who stated no residents were receiving medication and that nurses are responsible for routinely checking the medication room for out-of-date medications. On 9/5/17 at approximately 12:35 PM the Administrator acknowledged the finding and stated that Pharmacy should have found this since they are here monthly and were here approximately two weeks ago. On 9/5/17 at approximately 3:22 PM a review of the pharmacy monthly inspections for the past 6 months did not include a finding of outdated Sterile Water for Inhalation. On 9/5/17 at approximately 4:02 PM a review of the Consultant Pharmacist Services Provider Requirement revealed the following: 3. The Consultant Pharmacist, or his designee, provides consultant pharmacist services, including but not limited to the following: Checking the medication storage facilities at least monthly in conjunction with a nursing staff representative and the medication carts at least quarterly, for proper storage of medications, cleanliness, and removal of expired medications. | 2020-09-01 |
| 4054 | 4054 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 441 | E | 0 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policies for infection control, the facility failed to follow procedures designed to provide a safe, sanitary and comfortable environment and to help prevent development and transmission of disease and infections. The facility failed to follow the physician's orders [REDACTED].#257. Staff failed to don PPE (Personal Protective Equipment) prior to entering an isolation room for 2 of 2 residents observed on contact isolation. Additionally soiled linen not bagged, handled and transported properly, and clean linen not handled properly during the folding process in 1 of 1 laundry room. Soiled linen bagged and on floor of Unit 200. The findings included: An observation on 9/7/2017 at approximately 8:10 AM during the transporting of soiled linen from the soiled utility room to the laundry room revealed soiled linen in bins not bagged. An interview on 9/7/2017 at approximately 8:12 AM with the Laundry Aide confirmed that the soiled linen should be bagged before leaving the resident's room and before putting it in the bins in the soiled utility room. An observation on 9/7/2017 at approximately 8:45 AM during the clean laundry folding process revealed the Laundry Aide folding clean sheets and allowing them to touch the floor. During an interview on 9/7/2017 at approximately 8:48 PM with the Laundry Aide, he/she confirmed the clean linen was touching the floor during the folding process. A random observation on 9/7/2017 at approximately 9:10 AM revealed Licensed Practical Nurse (LPN) #1 coming out of a resident room on the 600 Unit carrying soiled linen with his/her bare hands and holding it against his/her uniform. He/she then threw it in a pile on the floor in the hallway. This surveyor asked if that was the policy of the facility to handle soiled linen in that manner and he/she stated, I came out of the room to get a plastic bag but we usually bag the soiled linen in the resident room first. He… | 2020-09-01 |
| 4055 | 4055 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 456 | F | 1 | 1 | 4HVH11 | > Based on observations, interviews and review of the facility policy title, Cleaning of Laundry Equipment, the facility failed to ensure an excessive build up of lint was removed from the upper sides and around the wiring above the lint traps in 3 of 3 clothes dryers. The findings included: An observation on 9/7/2017 at approximately 8:25 AM of the clothes dryers revealed an excessive build up of lint on the upper sides and on the wiring above the lint traps of 3 of 3 clothes dryers. An interview on 9/7/2017 at approximately 8:40 AM with the Administrator, and after he/she observed the inside lower aspect of the clothes dryers, above the lint traps confirmed the findings. Review on 9/7/2017 at approximately 9:58 AM of the facility policy titled, Cleaning of Laundry Equipment, states under, Dryers, states, It is important that dryer filters be cleaned after every load. The frame should be cleaned daily, or as needed with a disinfectant. At the end of the day, the door should be left open to allow the gasket to reshape. Items to be cleaned on the machines are, but not limited to: Dryer filter, shelf above the filter, and the floor under the filter. | 2020-09-01 |
| 4056 | 4056 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 490 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, the facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation for 2 of 3 sampled residents reviewed for death in the facility. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide cardiopulmonary resuscitation (CPR). The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide… | 2020-09-01 |
| 4057 | 4057 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 498 | F | 1 | 1 | 4HVH11 | > Based on 10 of 10 records reviewed and interview, the facility failed to ensure that Certified Nursing Assistants (CNA) received the required training of 12 hours per year to include dementia and resident abuse prevention training. The findings included: On 9/15/17 at 1:30pm, review of the electronic records and sign in sheets for in-services revealed the facility did not use a system to track and ensure the CNAs received 12 hours of in-services per year to include dementia and resident abuse prevention training based on data presented. Review of 10 of the CNA electronic documents provided revealed that the training dates were not in order and dated back to 2014. Of the 10 reviewed, there was no evidence that the CNAs received 12 hours per year. The hand written signature sign in in-services were not entered into the electronic database. Based on the documents printed and delivered, the facility was unable to produce evidence that demonstrated the tracking of the courses and number of hours for each CNA. During an interview on 9/15/17 at 2:17pm, the staff educator verified that s/he wasn't tracking to ensure every CNA received the required 12 hours of training every year. S/he was unable to produce verification or confirmation that each CNA received at least 12 hours of training to include dementia and resident abuse prevention training. | 2020-09-01 |
| 4058 | 4058 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 500 | C | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview during the Extended Survey, the facility failed to have secured agreements without outside resources for all needed areas. The findings included: Record review during the Extended Survey revealed that at the time of the survey, there were Seven different [MEDICAL TREATMENT] Centers providing services to current residents. During an interview with the Administrator on 9/15/17 at 4:53 PM, he/she provided signed contracts for three local [MEDICAL TREATMENT] Centers; however, he/she could not provide signed contract agreements for six of the seven [MEDICAL TREATMENT] Centers which were providing services to current residents. | 2020-09-01 |
| 4059 | 4059 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 502 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure lab work was completed as ordered for 1 of 1 sampled residents reviewed for range of motion, 1 of 1 sampled residents reviewed for nutrition, and 1 of 4 sampled residents reviewed for pressure ulcers. Resident #156, Resident #95, and Resident #178 had no evidence that labs were completed as ordered. The findings included: The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. There was no evidence in the record that the resident had lab work completed every 6 months. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. There was no evidence of labs completed prior to 7/17/17 in the medical record. There was no evidence in the record that the resident had lab work completed every 6 months prior to the lab results dated 7/17/17. During an interview on 9/9/17 at 4pm, the Director of Nursing verified that no further labs were found for Resident #156 or Resident #95. The facility admitted Resident #178 with [DIAGNOSES REDACTED]. Review on 9/7/2017 at approximately 4:20 PM of the medical record for Resident #178 revealed Physician's Monthly Orders dated 7/19/2017 for a CMP (Complete Metabolic Panel) and a Lipid Panel to be completed on admission. No results for the CMP nor the Lipid Panel were found in the medical record for Resident #178. During an interview on 9/8/3017 at approximately 6:40 PM with the DON (Director of Nursing) stated, I have looked through the chart and everywhere and I cannot find the lab results for the CMP and the Lipid Panel. | 2020-09-01 |
| 4060 | 4060 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 505 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to promptly notify the physician of lab results for Residents #156, #207 and #22, for 1 of 5 residents reviewed for unnecessary medication, 1 of 1 resident reviewed for Urinary Tract Infections and 1 of 3 residents reviewed for hospitalization . The findings included: Resident #207 was admitted to the facility with [DIAGNOSES REDACTED]. Since the resident's admission to the facility there were multiple orders for Ammonia levels to be drawn secondary to the resident's diagnoses. Review of the resident's record at 5:14 p.m. on 9/8/17 revealed 2 lab results for Ammonia levels that had not been signed by the physician. Each lab was processed through a different laboratory but the results were both outside of the referenced range as indicated by the laboratory that conducted each test. Review of the nurses' notes and physician progress notes [REDACTED]. The facility's policy, Laboratory Services - Healthcare Centers ,does not address notifying the physician of lab results nor of procedures for reporting abnormal lab work, lower or higher, than the referenced range. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 09/08/2017 at 4:35 PM revealed 07/06/2017 and 08/22/2017 physician's orders [REDACTED]. Review of the lab results revealed that the blood was collected on 07/06/2017 and lab results reported the same day. On 08/22/2017, lab results revealed that the blood was collected the same day and the facility received the results via fax on 0[DATE], 3 days later. There was no evidence in the record to indicate s/he was notified/reviewed lab results as required. During an interview on 09/08/2017 at approximately 5:00 pm the Director of Nursing reviewed the record and s/he was unaware the physician was not informed of lab results for either date. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Review of laboratory results on 9/7/17 at 11:30am reveal… | 2020-09-01 |
| 4061 | 4061 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 514 | F | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure complete and accurate medical records resident records on 2 of 2 units. The following was not accurately documented and or readily accessible: 1. Nursing notes incomplete for Residents #[AGE] and Resident #257. 2. Dietary documentation incomplete for Resident #90. 3. Care Plan meeting held on 7/20/2017 and the Interdisciplinary Team signed as attending the care plan meeting on 7/19/2017. 4. Resident #111's MAR (Medication Administration Record) incomplete. 5. Resident #247's MAR indicated [REDACTED]. 6. No evidence of psychiatric evaluation for Resident #55. 7. Resident #156's medical record contained incomplete treatment records, missing May physician's orders [REDACTED].> missing skin consults. 8. Staff failed to provide documentation requested in a timely manner. 9. No method in place to track resident medical records when taken off the unit. 10. Multiple resident's records reviewed with no current Monthly physician's orders [REDACTED]. The findings included: The facility admitted Resident #1[AGE] with [DIAGNOSES REDACTED]. Review on 9/8/2017 at approximately 2:20 PM of the medical record for Resident #1[AGE] revealed a care plan attendance sheet dated and signed by the family as attending on 7/20/2017. Further review of the care plan attendance sheet indicated the Interdisciplinary Team signed as attending the care plan meeting on 7/19/2017. An interview on 9/8/2017 at approximately 2:30 PM with a Social Service worker provided documentation that the Care Plan Meeting was held on 7/20/2017. Review on 9/8/2017 at approximately 2:30 PM of the Social Services notes provided indicated a note dated 7/20/2017 states, Care Plan meeting held with this writer, MDS, Activity Director and Resident's sisters, RP (responsible party.) The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Review on 9/8/2017 at approximately 3:00 of the medical record for Resident #90 reveale… | 2020-09-01 |
| 4062 | 4062 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 516 | E | 1 | 1 | 4HVH11 | > Based on observation and interview, the facility failed to safeguard medical records, as evidenced by not accurately tracking resident's records off of the unit. The findings included: Review of the facility's policy, Signing out Active Records - reviewed and revised on 11/22/2016, on 9/15/17 at 3:42pm, revealed a detailed procedure for signing out medical records from the chart room. The policy described the Active Record Locator Form, that was to be used to identify which record was removed, the date and time it left, a signature and location of the record. During the survey, there was no form noted to be titled, Active Record Locator Form, nor was there a designated form or document to serve that purpose. There were multiple occurrences of staff members and surveyors being unable to locate medical records that were not in the chart room and no method or means of locating the record for extended periods of time. | 2020-09-01 |
| 4063 | 4063 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 520 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 11:45 AM that Immediate Jeopardy existed at CFR4[AGE].[AGE] F-520 at a scope and severity level of (J) beginning on [DATE]. The facility failed to identify quality deficiencies related to 2 of 3 sampled residents reviewed for death in the facility for whom cardiopulmonary resuscitation (CPR) was not provided as required. The facility failed to implement a plan of action related to Advance Directives for and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure residents who exhibited absence of pulse and respirations received CPR when indicated and according to State Law resulted in Immediate Jeopardy for Residents #205 and #210. It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resusci… | 2020-09-01 |
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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 );