cms_SC
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39 rows where "inspection_date" is on date 2018-02-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 917 | 917 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 568 | D | 0 | 1 | 80ZB11 | Based on interview and record review, the facility failed to share quarterly statements with 82 residents and/or responsible parties. The facility had no system in place to confirm that residents or appropriate family members received their quarterly statements. The findings included: Interview with Resident #7 on 1/29/18 at approximately 11:12 AM revealed that the resident did not get a quarterly statement of his/her personal funds account from the facility. Interview with the family of Resident #28 on 1/30/18 at approximately 9:51 AM revealed s/he did not get the quarterly statement of the resident's personal funds account from the facility. Interview with the Business Office Manager (BOM) on 1/30/18 at approximately 2:18 PM revealed the resident and the family member received quarterly statements, but there was no way for the facility to confirm the quarterly statements were received by either. | 2020-09-01 |
| 918 | 918 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 577 | B | 0 | 1 | 80ZB11 | Based on interview and observation the facility failed to post DHEC survey results accessible to all residents. The DHEC survey results were posted out of reach to wheel-chair bound residents. The findings included: Interview with Resident Council on 1/29/18 at approximately 3:20 PM revealed that the survey results were not accessible to those in the wheelchair. Observation on 1/29/18 at approximately 4:08 PM revealed the survey results were approximately 1 foot above the handrails and might not be accessible to all wheelchair bound residents. | 2020-09-01 |
| 919 | 919 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 583 | D | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that a resident received personal care in privacy when a medication was given. Resident #101 was given an insulin treatment at the nurse's station on the Unit 3. Random observation on 1 of 3 units and 1 of 5 residents reviewed for unnecessary medication. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. A random observation on 1/31/18 at approximately 3:30 PM revealed a nurse talking to Resident #101 who was seated in a wheelchair in front of the nursing station on Unit 3. The nurse informed the resident it time to take your insulin treatment. The nurse did not offer to take the resident to his/her room or did not ask the resident's consent to take the insulin treatment while seated at the nurse's station. There were nursing staff and other residents present when the insulin was given. After the nurse gave the resident the insulin while seated at the nursing station, Registered Nurse (RN) #1 was observed going over to the nurse, leaning to talk quietly into his/her ears. An interview on 1/31/18 at approximately 3:34 PM with RN #1 confirmed the observation of the nurse giving Resident #101 his/her insulin while he/she was seated in a wheelchair at the nurse's station. RN#1 stated he/she addressed the observation with the nurse on the unit after the incident. | 2020-09-01 |
| 920 | 920 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 645 | D | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) form was completed prior to admission. Resident #115 was admitted to the facility prior to the PASARR being completed. One of three discharged resident's charts reviewed. The findings included. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. A record review on 1/31/18 at approximately 12:20 PM revealed the resident was admitted on [DATE] and the Preadmission Screening and Resident Review (PASARR) form was not completed until 9/08/17. An interview on 1/31/18 at approximately 12:30 PM with Registered Nurse (RN) #1 confirmed the findings. RN #1 further stated he/she will inform the Director of Nursing (DON). An interview on 1/31/18 at approximately 3:30 PM with the DON revealed the facility was looking to determine if there was another PASARR because Resident #115 was at the facility previously for respite care. An interview on 2/01/18 at approximately 9:34 AM with the DON revealed the facility did not have documentation to indicate a PASARR was done prior to admission for Resident #115. | 2020-09-01 |
| 921 | 921 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 679 | D | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that an ongoing program of activities were provided for 1 of 3 sampled residents reviewed. Resident #62 was observed in his/her room on Unit 1 with no structured activities in progress. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Resident #62 was not observed being provided a structured program of activities on the days of the survey. The resident was observed in his/her room in bed. An observation on 1/30/18 at approximately 11:51 AM revealed resident in room in bed on specialty mattress. The resident was observed to be severely contractured. Random observations throughout the survey reviewed the resident was in his/her room in bed. A review of the medical chart 1/30/18 on the unit at approximately 12:01 PM revealed the last activity assessment completed on the resident 5/10/15. At approximately 3 PM the activity department was interviewed and the surveyor requested documentation of one to one being provided for the resident. On 1/31/18 the documentation of one to one was provided. The facility also provided an updated activity assessment dated [DATE]. The activity assessment form indicated staff determined the resident's activities of choice. The form also indicated in one section the resident prefers activity setting in his/her own room and activities in the day/activities rooms. Review of the care plan indicated provide one 1:1 activities as needed or requested, staff to transport to activities provide manicures. No 1:1 activities were observed on the days of the survey. A review of a Quarterly Minimum Data Set (MDS) data 10/01/17 and an Annual MDS dated [DATE] that indicated the resident was severely cognitively impaired and rarely/never made decision. A review of 1:1 activity sheets from 11/06/17 to 1/30/18 revealed resident participated in one out of room activity on 1/06/18. The activity sheets did not indicate t… | 2020-09-01 |
| 922 | 922 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 684 | D | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that a resident with a physician's order for gerri sleeves to be worn to prevent injuries for 1 of 5 sampled resident reviewed for unnecessary medications. Resident #61 had physician's orders for gerri sleeves to be worn to prevent injuries. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. An observation on 1/29/18 at approximately 9:16 AM revealed Resident #61 self ambulating in wheelchair with a sitter present. The resident was not wearing gerri sleeves. A review of the medical record on 1/30/18 at approximately 2:58 PM revealed a physician's order dated 1/24/18 that indicated gerri sleeves . to prevent injuries. An observation on 1/30/18 at approximately 3:11 PM revealed resident seated in wheelchair with sitter present and no gerri sleeves were observed to arms. An interview and observation on 1/31/18 at approximately 12:05 PM with the Director of Nursing (DON) confirmed the resident was not wearing gerri sleeves as ordered. The DON stated the resident was not in compliance with wearing the gerri sleeves although an order was written as recently as 1/24/18 for gerri sleeves to be worn to prevent injuries. At approximately 12:14 PM on 1/31/18 a care plan coordinator provided a care plan that indicated the resident was non compliance with wearing gerri sleeves (MONTH) (YEAR). An interview on 1/31/18 at approximately 3:37 PM with the facility Administrator confirmed the observation that Resident #61 did not have physician ordered gerri sleeves in place. 01/31/18 03:27 PM Res observed at NS without PO gerri sleeves in place. The Administrator stated the nurse practitioner was not aware of the resident's non compliance when the physician order was written. | 2020-09-01 |
| 923 | 923 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 812 | E | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed to ensure cleanliness of the kitchen and failed to ensure residents leaving the facility for [MEDICAL TREATMENT] had a lunch with them (the resident) that was kept at the right temperature to allow for quality and safety of the food. Resident #163 was observed transported out for his [MEDICAL TREATMENT] treatment without his/her lunch bag that was a clear plastic bag (no insulation) containing an egg salad sandwich and juice. Another lunch was also observed in a plastic, re-sealable zipper storage bag that consisted of a ham and cheese sandwich and juice. The findings included: An initial tour of main kitchen on 1/29/18 at approximately 8:55 AM with the Food Director/Dietary Manager revealed a white basin hand washing sink noted with dark stains and discolorations throughout. The trash can near the sink was filled to the top. The walk in freezer had magic cups noted on the floor under the shelves. The Food Director/Dietary Manager confirmed the findings and stated the magic cups will be thrown in the trash can. The facility admitted Resident #163 with a [DIAGNOSES REDACTED]. An observation on 1/29/18 at approximately 9:30 AM revealed Resident #163 being transported on a gurney to [MEDICAL TREATMENT] by medical transportation. One of the transportation staff asked Licensed Practical Nurse (LPN) #1 where was the resident's lunch. LPN #1 instructed the transportation staff that the kitchen would provide the lunch. An observation on 1/29/18 at approximately 9:43 AM revealed the medical transport staff taking Resident #163 to the ambulance without going to the kitchen. An interview on 1/29/18 at approximately 9:50 AM with LPN #1, the surveyor asked LPN #1 who was supposed to get the lunch for Resident #163. LPN #1 stated the medical transport staff was supposed to go by the kitchen. When LPN #1 was informed that the medical transport staff took the resident directly to the ambulance wit… | 2020-09-01 |
| 924 | 924 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 842 | D | 0 | 1 | 80ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record review and interviews, the facility failed to ensure that clinical records were accurate for 1 of 1 sampled resident reviewed for range of motion. Resident #62 had a therapy referral and screening form that indicated a communication from dietary and therapy to refer resident to hospice with no follow up that was dated 6/12/17. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. A review of the medical record on 1/30/18 at approximately 12:01 PM reveal a Therapy Referral and Screening Form dated 6/12/17 that indicated in a therapist observation section refer to hospice. There was a section on the form that indicated the resident had a recent weight loss. There was no documentation in the medical record to indicate the resident was referred to hospice. An interview on 1/31/18 at approximately 3:10 PM with the Speech Therapist (ST) confirmed the refer to hospice note on the referral form. The ST refer to hospice note was in error and that dietary informed therapy about the resident's weight loss and speech would not be able to address weight loss. The form was used as a communication sheet to dietary and not meant as a referral to hospice. Per the ST the form was not sent back to dietary. The Director of Nursing (DON) and the facility consultant was also present during the interview. The DON and facility consultant stated the therapist thought the resident was already on hospice when the note was written. The DON further stated the resident was not on hospice. Review of activity note dated during the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) that indicated the resident was receiving hospice services. An interview on 2/01/18 at approximately 9:34 AM with the DON and facility consultant confirmed the findings and stated the activity notes were in error and that Resident #62 was not receiving hospice services. The DON provided a note that indicated the resident had not received hospice… | 2020-09-01 |
| 925 | 925 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2018-02-01 | 880 | E | 0 | 1 | 80ZB11 | Based on observations and interviews the facility failed to clear the laundry room of dust and debris as well as a closet used to store clean linens. The findings included: Random observation on 2/01/18 at approximately 9:43 AM with the Laundry Manager and Laundry Account Manager revealed a large dark gray clump hanging from the light fixture over the dryer. There was large area of dust/spider web on the ceiling to the right side of the dryer and multiple clumps of spider webs on the window in the laundry room near the dryer and clean clothes side. The Laundry Manager and Laundry Account Manager confirmed the findings. Random observation of the clean linen closet on 2/01/18 at approximately 9:56 AM revealed a heavy build up of dust and debris on the floor under the linen shelves. The observation was confirmed by the Laundry Account Manager. The Laundry Account Manager confirmed the build up of dust, spider webs and debris had been there for awhile. | 2020-09-01 |
| 1512 | 1512 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-02-01 | 609 | D | 1 | 0 | 7BL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy titled Abuse Prevention, Intervention, Reporting, and Investigation, the facility staff failed to report an injury of unknown origin for Resident #1. One of one resident reviewed for injuries of unknown origin. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/29/18 revealed Resident #1 had an unwitnessed fall on 9/22/17 at 7:05 AM and sustained a large hematoma to the right side of her/his forehead and was assessed with [REDACTED]. Review of facility reportable incidents to the State Agency on 2/1/18 revealed that the incident on 9/22/17 was not reported to the State Agency nor was an investigation of the incident done. During an interview with the Administrator on 1/29/18, s/he stated the facility needed to improve on their investigating. Review of the facility policy titled Abuse, Prevention, Intervention, Reporting, and Investigation revealed the following: 9. Reporting/Response a. It is the policy of the facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through es… | 2020-09-01 |
| 1513 | 1513 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-02-01 | 610 | D | 1 | 0 | 7BL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy titled Abuse Prevention, Intervention, Reporting, and Investigation, the facility staff failed to investigate an injury of unknown origin for Resident #1. One of one resident reviewed for injuries of unknown origin. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/29/18 revealed Resident #1 had an unwitnessed fall on 9/22/17 at 7:05 AM and sustained a large hematoma to the right side of her/his forehead and was assessed with [REDACTED]. Review of facility reportable incidents to the State Agency on 2/1/18 revealed that the incident on 9/22/17 was not reported to the State Agency nor was an investigation of the incident done. During an interview with the Administrator on 1/29/18, s/he stated the facility needed to improve on their investigating. Review of the facility policy titled Abuse, Prevention, Intervention, Reporting, and Investigation revealed the following: 9. Reporting/Response a. It is the policy of the facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law throu… | 2020-09-01 |
| 1514 | 1514 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-02-01 | 657 | E | 1 | 0 | 7BL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to update the Certified Nursing Assistant (CNA) Care Plan Guide to reflect fall interventions for Resident #2, and #3. Two of three residents reviewed for falls. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 2/1/18 revealed Resident #2 had multiple falls. Further review of the CNA Care Plan Guide revealed the care plan had not been updated to reflect fall interventions implemented. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 1/30/18 revealed Resident #3 had multiple falls. Further review of the CNA Care Plan Guide revealed the care plan had not been updated to reflect fall interventions implemented. During an interview on 1/31/18 at 2:20 PM with CNA #1, s/he did not know where the CNA Care Plan was located. When asked how do you know what to do for the resident in your care, s/he stated we have a meeting with the previous shift. During an interview on 1/31/18 at approximately 2:30 PM with CNA #2, s/he stated a report is given to the CNA's at the beginning of the shift S/he stated the CNA care plan book was located in a binder at the nurse's station. During an interview on 2/1/18 at 10:25 AM with the Care Plan Coordinator, s/he stated any nurse could update the care plan and confirmed the CNA care plans had not been updated. | 2020-09-01 |
| 1515 | 1515 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-02-01 | 689 | D | 1 | 0 | 7BL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview, the facility failed to ensure the environment remained as free of accident hazards as possible for 1 of 3 residents reviewed for falls. Resident #3's room was observed cluttered. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 1/30/18 revealed a care plan for falls which listed interventions such as: Keep floor free of debris and clutter and Rearrange room for access. Observation of the resident's room on 2/1/18 at 9:30 AM revealed Resident #3 was lying in bed. The resident's over the bed table was located midway down the side of the bed at an angle. In the pathway to the restroom, a wheelchair was positioned to the left and an upright chair was positioned on the right. During an interview on 2/1/18 at 9:30 AM with Certified Nursing Assistant #3, s/he confirmed the room was not clutter free and stated another staff member had assisted the resident at breakfast and s/he had not gone back in the room to ensure items were in their proper place and the room was clutter free. | 2020-09-01 |
| 1516 | 1516 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2018-02-01 | 761 | D | 1 | 0 | 7BL511 | > Based on observation, interview, and review of the facility policy titled Storage of Medications, the facility failed to ensure all drugs and biological's were secured on 1 of 3 nursing units observed. A staff member was observed to leave a medication cart unsecured. The findings included: On 1/29/18 at 3:25 PM, during observation of medications and medication carts, Licensed Practical Nurse (LPN)#1 left the medication cart unsecured and entered into the medication room. At the time of the survey, residents of the facility were sitting at the nursing station near the medication cart. During an interview with LPN #1 on 1/31/18 at 5:05 PM, s/he stated the cart had not been secured when s/he entered into the medication room. Review of the facility policy titled Storage of Medications revealed the following under the Procedure section: B. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. | 2020-09-01 |
| 3330 | 3330 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 550 | D | 0 | 1 | IKPR11 | Based on observations, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for one of one dining room observed for dining. The findings included: On 1/2/18 at 1140am, CNA #2 and CNA #3 were observed to place clothing protectors on residents without asking them. During this time, it was also observed that both CNAs were not sanitizing or washing their hands before serving drinks or assisting serval residents with preparing their food. | 2020-09-01 |
| 3331 | 3331 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 554 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess clinical appropriateness and safety considerations for one of one resident reviewed for self administration of medication. Resident #91 had medication at the bedside without evidence of assessment of cognitive and functional ability to manage them. The findings included: During observation of medication administration on 1-4-18 at 10 AM, Resident #91 was noted with a bottle of Tums tablets and a bottle of AZO tablets on the bedside table. When asked if s/he took the Tums for indigestion, the resident replied, Sometimes. Record review on 1-4-18 at 11 AM revealed no assessment for self-administration of medication or physician's orders [REDACTED]. During an interview at 5:15 PM on 1-4-18, Licensed Practical Nurse (LPN) #6 stated s/ he did not hear the surveyor ask the resident about the Tums and was unaware the resident had the medications at the bedside. When asked if Resident #91 had an order to keep medication at the bedside, the 400 Hall Unit Manager and LPN #6 stated s/he did not. When asked if the resident had been assessed for self administration, the UM said,No. The UM asked LPN #6 if the resident had AZO or Tums ordered. The nurse reviewed the Medication Administration Record [REDACTED]. | 2020-09-01 |
| 3332 | 3332 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 585 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to respond to complainants with written decisions for 1 of 2 sampled residents reviewed for grievances. The family of Resident #448 did not receive a written response to a voiced complaint as required. The finding included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Review of the 6-21-17 Admission MDS revealed that the resident required extensive assistance of one person with personal hygiene. Review of the Grievance Log on 1-19-17 at 8:50 AM revealed that the family of Resident #448 voiced a complaint on 7-19-17 related to oral/denture care. There was no evidence provided of a written response to the grievance. During an interview at 10:14 AM on 1-19-17, the Director of Nursing and Administrator stated they did not start this until 11-17 as they thought this was part of the Phase 2 implementation of new regulations. | 2020-09-01 |
| 3333 | 3333 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 600 | G | 1 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16) the facility failed to ensure that one of two sampled residents reviewed for abuse remained free of neglect. Following investigation of an injury of unknown origin, it was determined that 2 Certified Nursing Assistants (CNAs) transferred the resident manually instead of using a mechanical lift resulting in a comminuted mid [MEDICATION NAME] patellar fracture. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 6-24-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 2 people with bed mobility and transfers. Record review on 1-5-18 at 4:18 PM revealed a 9-9-17 Nursing Note: 7:45 PM Called to room by (Certified Nursing Assistant), residents right knee observed to be red, swollen, warm to touch, painful to touch. The physician and family were notified and the resident was sent to the emergency room for evaluation. Review of hospital records revealed that the resident presented with a red hot inflamed right knee. Per the nursing home, this started earlier today and got worse throughout the day . Right knee with significant swelling and [DIAGNOSES REDACTED] . There are patchy petechial like [MEDICAL CONDITION] on the back of the leg extending to the calf. A computed tomography (CT) scan in the emergency room revealed that Resident #16 had a comminuted mid [MEDICATION NAME] patellar fracture with 10 millimeter diastases of the more proximal fragment. The resident was admitted to the hospital and treated conservatively with an immobilizer. A Doppler of the leg showed a common femoral [MEDICAL CONDITIONS]. Patient with IVC (inferior vens cava) filter. This is a new clot for her (him) .Patient is paralyzed and can only transfer via the staff. To the (family) this indicates that… | 2020-09-01 |
| 3334 | 3334 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 607 | G | 1 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16) the facility failed to implement established policies and procedures for investigation of an injury of unknown origin for one of two sampled residents renewed for abuse. Resident #16 was diagnosed with [REDACTED]. Of the six licensed nurses assigned to the 200 Hall for the 24-48 hour period prior to the reported symptoms, there was only one written statement. Of the 14 Certified Nursing Assistants on duty, there were only 4 written statements. There was no evidence of interviews of the remaining nursing staff assigned to the 200 Unit. There were no statements/interviews of ancillary staff (therapy, maintenance, housekeeping) to determine when/how the fracture actually occurred. There were no interviews conducted with the resident's roommate or with the 2 families of residents residing in the room. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 6-24-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 2 people with bed mobility and transfers. Record review on 1-5-18 at 4:18 PM revealed a 9-9-17 Nursing Note: 7:45 PM Called to room by (Certified Nursing Assistant), residents right knee observed to be red, swollen, warm to touch, painful to touch. The physician and family were notified and the resident was sent to the emergency room for evaluation. Review of hospital records revealed that the resident presented with a red hot inflamed right knee. Per the nursing home, this started earlier today and got worse throughout the day . Right knee with significant swelling and [DIAGNOSES REDACTED] . There are patchy petechial like [MEDICAL CONDITION] on the back of the leg extending to the calf. A computed tomography (CT) scan in the emergency room revealed that Resident #16 … | 2020-09-01 |
| 3335 | 3335 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 610 | D | 1 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16) the facility failed to thoroughly investigate an injury of unknown origin for one of two sampled residents renewed for abuse. Resident #16 was diagnosed with [REDACTED]. Of the six licensed nurses assigned to the 200 Hall for the 24-48 hour period prior to the reported symptoms, there was only one written statement. Of the 14 Certified Nursing Assistants on duty, there were only 4 written statements. There was no evidence of interviews of the remaining nursing staff assigned to the 200 Unit. There were no statements/interviews of ancillary staff (therapy, maintenance, housekeeping) to determine when/how the fracture actually occurred. There were no interviews conducted with the resident's roommate or with the 2 families of residents residing in the room. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 6-24-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 2 people with bed mobility and transfers. Record review on 1-5-18 at 4:18 PM revealed a 9-9-17 Nursing Note: 7:45 PM Called to room by (Certified Nursing Assistant), residents right knee observed to be red, swollen, warm to touch, painful to touch. The physician and family were notified and the resident was sent to the emergency room for evaluation. Review of hospital records revealed that the resident presented with a red hot inflamed right knee. Per the nursing home, this started earlier today and got worse throughout the day . Right knee with significant swelling and [DIAGNOSES REDACTED] . There are patchy petechial like [MEDICAL CONDITION] on the back of the leg extending to the calf. A computed tomography (CT) scan in the emergency room revealed that Resident #16 had a comminuted mid [MEDICATION NAME] patel… | 2020-09-01 |
| 3336 | 3336 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 623 | F | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy entitled Transfers and Discharges, the facility failed to notify the Ombudsman of a facility-initiated discharge for one of one sampled resident reviewed for discharges related to non-payment (Resident #13). The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an interview on 1-18-18 at 9:38 AM, Social Services provided information related to Resident #13's discharge. Although not required for exhaustion of benefits, the facility provided the family with a SNF (Skilled Nursing Facility) Determination on Continued Stay (signed on 9-18-17) letter and a CMS -NOMNC Notice of Medicare Non-Coverage (signed on 10-11-17) informing the family of the last Medicare covered day on 10-6-17 and the estimated cost of continued stay. Record review and interview with the Administrator on 1-18-18 at 9.46 AM revealed that Resident #13 was issued two 30 day discharge notices (Notice of Resident Transfer or Discharge) for non-payment. One 30 day notice was sent certified to the home and to the Post Office Box on 10-25-17. The second was issued and signed by the resident's family on 11-27-17. There was no evidence in the record that the Ombudsman received copies of the Notice of Resident Transfer or Discharge forms. During an interview on 1-18-18 at 1:01 PM, the Ombudsman stated s/he had not received copies of the discharge notices. During an interview on 1-18-18 at 2 PM, the Administrator stated s/he was not aware of the requirement for immediate Ombudsman notification of 30-day discharge notices or of all facility-initiated transfers. The policy provided by the facility entitled Transfers and Discharges states: A copy of the notice of transfer/discharge will be sent to a representative of the Office of the State Long-term Care Ombudsman for all facility initiated transfers or discharges . Notice to the Office of the State Long-Term Care Ombudsman must occ… | 2020-09-01 |
| 3337 | 3337 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 641 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set Assessment (MDS) for one of 4 sampled residents reviewed for range of motion. The MDS assessments for Resident #16 did not accurately reflect the resident's [DIAGNOSES REDACTED]. Resident interviews were not attempted as required. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 9-19-17 Significant Change in Status Assessment at 1:10 PM on 1-4-18 revealed that Resident #16 had unclear speech but usually understood what was said to her/him and was sometimes able to make her/himself understood. Review of Sections C and D of the MDS revealed that the Brief Interview for Mental Status and the Mood Interview had not been attempted. C0100 and D0100 were coded that the interview should not be completed because the resident was rarely/never understood. During an interview at 2:41 PM on 1-19-18, the MDS Coordinator stated that Social Services was responsible for completion of Sections C, D, E, and Q. S/he did verify that if B 0700 was coded anything other than rarely/never understood, the interviews should be attempted. Further review of the 6-24-17 Quarterly MDS revealed that Section I. [DIAGNOSES REDACTED]. The 9-19-17 Significant Change in Status Assessment did not include the [DIAGNOSES REDACTED]. During an interview on 1-19-18 at 2:53 PM, after reviewing the record, the MDS Coordinator verified the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 3338 | 3338 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 656 | E | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the Care Plan was followed for one of one resident reviewed with splints. Resident #16 did not have palmar guards in place as ordered. In addition the facility failed to ensure that the care plan for elopement prevention intervention was followed for one of five sample resident reviewed for accidents. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Observation on 1-2-18 at 10:32 AM revealed that the resident had contractures of both hands with no hand rolls or splints in place. Hands were both in the fisted position. During an interview on 1-2-18 at 2:07 PM, the family stated Resident #16 had developed the contractures in her/his hands in the last 6 months. Prior to the hospitalization for the fractured patella in 9-17, the resident had been able to feed his/herself, predominantly with finger foods. Record review on 1-19-18 at 3:40 PM revealed that Resident #16 was seen by Occupational Therapy from 9-13-17 through 9-25-17 because Patient noted to be at risk for further deterioration in PROM (passive range of motion) in B(ilateral) fingers . The resident presented with decreased AROM (active range of motion)/PROM of both hands, held in clenched position influencing ability to tolerate hygiene. Daily notes indicated that the resident was gradually adjusting to placement of palmar guards. A 9-21-17 note stated, Without palmar guards hands are clenched and nails dig into palm of hand. Upon discharge, staff were educated on the need for palm protectors. Further review revealed a 9-26-17 physician's orders [REDACTED]. Record review on 1-19-18 at 2:17 PM with the Minimum Data Set (MDS) Coordinator revealed a Care Plan problem of contractures to bilateral upper and lower extremities with interventions including palm protectors to both hands. Review of 9-17 through 12-17 Restorative Nursing Program Flow Records with the Director of Nursing (D… | 2020-09-01 |
| 3339 | 3339 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 657 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure participation by required interdisciplinary team members in the care planning process for one of four sampled residents reviewed for hospitalization . (Resident #448) The findings included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Review of the 6-28-17 Care Plan at 3:08 PM on 1-18-17 revealed that it addressed disease- and medication-specific problems and identified problems related to pain, nutrition, skin tears, pressure ulcers on the right heel and sacrum, cognition, incontinence, activities of daily living, and constipation. There was no evidence in the record of resident and/or family (as applicable) participation in the Care Plan. Nor were nutrition services, a Registered Nurse familiar with the resident, a Certified Nursing Assistant or the physician represented. Only Social Services and Therapy representatives signed as having participated. During an interview on 1-18-17 at 3:12 PM, the Director of Nurses (DON) stated they did not start documentation of Care Plan participation until 11-17 as part of the Phase 2 regulation changes. During an interview at 9:25 AM on 1-19-17, Social Services stated, We did an admission meeting and went over the Initial/Interim Care Plan. Social Services did not know if a meeting had been held with the resident and/or family in conjunction with the 6-28-17 interdisciplinary care plan. S/he verified there was no evidence of participation by nursing, dietary, certified nursing assistant, or physician. Review of the 6-14-17 (admission) Family & Resident Education Checklist revealed 6-16-17 signatures of 2 family members, Social Services, and an Occupational Therapist. The checklist noted that the Initial Resident Review was scheduled the same date but did not indicate what had been reviewed other than Advance Directives, Discharge Plan Agreement, Resident Responsibilities, Policy and Procedure for Filing a Grievance o… | 2020-09-01 |
| 3340 | 3340 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 684 | E | 0 | 1 | IKPR11 | **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 one of seven sampled residents reviewed for unnecessary medication. A multivitamin was omitted for the entire month of ,[DATE] and pain medication and [MEDICATION NAME] sulfate were not administered as ordered for Resident #448. Based on record review and interview, the facility also failed to ensure collaboration of care for one of two residents reviewed for hospice services. There was no evidence of follow through for palliative care initiated during a hospitalization in ,[DATE]. Documentation of care and services provided by hospice beginning on [DATE] were not maintained at the facility for Resident #99 to enable ongoing communication between facility and hospice staff. In addition the facility failed to turn and reposition Resident #74 per the resident's care directive. The findings included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Record review on [DATE] at 11:02 AM revealed a [DATE] physician's orders [REDACTED]. Review of the ,[DATE] MAR indicated [REDACTED]. Further review revealed a [DATE] order for [MEDICATION NAME] sulfate 325 mg (65 mg iron) tablet PO TID (three times daily) Review of the ,[DATE] Medication Administration Record [REDACTED]. The physician wrote an order on [DATE] for Tylenol 650 mg 1 tab(let) PO BID (twice daily) x 14 days. Review of the ,[DATE] MAR indicated [REDACTED]. Further review revealed physician's orders [REDACTED]. An order was written on [DATE] for [MEDICATION NAME] 50 mg 1 tab PO Q 8 hrs X 3 days PRN pain which was increased on [DATE] to q 6 hrs PRN. Review of the MARs revealed that [MEDICATION NAME] was administered at 8 AM and 12 PM on [DATE] (only 4 hours apart), at 4 AM, 8 AM, and 9 AM on [DATE] (4 hours apart, then repeated after another hour). There were multiple changes/strike-outs in times and/or dates of [MEDICATION NAME] and [MEDICATION NAME] administration on both the fron… | 2020-09-01 |
| 3341 | 3341 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 686 | E | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement physician-ordered interventions to prevent at-risk residents from developing pressure ulcers and/or treating existing pressure ulcers for one of 5 sampled residents reviewed for pressure ulcers. A therapeutic bed/mattress was not implemented as ordered for Resident #16. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 9-19-17 Significant Change in Status Assessment at 1:10 PM on 1-4-18 revealed that Resident #16 was totally dependent for bed mobility and transfers and at risk for pressure ulcers. Review of Physician's Progress Notes revealed that Resident #16 was readmitted from the hospital on 9-12-17 following a fractured patella with a decubitus ulcer. A therapeutic bed was ordered due to immobility, [MEDICAL CONDITION], contractures, early decubitus ulcer. The 9-17 Medication Administration Record [REDACTED]. There were no nurses' initials on the form to indicate that the order was followed. Review of Nurses Notes for 9-17 revealed no reference to a change in the resident's mattress or bed. Observations throughout the survey revealed no specialty bed or mattress in place. When asked about the therapeutic bed on 1-19-18 at 4:05 PM, the Director of Nursing was unsure of what the physician meant but confirmed that the resident had the standard pressure reduction mattress used for all residents of the facility. | 2020-09-01 |
| 3342 | 3342 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 688 | G | 1 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure services were provided to prevent decline in range of motion (ROM) and/or to maintain mobility for two of two sampled residents reviewed for restorative services. Resident #448 did not receive ROM five times per week as ordered. Services were not provided to prevent contracture development and palmar guards were not in place for Resident #16. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Observation on 1-2-18 at 10:32 AM revealed that the resident had contractures of both hands with no hand rolls or splints in place. Hands were both in the fisted position. During an interview on 1-2-18 at 2:07 PM, the family stated Resident #16 had developed the contractures in her/his hands in the last 6 months. Prior to the hospitalization for the fractured patella in 9-17, the resident had been able to feed his/herself, predominantly with finger foods. Review of the 8-10-17 Monthly Summary on 1-3-19 at 2 PM revealed no contractures of upper extremities. Record review on 1-19-18 at 3:40 PM revealed that Resident #16 was seen by Occupational Therapy from 9-13-17 through 9-25-17 because Patient noted to be at risk for further deterioration in PROM (passive range of motion) in B(ilateral) fingers . The resident presented with decreased AROM (active range of motion)/PROM of both hands, held in clenched position influencing ability to tolerate hygiene. Daily notes indicated that the resident was gradually adjusting to placement of palmar guards. A 9-21-17 note stated, Without palmar guards hands are clenched and nails dig into palm of hand. Upon discharge, staff were educated on the need for palmar guards. Further review revealed a 9-26-17 physician's orders [REDACTED]. Review of 9-17 through 12-17 Restorative Nursing Program Flow Records with the Director of Nursing (DON) on 1-19-18 at approximately 9 AM revealed that R0M was not initialed as having been… | 2020-09-01 |
| 3343 | 3343 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 689 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide interventions to ensure the residents were given the level of supervision to prevent accidents or delay regression of disease. Resident #16 was not given palm splints to avoid contractures of the hands and Resident #3 did not have care planned interventions in place to avoid elopement potential. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Observation on 1-2-18 at 10:32 AM revealed that the resident had contractures of both hands with no hand rolls or splints in place. Hands were both in the fisted position. During an interview on 1-2-18 at 2:07 PM, the family stated Resident #16 had developed the contractures in her/his hands in the last 6 months. Prior to the hospitalization for the fractured patella in 9-17, the resident had been able to feed his/herself, predominantly with finger foods. Review of the 8-10-17 Monthly Summary on 1-3-19 at 2 PM revealed no contractures of upper extremities. Record review on 1-19-18 at 3:40 PM revealed that Resident #16 was seen by Occupational Therapy from 9-13-17 through 9-25-17 because Patient noted to be at risk for further deterioration in PROM (passive range of motion) in B(ilateral) fingers . The resident presented with decreased AROM (active range of motion)/PROM of both hands, held in clenched position influencing ability to tolerate hygiene. Daily notes indicated that the resident was gradually adjusting to placement of palmar guards. A 9-21-17 note stated, Without palmar guards hands are clenched and nails dig into palm of hand. Upon discharge, staff were educated on the need for palmar guards. Further review revealed a 9-26-17 physician's orders [REDACTED]. Review of 9-17 through 12-17 Restorative Nursing Program Flow Records with the Director of Nursing (DON) on 1-19-18 at approximately 9 AM revealed that R0M was not initialed as having been completed as ordered. Services were… | 2020-09-01 |
| 3344 | 3344 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 692 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to assess the meal intake as ordered for one of four sampled residents reviewed for nutrition/weight loss. A calorie count was not completed for Resident #16 as ordered. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 9-19-17 Significant Change in Status Assessment at 1:10 PM on 1-4-18 revealed that Resident #16 required extensive assistance required for eating. Review of Dietary Notes on 1-19-18 at 3:15 PM revealed that staff noted Resident #16 with a 10 pound weight loss (138# to 128#) in 43 days on 9-15-17. On 10-11-17, staff noted a 9% loss in the previous month (weight=121#). Interventions included a mechanically altered diet, fortified foods, Med Plus, and house shakes to promote caloric intake. Review of Physician's Progress Notes on 1-5-18 at 10:05 AM revealed that the physician saw Resident #16 on 11-1-17 for a weight loss of 7 pounds in one month. S/he noted that Nursing Notes say eating 50-100%! R/O (rule out) Wasting Syndrome and wrote orders to Ask dietary to perform calorie count eval(uation) of intake x 1-2 days to assess adequacy of intake. The results of the calorie count could not be located in the medical record. There was no reference to it having been completed in Dietary Notes. During an interview on 1-19-18 at 2:35 PM, in the presence of the Registered Dietitian, the Certified Dietary Manager (CDM) confirmed the physician's orders [REDACTED]. The CDM verified the calorie count had not been completed as ordered. | 2020-09-01 |
| 3345 | 3345 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 755 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy entitled Administration of Medication, the facility failed to follow a procedure to maintain records of controlled substances for one of seven sampled residents reviewed for unnecessary medication, to enable the monitoring of administration and reconciliation (Resident #448). The findings included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Record review on 1-5-18 at 11:02 AM revealed Physician's Orders for [MEDICATION NAME] 7.5/325 mg (milligrams) l tab(let) PO (by mouth) Q (every) 8 h(ou)rs PRN (as needed) pain which was increased to q 6 hrs PRN on 6-16-17. An order was written on 6-18-17 for [MEDICATION NAME] 50 mg 1 tab PO Q 8 hrs X 3 days PRN pain which was increased on 6-19-17 to q 6 hrs PRN. Review of the Medication Administration Records (Mars) revealed that [MEDICATION NAME] was administered at 8 AM and 12 PM on 6-20-17 (only 4 hours apart), at 4 AM, 8 AM, and 9 AM on 7-17-17 (4 hours apart, then repeated after another hour). There were multiple changes/strike-outs in times and/or dates of [MEDICATION NAME] and [MEDICATION NAME] administration on both the fronts and backs of the 7-17 Mars. Review of Nursing Progress Notes revealed that [MEDICATION NAME] was given on 6-21-17 and 6-24-17 and a pain med was given on 6-30-17 with no entries made on the MAR. During an interview on 1-19-17 at 9:51 AM, the Director of Nursing (DON) reviewed the medical record with the surveyor and verified the above information. Controlled drug records (narcotic count sheets) for the [MEDICATION NAME] and [MEDICATION NAME] were requested for review at that time to compare to the MAR. At 1:59 PM, the DON stated S/he was unable to locate the controlled drug records. The policy provided by the facility entitled Administration of Medication did not address the handling of controlled substances. | 2020-09-01 |
| 3346 | 3346 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 757 | E | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to consistently follow a process of monitoring effectiveness of medication administered for pain for one of 7 sampled residents reviewed for unnecessary medication. Staff failed to assess the location of pain and/or use a measuring tool/scale to evaluate the effectiveness of medication administered for pain for Residents #448 and #100. In addition, based on record review and interview, the facility failed to monitor residents' medication regimen for the need for continued use for 1 of 7 residents reviewed for unnecessary medication. Calcium and Vitamin D levels were not drawn for Resident #16. The findings included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Record review on 1-5-18 at 11:02 AM revealed physician's orders [REDACTED]. Review of the 6-17 MAR indicated [REDACTED]. Three (6-27, 28, 29-17) had no location of pain noted and six (6-16, 17, 18, 27, 28, 29-17) had no use of a measuring tool/scale to determine effectiveness of the medication administered. Further review revealed that [MEDICATION NAME] was administered 9 times in 6-17. Eight of the 9 had incomplete pain assessments. Eight (6-20 x 2, 22, 23 x 2, 24, 26, 30-17) had no location of pain noted and no use of a measuring tool/scale to determine effectiveness of the medication administered. Review of the 7-17 MAR indicated [REDACTED]. Further review revealed that [MEDICATION NAME] was administered 17 times. Fifteen of the 17 had incomplete pain assessments. Eight (7-1, 7, 8, 12, 14, 25, 26, 27-17) had no location of pain noted and 15 (7-1, 7, 8, 12 X 2, 14, 15, 17 x 2, 20, 21, 25*2, 26, 27-17) had no use of a measuring tool/scale to determine effectiveness of the medication administered. During an interview on 1-19-18 at 10:38 AM, the Director of Nursing reviewed the medicaI records and confirmed the multiple doses of [MEDICATION NAME] and [MEDICATION NAME] documented as given without location and/or m… | 2020-09-01 |
| 3347 | 3347 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 758 | E | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behavioral symptoms and attempt non-pharmacological interventions prior to administration of as needed (PRN) psychoactive medication for 1 of 7 sampled residents reviewed for unnecessary medication. Nursing staff administered [MEDICATION NAME] to Resident #100 with no specific behaviors documented and no evidence of non-pharmacological interventions prior to administration. The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Record review on 1-29-18 at 9:25 AM revealed an admission physician's orders [REDACTED]. Further review of the PRN Administration Record revealed that the [MEDICATION NAME] was administered on 8-19-17, 8-20-17, and 8-24-17 for sleeplessness or restlessness. No specific behaviors were documented and there was no evidence of non-pharmacological interventions attempted prior to administration. During an interview on 1-29-18 at 2:28 PM, the Director of Nursing (DON) reviewed the record and stated s/he could not locate a behavior monitoring form in the record and there was no documentation in the Nursing Notes of attempts at non-pharmacological interventions. | 2020-09-01 |
| 3348 | 3348 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 759 | E | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that its medication error rate was not greater than 5%. During observation of medication administration, there were 4 errors in 31 opportunities, resulting in a 12.9% medication error rate. The findings included: ERROR #1 During observation of medication administration on 1-3-18 at 9:25 AM, Licensed Practical Nurse (LPN) #4 administered Artificial Tears one drop to each of Resident #60's eyes. Record review on 1-4-18 at 7:27 PM revealed a 3-3-17 physician's orders [REDACTED]. The dose (number of drops) and route (which eye/both eyes) were not specified. At that time, the 100 Hall Unit Manager (UM) and LPN #4 verified the physician's orders [REDACTED]. When asked how s/he knew how many drops to administer, the LPN stated s/he went by the package insert. When both were asked what should be done when an order like this was received, the UM stated, Get clarification. At 7:40 PM, the physician's orders [REDACTED]. ERROR #2 During observation of medication administration on 1-4-18 at 10 AM, LPN #6 administered one [MEDICATION NAME]-Saccharomyces Boulardii to Resident #91. Record review on 1-4-18 at 7 PM revealed a 11-13-17 physician's orders [REDACTED]. During an interview on 1-4-18 at 7 PM, the 400 Hall UM reviewed the physician's orders [REDACTED].#6, and confirmed the error. ERRORS #3 & #4 During observation of medication administration on 1-4-18 at 10 AM, LPN #7 administered one Multivitamin with Minerals tablet and one [MEDICATION NAME] Chew 80 mg (milligram) tablet to Resident #69 via Gastrostomy (G-) tube. Record review on 1-5-18 at 7:15 AM revealed an 8-18-17 physician's orders [REDACTED]. The order did not contain the strength of the medication to be administered. During an interview on 1-5-18 at 7:15 AM, LPN #7 confirmed the over-the-counter medications s/he had given and verified the physician's orders [REDACTED]. Review of the Gas X website at 7:20 AM r… | 2020-09-01 |
| 3349 | 3349 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 812 | E | 0 | 1 | IKPR11 | Based on observation, interviews and record review, the facility failed to store, prepare distribute and serve food in accordance with professional standards for food service safety. The findings included: On initial observation of the kitchen on 1/2/18 at 1023am, Seafood fish patties and French Toast sticks were found to be in an open and exposed bag in the freezer. CDM immediately removed these items from freezer upon recognizing the issue. During a follow up tour of the kitchen on 1/5/18 at 440pm, kitchen staff were observed while taking the temperatures of the foods that would be served for dinner. While temping the mashed potatoes, staff member accidentally placed hand in the potatoes. Staff was then asked if she remembered having her fingers in the potatoes and s/he stated yes and continued temping other items. While preparing trays for resident dining, the same staff member was observed to place the same contaminated potatoes on a place to be served to residents. When asked if those same potatoes where going to be served to residents, staff member asked surveyor what to do. After being informed that surveyor cold not advise on next steps, CDM advised staff member to take potatoes off of the hot line and to take back the ones that s/he had already plated for delivery. | 2020-09-01 |
| 3350 | 3350 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 842 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain accurately documented medical records for one of two sampled residents reviewed for restorative services. The findings included: Review of Restorative Records for Resident #448 on 1-18-18 at 3:45 PM revealed that ROM was noted as having been provided for 20 minutes on 7-31-17, after the resident was discharged . During an interview on 1-19-18 at 9:51 AM, the Director of Nursing verified that ROM was initialed as completed on 7-31-17 after Resident #448 was discharged on [DATE]. | 2020-09-01 |
| 3351 | 3351 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2018-02-01 | 880 | D | 0 | 1 | IKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer step 2 of the [MEDICATION NAME] skin test as ordered for one (Resident #448) of seven residents reviewed for unnecessary medication. The findings included: The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Record review on 1-5-18 at 11:02 AM revealed a physician's orders [REDACTED]. Read on 6-23-17. Review of the 6-17 Medication Administration Record [REDACTED]. Review of the Resident TB Screening and Immunization Record revealed no entry/results for completion of the 2nd step PPD on admission. During an interview on 1-19-18 at 1:57 PM, the Director of Nurses stated s/he had reviewed the resident's medical and infection control records and was unable to locate any information that the TB test had been done as ordered. | 2020-09-01 |
| 4171 | 4171 | BISHOP GADSDEN EPISCOPAL HEALTH CARE CENTER | 425411 | 1 BISHOP GADSDEN WAY | CHARLESTON | SC | 29412 | 2018-02-01 | 758 | D | 0 | 1 | Y9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy, the facility failed to implement nonpharmacological interventions prior to giving a psychoactive medication for 1 of 5 sampled residents reviewed for Unnecessary Medications. Staff administered an as needed (PRN) Antipsychotic Medication to Resident #101 on multiple occasions without attempting other measures before using the drug. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Record review on 02/01/18 at approximately 9:39 AM revealed the Medication Administration Records (MARs) for (MONTH) (YEAR) documented that Resident #101 received PRN [MEDICATION NAME] on (MONTH) 23, 24, 25, 26 and 28, (YEAR) for agitation. The staff did not document any nonpharmacological interventions in the notes section of the MAR. Further review of the Nurses Notes revealed no interventions taken prior to administration on those same dates and there was no documentation of giving the medication on (MONTH) 25th, 26th and 28th. Review of facility policy entitled Documentation for Long Term Care Resident Records revealed, .All pertinent information and/ or exceptions will be documented on a daily basis. In an interview on 02/01/18 at 12:44 PM the Minimum Data Set (MDS) Coordinator stated the nurses had not entered information into the system correctly to activate a prompt which asks what nonpharmacological measures have been attempted prior to administering the [MEDICATION NAME]. In an interview on 02/1/18 at 3:45 PM the Director of Nursing stated more accurate documentation would be expected. The facility documents by exception and giving the medication would be an exception. | 2020-09-01 |
| 4172 | 4172 | BISHOP GADSDEN EPISCOPAL HEALTH CARE CENTER | 425411 | 1 BISHOP GADSDEN WAY | CHARLESTON | SC | 29412 | 2018-02-01 | 759 | D | 0 | 1 | Y9I611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and manufacturer package insert the facility failed to ensure a medication error rate of less than 5 % (percent) during medication administration observations. The medication error rate was 14.3% based on 4 of 28 observations. .The findings include: ERROR # 1: On 1/30/17 at approximately 5:14 PM, RN (Registered Nurse) # 2 administered one tablet of [MEDICATION NAME]-D 600/400 to Resident 157. On 1/30/17 at approximately 5:20 PM, RN # 1 stated that the evening meal had not yet been served, but should be served around 5:45 PM. During medication pass reconciliation on 1/30/17 at approximately 6:03 PM, a review of the January, (YEAR) physician orders [REDACTED]. ERROR #s 2, 3 & 4: On 1/31/18 at approximately 8:49 AM, RN # 1 administered one puff of [MEDICATION NAME] HFA (hydrofluoroalkane) 45/21 (45 mcg (microgram)/21 mcg)) to Resident 157 (error 2) and had the resident swallow water instead of swishing mouth with water and then spitting out (error 3). RN # 1 also administered on 2 sprays of [MEDICATION NAME] Nasal Spray to Resident 157 (error 4). During medication pass reconciliation on 1/31/18 at approximately 8:55 AM, a review of the January, (YEAR) physicians orders revealed that Resident 157 should have received 2 puffs of [MEDICATION NAME] HFA 4 mcg - 21 mcg. A review of the the manufacturer package insert states: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. | 2020-09-01 |
| 4173 | 4173 | BISHOP GADSDEN EPISCOPAL HEALTH CARE CENTER | 425411 | 1 BISHOP GADSDEN WAY | CHARLESTON | SC | 29412 | 2018-02-01 | 880 | D | 0 | 1 | Y9I611 | Based on observations, interview and Facility Policy and Procedures, the Facility failed to follow standards of practice related to handling of oral medications with bare hands. This occurred during 1 of 28 medication pass observations. The findings include: On 1/30/18 at approximately 1:01 PM, RN (Registered Nurse) # 1 released one capsule of Tamsulosin 0.4 mg ER (extended release) from a punch card into his/her bare hand, then placed the capsule in a medicine cup and administered to Resident 202. On 1/30/18 at approximately 1:09 PM, the nurse acknowledged that he/she had handled the capsule with bare hands and was advised by the Surveyor that this is contrary to nursing standards of practice. Subsequent to the observation on 1/30/18 at approximately 2:07 PM, a review of the[NAME]Gadsden Retirement Community Policy & Procedures revealed under 3. Dose preparation: Staff should not touch the medication when opening a bottle or unit dose package. A review of the Infection Control Manual/ Medication Pass Worksheet revealed under Medication Administration: Does not hold pills with bare hands. | 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 );