cms_SC
Data source: Big Local News · About: big-local-datasette
40 rows where "inspection_date" is on date 2018-05-02
This data as json, copyable, CSV (advanced)
Suggested facets: facility_name, facility_id, address, city, zip, scope_severity, complaint, eventid, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1908 | 1908 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 550 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy entitled Dignity (6-17-08), the facility failed to promote dignity during the dining experience during 3 of 3 dining observations. Glasses were not provided for residents served drinks in cartons and cans. The facility also failed to promote dignity for 1 of 2 sampled residents with urinary catheters. Resident #328 was observed with an uncovered catheter drainage bag on multiple occasions. Staff failed to knock on resident room doors and wait for permission prior to entering on 2 of 2 units (Residents #23, #55, #328). In addition, staff failed to treat one of two sampled residents reviewed for dignity with respect while providing assistance with activities of daily Living (Resident #519). The findings included: During observation of the noon meal on the 100 and 200 Halls on 3-19-18 , residents were served milk and shake-ups in cartons and soda in cans without glasses provided or offered from which to drink. During observation of the noon meal on the 400 and 500 Halls on 3-20-18 , residents were served milk and shake-ups in cartons and soda in cans without glasses provided or offered from which to drink. On 3-21-18 at 8:25 AM, Resident #27 was observed to be drinking milk from a carton. S/he stated no glass had been provided for the milk. The facility admitted Resident #328 with [DIAGNOSES REDACTED]. Multiple observations (on 3-21-18 at 1:30 PM and 3:45 PM; on 3-22-18 at 8:38 AM, 9:03 AM and 2:40 PM) revealed the resident in bed with an uncovered catheter drainage bag hooked onto the bed frame. The room door was open and the drainage bag was visible to all passersby in the corridor. At 2:40 PM on 3-22-18, the observation was verified by the Director of Nurses (DON). Following observation of the oxygen concentrator in Resident #328's room, the condition of the filters was brought to the attention of Licensed Practical Nurse (LPN) #1. LPN #1 entered the resident's room without … | 2020-09-01 |
| 1909 | 1909 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 552 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, one of two residents reviewed for hospice did not make his/her own choices related to election of Medicare benefits. Although the resident had not been deemed unable to make his/her own decisions, Resident #328's family signed the election form for the hospice benefit. The findings included: The facility admitted Resident #328 with [DIAGNOSES REDACTED]. Review of the 3-8-18 Minimum Data Set assessment at 10:52 PM on 3-21-18 revealed that the resident had a Brief Interview for Mental Status score of 15 (cognitively intact). Record review on 3-22-18 at 10:12 AM revealed 2-14-18 readmission physician's orders [REDACTED]. Review of hospice documentation revealed that the election of hospice benefits was signed by a family member. This and the resident's cognitive status were verified by the Director of Nursing at 3:15 PM on 3-22-18. | 2020-09-01 |
| 1910 | 1910 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 574 | C | 0 | 1 | KRST11 | Based on observation interview, the facility failed to ensure that residents were aware of the location of the ombudsman's contact information for 11 of 11 residents present in the Resident Council Group Meeting. The findings included: On 3/19/18 at 310PM, residents present in the Resident Council Group meeting were asked if they were aware of the location of the ombudsman's contact information and all responded No. | 2020-09-01 |
| 1911 | 1911 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 577 | C | 0 | 1 | KRST11 | Based on interview and observation, the facility failed to ensure that residents were aware of the location of the state inspection results and that postings were posted at an appropriate reading level for 11 of 11 patients who attended the resident council meeting. The findings included: On 3/19/18 at 310PM, residents in the Resident Council Group meeting were asked if they were aware of the location of the state inspection results and all residents responded No. Following the meeting, the Executive Director (ED) was informed of how high the required postings were. ED agreed that they were too high and stated that it would be corrected. According to the Assistance on the Americans with Disabilities Act (ADA), Eye level of a man sitting in a wheelchair is 43-51 inches. | 2020-09-01 |
| 1912 | 1912 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 580 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician (MD) and Responsible Party (RP) of changes in residents' conditions for 5 of 5 reviewed for unnecessary medications. The findings included: Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the physician (MD) orders on 3/21/18 revealed that Resident 61 had an order to start on 2/17/18 for [MEDICATION NAME] 1mg every Wednesday. Further review of the Medication Administration Record (MAR) revealed that the resident received the medication daily from 2/17/18-2/22/18. The medication error was recognized by Licensed Practical Nurse (LPN) #3 on 2/22/18 and wasn't given again until Wednesday, 2/28/18. The medication error report was provided on 3/21/18 at 510PM and revealed that MD and RP were not notified until 3/1/18, approximately 1 week after the error had occurred. In an interview with DON on 3/21/18 at 445PM, DON stated that LPN #3 identified the error on 2/22/18 but did not bring it to the attention of DON at that time. It was only when DON ran the monthly report on 3/1 that it was discovered that a medication error had occurred; it was at this time when MD or RP were notified. Further review of Resident 61's Nurse's notes revealed that on 1/30/18, the resident had an oxygen saturation (O2 Sat) of 68% and was sent to the emergency room (ER) without MD being notified. On 1/31/18, the Resident was noted to have an O2 Sat of 83% and was transferred to the ER without MD notification. On 2/16/18, the Resident had a blood pressure (BP) of 57/43 and an O2 Sat of 80%. According to the note, the MD was not notified; instead, the nurse received orders from [MEDICAL TREATMENT] to transfer resident to the emergency room (ER). On 3/2/18, the resident had a very low blood pressure and was sent to the ER. Again, the MD was not notified in this instance. According the facility's Changes in Resident's Condition or Status policy, Nursing servic… | 2020-09-01 |
| 1913 | 1913 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 607 | K | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to implement policies developed related to identification of abuse, investigation of abuse, resident protection, and reporting allegations of abuse to the State Agency, for four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], two residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) noti… | 2020-09-01 |
| 1914 | 1914 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 609 | K | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to identify, report to the State Agency, and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], 2 residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[D… | 2020-09-01 |
| 1915 | 1915 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 610 | K | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the grievance file, review of the facility's abuse policies and procedures, and interview, the facility failed to identify, report to the State Agency, and thoroughly investigate four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. Resident A was told to go to the bathroom in her/his brief, causing anxiety, fear, and humiliation. Resident B reported neglect and threats to delay [MEDICAL CONDITION] care. Resident #9 reported rough handling, humiliation, and verbal abuse and was visibly upset. Resident #529 reported verbal abuse and humiliation. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], 2 residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shift change from ,[D… | 2020-09-01 |
| 1916 | 1916 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 623 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy on notification, the facility failed to ensure Resident #29, #23, #24 and Resident #61 and the resident's Personal Representative was notified in writing in a language they could understand of the reason for facility initiated transfers/discharges to the hospital. The facility further failed to ensure the Office of the State Long Term Care Ombudsman was notified of the transfer/discharge to hospital in a timely manner for 4 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review on 3/23/2018 at approximately 11:50 AM of the Nurses Notes dated 3/1/2018 at 12:25 AM indicated that Resident #29 was sent out to the hospital due to a possible [MEDICAL CONDITION] at approximately 9:15 PM on 2/28/2018. No documentation could be found in the medical record for Resident #29 to ensure Resident #29 and the Personal Representative for Resident #29 were notified in writing of the reason for the transfer/discharge in a language they could understand. And no documentation could be found in the medical record for Resident #29 to ensure the same notification was sent to the state Ombudsman in a timely manner. During an interview on 3/23/2018 at approximately 1:55 PM with the DON (Director of Nursing) he/she could not confirm whether Resident #29 and his/her Personal Representative had received notice of the reason for the transfer/discharge to the hospital. The DON could not confirm that the state Ombudsman was sent a copy of the notification of the transfer/discharge to the hospital in a timely manner. The facility readmitted Resident #23 on 2-12-18 with [DIAGNOSES REDACTED]. Review of Nurses Notes on 3-23-18 at 8:12 AM revealed that the Certified Nursing Assistant reported that Resident #23 was found unresponsive when his/her supper tray was delivered. Assessment completed . incoherent . The resident was unab… | 2020-09-01 |
| 1917 | 1917 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 625 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on on record review, interviews and review of the facility policy titled, Bed Hold/Reservation of Room Policy, the facility failed to ensure Resident #29 and #23 or the resident's Personal Representative was provided written information that specifies the duration of the state bed-hold policy before transfer to the hospital for 2 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review on 3/23/2018 at approximately 11:50 AM of the Nurses Notes dated 3/1/2018 at 12:25 AM indicated that Resident #29 was sent out to the hospital due to a possible [MEDICAL CONDITION] at approximately 9:15 PM on 2/28/2018. No documentation could be found in the medical record for Resident #29 to ensure the resident or the Personal Representative for Resident #29 were given a copy of the Bed-Hold Policy before transfer/discharge to the hospital. During an interview on 3/23/2018 at approximately 2:10 PM the DON (Director of Nursing ) stated, residents and their personal representatives do not get a copy of the Bed Hold Policy at the time of the transfer to the hospital, The DON went on to say, nursing has nothing to do with giving a copy of the bed hold policy to the resident or the personal representative at time of transfer, that is handled by the the business office or Social Services. Review on 3/23/2018 at approximately 2:15 PM of the facility policy titled, Bed Hold/Reservation of Room Policy, states, under Policy: Before the patient transfers to a hospital or the patient goes on therapeutic leave the facility will provide written information to the patient or patient representative regarding bed holds. Under Procedure: states, 1. Bed hold policies will be provided and explained to the patient upon admission and explained to the patient before each temporary absence. 2. Before the patient transfers to a hospital or the resident goes on therapeutic, the facility will provide … | 2020-09-01 |
| 1918 | 1918 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 655 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan for Resident #519 related to wounds and for Resident #320 related to [MEDICAL CONDITION] within 48 hours of admission for 2 of 2 residents reviewed for Baseline Care Plans. The findings included: The facility admitted Resident #519 with [DIAGNOSES REDACTED]. Review on 3/22/2018 at approximately 12:16 PM of the medical record for Resident #519 revealed a Baseline Care Plan. Further review on 3/22/2018 at approximately 12:16 PM of the Baseline Care Plan for Resident #519 did not indicate wounds of any kind. An interview on 3/23/2018 at approximately 2:00 PM with the DON (Director of Nursing) confirmed that the baseline care plan for Resident #159 did not include the infected incision site nor a sacral pressure ulcer. Review on 3/23/2018 at approximately 3:15 PM of the facility policy titled, Baseline Care Plan, states under Purpose: To develop a baseline care plan within 48 hours of admission to direct the care team while the comprehensive care plan is developed that incorporates the resident's goals, preferences and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The Policy states, A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility admitted Resident #320 with [DIAGNOSES REDACTED]. Record review on 03/21/18 at approximately 8:45 AM revealed that the Baseline Care Plan completed at admission did not include interventions related to Resident #320's [DIAGNOSES REDACTED]. In an interview on 03/21/18 at approximately 4:35 PM the Director of Nursing stated that the admitting nurse should have reviewed the dis… | 2020-09-01 |
| 1919 | 1919 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 656 | E | 1 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop a care plan and/or implement established interventions for 4 of 15 sampled residents reviewed for care plans. Resident #519 did not have a care plan developed for activities. Resident #23's care plan related to shortness of breath was not followed. Resident #328 and #329 did not have care plans developed to address specific behaviors and interventions related to use of psychoactive medication use on an as needed (PRN) basis. The findings included: The facility readmitted Resident #23 on 2-12-18 with [DIAGNOSES REDACTED]. Record review at 8:12 AM on 3-23-18 revealed an entry in the Nurse's Notes on 1-8-18 at 8:04 PM that Resident #23 complained of shortness of breath at 5 PM. O2 sat (oxygen saturation) at 64(%). Resident was put on 2 liters of oxygen via nasal cannula. At 6 PM O2 sat at 100%. Resident refused both lunch and dinner. Complains of 'feeling full'. There was no evidence that the physician was notified until the next day. On 1-27-18 at 6:30 AM, the resident was noted as having Fatigue and weakness upper and lower extremities. pallor. Cough congested, productive thick white sputum. Expiratory wheezing. Lungs sounds diminished throughout A(nterior)/ P(osterior) lobes. There was no evidence that the physician was notified. Review of the care plan at 9:41 AM on 3-23-18 revealed on-going problems of (1) Resident is at risk for cardiac distress relating to a-fib, [MEDICAL CONDITION], CAD,[MEDICAL CONDITION] (2) Potential for compromised oxygen exchange or SOB (shortness of breath) r/t (related to) dx (diagnosis) of [MEDICAL CONDITION]. Approaches (interventions) included to (1) Provide 02 (oxygen) if ordered by MD. Monitor 02 sats (saturation) as ordered. Document and report abnormal results to physician. and (2) Observe and report s/s (signs & symptoms) of resp(iratory) distress i.e., confusion, rapid breathing, pallor, blue lips, sweating, reports that can't breathe,… | 2020-09-01 |
| 1920 | 1920 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 657 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Nutrition Intervention Program Overview, the facility failed to ensure the Comprehensive Plan of Care for Resident #23 for [MEDICAL TREATMENT] and [MEDICAL CONDITION], Resident #61 for most recent Advance Directive and Resident #29 for interventions to stabilize weight and/or prevent further weight loss for 1 of 2 residents reviewed for [MEDICAL TREATMENT], for 1 of 1 residents reviewed with recent change in Advance Directives and for 1 of 3 residents reviewed for Nutrition. The facility further failed to ensure the CNA (Certified Nursing Assistant) most involved with Resident #29's care and the CDM (Certified Dietary Manager) had input into the care planning process for Resident #29, and the physician and the CNA involved with the care for Resident #27 had input into the care planning process for 4 of 15 care plans reviewed. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review on 3/23/2018 at approximately 11:26 AM of the medical record for Resident #29 revealed an eight pound weight loss from 3/1/2018 through 3/21/2018. No interventions were documented in the medical record to ensure the dietary department was monitoring the weights and adding interventions to improve or to stabilize Resident #29's weight. Review on 3/23/2018 at approximately 11:38 AM of the facility policy titled, Nutrition Interventions Program Overview, states, under Standard: This facility is committed to ensuring that each resident maintains acceptable parameters of nutritional status as indicated by clinical measures, such as body weight, protein status, and hydration, unless a resident's clinical condition demonstrates that this is not possible. To encourage food and beverage intake, special attention is directed towards creating a positive and fulfilling dining experience and ensuring that residents receive a therapeutic diet when there is a nutrition… | 2020-09-01 |
| 1921 | 1921 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 676 | D | 0 | 1 | KRST11 | Based on observation, the facility failed to provide the care necessary to maintain the highest level of dignity and daily functioning with activities of daily living for 1 of 3 meal observations. The findings included: Meal observation on 3/20/18 at 1155AM revealed Resident #12 having apparent difficulty cutting a slice of bread. Dining room staff was observed to look in her direction several times, however, failed to offer help. After approximately 3 minutes of trying, the Resident gave up and continued eating other items on her plate. The resident made another unsuccessful attempt at cutting the bread and became frustrated and threw the knife down. At that point, the surveyor went over to the table and asked the resident how things were going and she stated I just can't cut it. Surveyor then alerted a staff member and informed them that the Resident was having issues. The staff member confirmed that the resident was unable to cut the bread then proceeded to assist. | 2020-09-01 |
| 1922 | 1922 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 679 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an ongoing program of activities for Resident #519 designed to meet the interests of and to support his/her physical, mental and psychosocial well being and to include group and independent activities for 1 of 1 resident reviewed for Activities. The findings included: The facility admitted Resident #519 with [DIAGNOSES REDACTED]. Review on 3/23/2018 at approximately 2:15 PM of the Comprehensive Plan of Care for Resident #519 dated 3/5/2018 revealed no ongoing program of activities to include his/her choices, preferences and current interests. During an interview on 3/23/2018 at approximately 5:06 PM the Care Plan Coordinator concerning the activities for Resident #519 he/she stated, Oh, there are no activities on the care plan because we have not had an Activity Director for about 6 months. But we just got one in the last couple of weeks. | 2020-09-01 |
| 1923 | 1923 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 684 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physicians orders for medication administration for one of two sampled residents reviewed for [MEDICAL TREATMENT]. Resident #23 did not receive treatments for a rash and thrush as ordered. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 3-22-18 at 4:30 PM revealed 2-16-18 physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) on 3-23-18 at 10:03 AM revealed that day shift nurses applied the cream on 2-17-18 and 2-18-18. Evening shift started the topical medication on 2-22-18 and applied it for the 7 days. During an interview at 11:03 AM on 3-23-18, the Director of Nurses (DON) accessed the computerized pharmacy delivery data and stated that the medication came in 2-17-18. S/he reviewed the MAR and verified it was signed off on 2-17-18 and 2-18-18 only on the day shift. The DON confirmed that it was missed 5 days on day shift. Further review on 3-22-18 at 4:30 PM revealed 2-16-18 physician's orders [REDACTED]. Review of the MAR on 3-23-18 at 10:03 AM revealed that it was only given for 9 days. During an interview at 11:10 AM 3-23, the DON reviewed the MAR and verified it was only given for 9 days. | 2020-09-01 |
| 1924 | 1924 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 686 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure proper cleaning of a sacral decubitus ulcer for Resident #519 for 1 of 3 residents reviewed with Pressure Ulcers. The findings included: The facility admitted Resident #519 with [DIAGNOSES REDACTED]. An observation on 3/21/2018 at approximately 10:30 AM during wound care for Resident #519 revealed a physician's orders [REDACTED]. LPN (Licensed Practical Nurse) #2 knocked on Resident #519's door and waited for the resident to give permission to enter. LPN #2 explained the procedure to the resident and this surveyor asked permission to observe the wound care and he/she stated, sure. Privacy was provided and both LPN #2 and the RN (Registered Nurse) assisting washed their hands and applied gloves. The RN and LPN #2 positioned Resident #519 and raised the bed and removed the brief. LPN #2 then, removed her gloves and washed his/her hands and applied gloves and removed the soiled dressing which contained a scant amount of drainage. The LPN them removed his/her gloves and washed her hands, the wound bed had 2 elongated areas in the upper part of the crack area. The wound bed is beefy and the surrounding tissue is red torturous with some dark areas noted. The LPN then removed his/her gloves and washed he/her hands and reapplied gloves, and the LPN cleaned with wound with normal saline X 2 wiping from top to bottom of the wound and then removed his/her gloves and washed his/her hands and reapplied gloves and applied the skin prep around the wound, and applied the [MEDICATION NAME] AG to the Allevyn dressing and placed it directly on the wound bed. The brief was refastened and the resident was made comfortable. The LPN bagged the trash and removed his/her gloves and washed his/her hands. During an interview on 3/23/2018 at approximately 2:22 PM LPN #2 confirmed that the sacral decubitus was cleaned from top to bottom. He/she went on to say that because of the location of the wound it wa… | 2020-09-01 |
| 1925 | 1925 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 689 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Fall Management, the facility failed to ensure Resident #519 was free from accidents/falls for 1 of 3 residents reviewed for Accidents. The findings included: The facility admitted Resident #519 with [DIAGNOSES REDACTED]. During an interview on 3/20/2018 at approximately 4:30 PM with Resident #519, he/she stated, staff came in to take me to the bathroom and I told them about 10 times that I could not stand or walk. They did not listen to me and took me to the bathroom and I could not stand, so they dropped me because I could not hold myself up and they could not hold me up. Review on 3/22/2018 at approximately 3:52 PM of a form titled, Incident/Accident Data Entry Questionnaire, dated 3/7/2018 at 9:30 AM states, Resident was lowered to floor during transfer and tip of knees touched the floor and was helped back up to toilet without injury noted. Review on 3/22/2018 at approximately 4:14 PM of the facility policy titled,Fall Management, states under Purpose, To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. Under, Pertinent regulatory Requirements, states. Based on comprehensive assessment of a patient, the facility must ensure that patient's receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the patient's choice. The patient environment remains as free of accident hazards as is possible and each patient received adequate supervision and assistive devices to prevent accidents. Review on 3/22/2018 at approximately 4:25 PM of the MAR (Medication Administration Record) for Resident #519 revealed that Resident #519 had received a blood pressure medication with parameters to hold if systolic blood pressure is less than 90, the dystolic blood pressure is less than 56 and the pulse is less than 60 prior to the f… | 2020-09-01 |
| 1926 | 1926 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 690 | E | 1 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide appropriate care and services to one of two sampled residents reviewed with urinary catheters. The facility failed to provide catheter care as ordered for Resident #329. The findings included: The facility admitted Resident #329 with [DIAGNOSES REDACTED]. Record review at 12:24 PM on 3-19-18 revealed physician's orders [REDACTED]. Review of the Treatment Administration Records at 1:49 PM on 3-19-18 revealed that catheter care was only signed off as having been provided daily. During an interview on 3-23-18 at 4:30 PM, with the Corporate Consultant present, the Director of Nurses (DON) reviewed the record and verified, It was ordered q (every) shift. S/he confirmed that catheter care had not been provided as ordered from 12-21-16 thru 12-31-16. Review of the Intake/Output (I&O) Records at 2:09 PM on 3-19-18 revealed that monitoring of the resident's output was inconsistent. Five of 11 days in 12-16 were incomplete. Fifteen of 29 days in 1-17 were incomplete. During an interview on 3-18-18 at 4:30 PM, the DON stated s/he was aware that the I&O records were incomplete. | 2020-09-01 |
| 1927 | 1927 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 692 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Nutrition Intervention Program Overview, the facility failed to ensure interventions were in place for Resident #29 to maintain acceptable parameters of nutritional status such as body weight for 1 of 3 residents review for Nutrition. The facility further failed to ensure a physician's order for a fluid restriction for Resident #23 was followed for 1 of 2 residents receiving [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review on 3/23/2018 at approximately 11:26 AM of the medical record for Resident #29 revealed an eight pound weight loss from 3/1/2018 through 3/21/2018. No interventions were documented in the medical record to ensure the dietary department were monitoring the weights and adding interventions to improve or to stabilize Resident #29's weight. Review on 3/23/2018 at approximately 11:30 AM of the Plan Of Care for Resident #29 indicated a problem area which reads, Resident is at nutrition risk as evidenced by resident leaves 25% or more of food uneaten at most meals. The goal states, The resident will sustain no significant weight loss through next review date. The interventions include, Invite, encourage and remind , escort to activity programs consistent with the resident's interests. Observe and report to the physician, signs and symptoms of malnutrition, Offer substitutes if 50% or less is consumed. Provide dining room meal accommodations and allow adequate time to eat, and provide a quiet, calm setting. Provide and observe intake of diet fluids, enhanced foods on tray and offer snacks. No interventions were in place to prevent further weight loss or to stabilize Resident #29's weight. During an interview on 3/23/2018 at approximately 11:40 AM the CD (Certified Dietary Manager) concerning the weight loss for Resident #29, he/she states, All I can do is encourage Resident #29 to eat and speak … | 2020-09-01 |
| 1928 | 1928 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 695 | D | 0 | 1 | KRST11 | Based on observations and interviews, the facility failed to ensure that oxygen equipment was maintained in good condition for 2 of 2 residents on oxygen (O2) therapy. Residents #328 and #520 were observed to have oxygen concentrator filters that were dust filled. The findings included: On 3-20-18 and 3-21-18, Resident #328's oxygen concentrator filters were noted to be dust-filled. This was verified by Licensed Practical Nurse (LPN) #1 at 3:54 PM on 3-21-18. S/he stated there were no other residents receiving O2 on the 100-200 halls. On the 400-500 halls, Resident #520 was identified as the only other resident on O2 therapy in the facility. At 4:10 PM on 3-21-18, both filters on Resident #520's concentrator were also noted with a heavy dust build-up. This was verified by LPN #4. S/he stated that Maintenance was responsible for cleaning the filters but did not know how often it was done. | 2020-09-01 |
| 1929 | 1929 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 698 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 2 sampled residents reviewed for [MEDICAL TREATMENT]. The facility failed to adhere to a physician-ordered fluid restriction and failed to monitor the [MEDICAL TREATMENT] for Resident #23. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of Nurses Notes at 8:12 AM on 3-23-18 revealed the resident had been hospitalized from 1-27-18 to 2-12-18. Record review on 3-22-18 at 4:30 PM revealed readmission physician's orders [REDACTED]. Observations revealed that the resident had water at the bedside on 3-21-18 at 12 PM and 4:21 PM. At 10:45 AM on 3-22-18, the resident had a can of soda on his/her overbed table. At 4:20 PM, Resident #23 was observed in the hallway outside his/her room drinking from a styrofoam cup. When asked if the staff were keeping track of what s/he drank, the resident stated that s/he could get something to drink when s/he wanted. When asked if the staff wrote down what s/he drank anywhere, the resident stated s/he did not think so. Further record review revealed no evidence of ongoing monitoring the resident's intake. Review of the diet card on 3-22-18 at the evening meal with the Director of Nursing (DON) revealed instructions for the fluid restriction but not how much was to be supplied with each meal. During an interview at 6:25 PM on 3-22-18, Licensed Practical Nurse (LPN) #1 verified that Resident #23 was on a 1200 cc fluid restriction. When asked how s/he knew how much s/he could give on her/his shift, the nurse stated, We do 12 hours, so I can do 600 cc. LPN #1 reviewed the record and verified that there were no specific orders for provision of fluids by dietary and nursing. When asked how s/he was keeping track of the intake, LPN #1 verified there was no intake record in the Medication Administration Record [REDACTED]&O sheet). We wi… | 2020-09-01 |
| 1930 | 1930 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 725 | E | 0 | 1 | KRST11 | Based on review of personnel files, interview, and review of the South [NAME]ina Board of Nursing Endorsement Requirements, the facility failed to ensure that one of 5 Licensed Practical Nurses (LPNs) reviewed had appropriate qualifications prior to hire. LPN #1 was working as a nurse in South [NAME]ina for approximately 6 months without the required license. The findings included: Review of personnel files on 5/01/18 at 4:33 PM revealed that LPN #1 was hired/started work on 12-13-16 with a Virginia multistate license. A South [NAME]ina temporary permit was not issued until 6-8-17. During an interview at 12:33 PM on 5-2-18, the Director of Nurses reviewed the file and verified that the LPN had worked for approximately 6 months without the required temporary license in place. The South [NAME]ina Board of Nursing Endorsement Requirements state: A current South [NAME]ina license or temporary license is required to practice nursing in this state . Therefore, all nurses must possess a current South [NAME]ina license or temporary license before beginning orientation . It is a violation of the Nurse Practice act .to begin orientation without the proper license and can result in action by the Board. The Board may issue a temporary license for up to sixty (60) days pending completion and approval of the application. | 2020-09-01 |
| 1931 | 1931 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 732 | C | 0 | 1 | KRST11 | Based on observations and interview, on all days of the survey, the staffing postings were located on an erasable board and did not include all required information for ready access to all visitors and residents on 2 of 2 units. The findings included: Observations on all days of the survey revealed that staffing information was posted on an erasable board and did not include total hours worked. During an interview on 3-22-18, the Administrator verified that the staffing information was not kept in the posted format for the required 18 months. S/he presented e daily Staffing Sheets which were kept by the facility. These forms included names and hours scheduled for individuals in the required categories by shift, but not what hours were actually worked. The form also did not include the daily census. | 2020-09-01 |
| 1932 | 1932 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 755 | E | 1 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to insure medications were available for Residents #320, 328, 519, 329, and 27. Medications were not started timely due to not being available for 5 of 15 sampled residents reviewed for Medications. The findings included: The facility admitted Resident #320 on March 16, 2018 with [DIAGNOSES REDACTED]. Record review on 03/23/18 at approximately 8:45 AM revealed a Nurse's Note dated 03/17/18 at 11:09 AM stating Resident alert and oriented. Therapy to evaluate today. Medications not in until tonight late. I am getting a [MEDICATION NAME] out of Pyxis for (him/her) and the pharmacy is sending her script stat so she can receive adequate pain relief today. Subsequent review of the Medication Administration Record (MAR) revealed that the following medication were not given until 03/18/18: [MEDICATION NAME] ([MEDICATION NAME]) 25 MG for Depression, [MEDICATION NAME] 10 MG for Hypertension and [MEDICATION NAME] ([MEDICATION NAME]) 500 MG for [MEDICAL CONDITION]. Review of facility training material used to train staff on 06/05/17 revealed staff is to obtain the medication from one of the facility's back up pharmacies (Burke's, CVS). You may also call the 24 hour emergency on-call pharmacist from [ENTITY]. If you are unable to obtain the medication from either back up pharmacy, notify the physician to obtain an order to give the medication when available. It is not acceptable to continue to document not available. Notify the physician to obtain an order to change medication to an equivalent or discontinue the medication, if applicable. In an interview on 0[DATE] the Director of Nursing (DON) provided a copy of the delivery record from the primary pharmacy indicating that the medication arrived the evening of 03/17/18. The DON stated that staff should have called the back up pharmacy but did not. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record reviews and interv… | 2020-09-01 |
| 1933 | 1933 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 757 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that resident's medication regimen was free from unnecessary medications and/or monitored for accuracy of administration for 2 of 7 residents reviewed for unnecessary medications. The findings included: Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the physician (MD) orders on 3/21/18 revealed that Resident 61 had an order to start on 2/17/18 for [MEDICATION NAME] 1mg every Wednesday. Further review of the Medication Administration Record [REDACTED]. The medication error was recognized by Licensed Practical Nurse (LPN) #3 on 2/22/18 and wasn't given again until 2/28/18. An interview with the Director of Nursing (DON) on 3/21/18 at 445PM confirmed that a medication error had occurred. The medication error report was provided on 3/21/18 at 510PM and revealed that the reason for the error was that LPN 3 did not read the actual order on MAR. The facility admitted Resident #519 on 3/5/2018 at 3:30 PM with [DIAGNOSES REDACTED]. Review on 3/21/2018 at approximately 1:25 PM of the admission physician orders [REDACTED]. Review on 3/21/2018 at approximately 2:30 PM of the MAR (Medication Administration Record [REDACTED]. Resident #519 received Losartan 100 mg 2 times daily on 3/9/2018, 3/10, 3/11, 3/14, 3/15, and 3/16. Further review on 3/21/2018 at approximately 2:20 PM of the MAR for Resident #519 revealed parameters to hold the medication Carvedilol 25 mg for a systolic blood pressure less than 90 and a dystolic blood pressure less than 56 and for a pulse less than 56. Review of the MAR indicated [REDACTED]. During an interview on 3/23/2018 at approximately 2:00 PM with the DON (Director of Nursing) confirmed that the medications were given in error and stated the physician should have been notified. The facility additionally failed to ensure Resident #591 received eye drops ordered for [MEDICAL CONDITION] were administered as ordered in a tim… | 2020-09-01 |
| 1934 | 1934 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 758 | E | 1 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to document specific behaviors and provide non-pharmacological interventions prior to administration of as needed (PRN) anti-anxiety medication for 2 of 7 sampled residents reviewed for unnecessary medication. Residents #328 and #329 were given [MEDICATION NAME] multiple times without specific behavior documented or evidence of non-pharmacological interventions attempted. In addition, the physician failed to reassess Resident #328 ( one of 2 sampled residents reviewed for unnecessary medication who were on PRN [MEDICATION NAME])14 days after readmission on PRN [MEDICATION NAME] to determine continued need and to establish specific timeframes for continued administration. The findings included: The facility initially admitted Resident #328 on 1-4-16 and readmitted her/him on 2-14-18 with [DIAGNOSES REDACTED]. Record review on 3-22-18 at 10:12 AM revealed an 8-25-17 physician's orders [REDACTED]. Give one tab(let) PO (by mouth) PRN 3 times a day. Review of the 2-18 Medication Administration Record [REDACTED]. The back of the MAR indicated [REDACTED]. No behaviors were noted. Review of the Nurses Notes on 3-22-18 at 1:04 PM revealed that no specific behaviors (how the anxiety was expressed) were documented and there was no evidence of non-pharmacological interventions attempted prior to administration of the medication. Nurses Notes for 2-1-18 actually indicated that Resident #328 was fatigued and sometimes difficult to arouse for meds and meals. Behavior Intervention Monthly Flow Records were reviewed on 3-22-18 at 12:24 PM. Anxiety was again noted as the behavior instead of how the anxiety was expressed. The only interventions noted on the form included redirect and 1:1 prior to [MEDICATION NAME] administration. Review of the care plan at 1:10 PM on 3-22-18 revealed that it failed to address individualized non-pharmacological interventions to be attempted prior to administration of th… | 2020-09-01 |
| 1935 | 1935 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 760 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure Resident #519 was free of significant medication errors. Resident # 519 received Losartan 2 times daily on multiple days and the order was for 1 time daily and Carvedilol was given with parameters to hold for low blood pressure and low pulse rate on 3/7/2018. The facility further failed to ensure Resident #519 received eye drops for [MEDICAL CONDITION] as ordered in a timely manner for 1 of 1 residents reviewed for significant medication errors. The findings included The facility admitted Resident #519 on 3/5/2018 at 3:30 PM with [DIAGNOSES REDACTED]. Review on 3/21/2018 at approximately 1:25 PM of the admission physician orders [REDACTED]. Resident #519 had a physician's orders [REDACTED]. The medication [MEDICATION NAME] for [MEDICAL CONDITION] ordered to be administered 2 times daily on 3/5/2018 and did not receive until 3/7/2018 at 9:00 AM. Review on 3/21/2 018 at approximately 2:30 PM of the MAR (Medication Administration Record [REDACTED]. Resident #519 received Losartan 100 mg 2 times daily on 3/9/2018, 3/10, 3/11, 3/14, 3/15, and 3/16. Further review on 3/21/2018 at approximately 2:20 PM of the MAR for Resident #519 revealed parameters to hold the medication Carvedilol 25 mg for a systolic blood pressure less than 90 and a dystolic blood pressure less than 56 and for a pulse less than 56. Review of the MAR indicated [REDACTED]. Resident #519 was ordered to receive eye drops of [MEDICAL CONDITION] and he/she did not receive them in a timely manner. During an interview on 3/23/2018 at approximately 2:00 PM with the DON (Director of Nursing) confirmed that the medications were given in error and or not administered timely and stated the physician should have been notified. | 2020-09-01 |
| 1936 | 1936 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 808 | D | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to comply with dietary standards for Resident #319. Green leafy vegetables were served to 1 of 1 on [MEDICATION NAME]. The findings included: The facility admitted Resident #319 with [DIAGNOSES REDACTED]. Record review on 03/22/18 at approximately 9:30 AM revealed that initial dietary order completed at admission stated regular diet and did not address the resident being on [MEDICATION NAME]. In an interview on 03/22/18 at approximately 12:22 Resident #319 stated she had been served spinach since coming to the facility on [DATE]. In a subsequent interview at approximately 12:42 PM the Dietary Manager stated that spinach was on the menu on selection card for 03/21/18 and the Resident #319 received meatloaf with gravy, mashed potatoes, spinach, cornbread, margarine and Boston cream pie. In an interview on 03/22/18 at approximately 1:03 PM the Director of Nursing stated the resident may have chosen despite education. Admitting nurses do not put the [MEDICATION NAME] information on the dietary communication card. | 2020-09-01 |
| 1937 | 1937 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 835 | K | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to be administered in a manner that protected residents from abuse. The Administrator's and Director of Nursing's (DON's) inaction and decisions following allegations of abuse placed other residents in their care in danger of neglect as well as physical, verbal, and emotional abuse. The Administrator and DON failed to implement abuse policies developed related to identification, investigation, and reporting allegations of abuse to the State Agency, for four of four residents' allegations of abuse/neglect reported to the facility involving 3 staff members via the facility's grievance process. The findings included: Review of the Grievance File on [DATE] at 4 PM revealed that the following incidents were reported to the facility via the grievance process: (1) On [DATE], two residents complained that Certified Nursing Assistant (CNA) #2 had neglected their needs resulting in anxiety and psychological harm. Licensed Practical Nurse (LPN) #2 wrote the following: This morning [DATE] when this nurse went to give (Resident A) her medication she appeared anxious. This nurse spoke with her about what she was so anxious about. She stated she wanted to go to the hospital. During further conversation about what she was feeling and why she wanted to go to the hospital, she shared with me that she was upset because last night when she would ask to go to the bathroom, she was told by the CNA to just go in her brief. (Resident A) is continent and this upset her. She then told the same story to her daughter when she arrived. The daughter then approached me in the early afternoon about what she needs to do to take her mom home. She stated that her mom was just very anxious and upset and she doesn't feel she will improve here in this setting . DON (Director of Nursing) and ED (Executive Director/Administrator) notified. Licensed Practical Nurse (LPN) #2 provided this written statement on [DATE]: At shif… | 2020-09-01 |
| 1938 | 1938 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 849 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all required hospice services were provided and documentation on site to ensure continuity of care for one of one hospice resident reviewed, Social Services was not provided and the hospice care plan was not at the facility for Resident #328. The findings included: The facility initially admitted Resident #328 on 1-4-16 and readmitted her/him on 2-14-18 with [DIAGNOSES REDACTED]. Record review on 3-22-18 at 10:12 AM revealed a readmission physician's orders [REDACTED]. Continued review on 3-22-18 at 12:21 PM revealed that the hospice care plan was not available in the hospice record for review. No social services notes were available for review. Review of the interdisciplinary care plan at 1:10 PM on 3-22-18 revealed it did not include the frequency of visits and responsibilities of the hospice staff. During an interview at 1:45 PM on 3-22-18, the above information was verified by the Director of Nursing. S/he also stated, I think the resident refused social services. Review of hospice records in the facility did not substantiate this. | 2020-09-01 |
| 1939 | 1939 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2018-05-02 | 880 | E | 0 | 1 | KRST11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify the need for and implement protective precautions for 1 of 1 sampled resident reviewed for Contact Precautions. Resident #320 was admitted to facility with a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #320 on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. Record review on 03/21/18 at approximately 8:45 AM revealed a Nurse's Note dated 03/19/18 that stated, During post admit chart audit, noted that resident had tested positive for [MEDICAL CONDITIONS]. This was not communicated during report from the hospital to facility staff. Resident immediately placed on isolation. Continues on [MEDICATION NAME]. During meal observation on 03/19/18 at approximately 12:17 PM observed that resident on precautions but dietary staff did serve meal in disposable containers. In an interview on 03/21/18 at approximately 10:21 AM the Director of Nursing (DON) stated that disposables are not used at the facility for residents on contact precautions. In a subsequent interview the Dietary Manager stated that nursing is to indicate that a resident is on contact precautions and should receive disposable dining ware. In an interview on 03/21/18 11:14 AM Certified Nursing Assistant (CNA) #1 stated related to removing food tray from resident's room while on precautions, s/he puts the tray down and takes of the protective garments, picks the tray up and takes it and puts it in the tray cart to be returned to the kitchen. In a related interview Dietary Aide #1 stated the carts are cleaned with a non-bleach solution. In an interview on 03/21/18 the DON stated related to contact precautions not being noted on dietary communication sheet, the admitting nurse should have communicated this to dietary. The DON also provided the facility's policy entitled [MEDICAL CONDITION] effective 04/2017 which stated Meal trays are bagged prior to removal from the room and are th… | 2020-09-01 |
| 2833 | 2833 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 609 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to report resident to resident abuse for 2 of 2 residents reviewed for abuse. Resident's #6 and #8 had a physical altercation that was not reported to the State Agency. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of Nurse's Notes for Resident #6 on 5/2/2018 at 10:05 AM, revealed a note from 4/22/2018 indicating Resident #6 had a physical altercation with another resident. Review of the facility's Investigation Worksheets for Residents #6 and #8 on 5/2/2018 at 12:17 PM, revealed the residents had a physical altercation on 4/22/2018. The Investigation Worksheet for Resident #6 revealed Resident #6 was observed hitting Resident #8 with a closed fist after Resident #8 grabbed Resident #6 by the arm and hit Resident #6 with his/her hand. The Investigation Worksheet for Resident #8 revealed the same findings. Nether Resident was injured per the facility's investigation. The Investigation Worksheets also revealed later in the day the 2 residents apologized to each other, shook hands and agreed to remain friends. Review of the Care Plans for Residents #6 and #8 on 5/2/2018 at 10:19 AM, revealed both had a history of [REDACTED]. During an interview with Licensed Practical Nurse (LPN) #3 on 5/2/2018 at 12:43 PM, LPN #3 stated she/he had been caring for both residents since they were admitted to the facility. LPN #3 stated the residents were friends. The day of the incident she/he witnessed the altercation. The two residents were in their wheelchairs at the nurse's station when Resident #6 made a comment to Resident #8 that was not appreciated by Resident #8. Resident #8 grabbed Resident #6 and the two residents hit each other. LPN #3 stated she/he immediately separated the two and returned the resident's to their rooms to cool off. LPN #3 stated neither resident had any injuries from… | 2020-09-01 |
| 2834 | 2834 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 622 | E | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to properly meet transfer requirements for 3 of 4 residents reviewed for hospitalization s. Residents #66, #55 and #28 were transferred out to the hospital for a stay and their information provided to the hospital by the facility was not complete as required. The findings include; Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon review of the medical record on 5/1/18, it was revealed that s/he was sent out to the hospital on [DATE] with a readmitted to the facility of 2/12/18 with [DIAGNOSES REDACTED]. The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 5/2/2018 at 10:16 AM, revealed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Resident Transfer Form on 5/2/2018 at 10:27 AM revealed the information provided to the hospital at the time of transfer did not include the contact information of the practitioner responsible for the care of the resident. In addition, comprehensive care plan goals were not included in the information provided to the hospital. During an interview with the Director of Nursing (DON) on 5/2/2017 at 10:27 AM, the DON confirmed the transfer information provided to the hospital did not include the practitioner's contact information and comprehensive care plan goals. The DON stated she/he was unaware that information was required to be included in the transfer information. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 5/2/2018 at 1:02 PM, revealed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the Resident Transfer Form on 5/2/2018 at 12:30 PM revealed the information provided to the hospital at the time of transfer did not include the contact information of the practitioner responsible for the care of the resident. In addition… | 2020-09-01 |
| 2835 | 2835 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 655 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to complete a baseline care plan for 1 of 3 residents reviewed. The findings include; Resident #280 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon review of the medical record on 4/30/18, it was revealed the base line care plan did not include active [DIAGNOSES REDACTED].#280 was admitted with an active Urinary Tract Infection and prescribed antibiotics for two days. An interview with the Director of Nursing on 5/2/18 at approximately 11:41 AM indicated it is the receiving nurses' job to complete the baseline care plan. However, it is his/her expectation that if a resident was receiving antibiotics or had an active Urinary Tract Infection, s/he would expect to see if on the base line care plan. An additional interview with the Nurse Consultant verified the facility did not have a direct policy related to the creation of base line care plans. | 2020-09-01 |
| 2836 | 2836 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 684 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that a resident with a physician's order to have a psych consult was done for 1 of 1 sampled resident and failed to ensure hospice services information was available at the facility for 1 of 1 sampled resident on hospice. Resident #7 with a physician's order dated 2/06/18 to have a psych consult was not done. Resident #131 with no documentation of hospice services being provided for the month of (MONTH) (YEAR) available in the facility. The findings included: The facility admitted Resident #7 on 11/08/17 with [DIAGNOSES REDACTED]. A review of the medical record on 5/01/18 at approximately 11:09 AM revealed social services progress notes dated 12/01/17 that indicated Resident #7 was depressed and tired of living. The social services progress note further indicated a psych consult would be offered to the resident. A social services progress note dated 12/04/17 indicated the resident had consistently expressed a want to not live any longer. The social services progress note further indicated the resident spoke about her/his spouse and son/daughter dying and not having a reason to live. Further review of the medical record revealed a physician's order dated 2/06/18 that indicated the resident was to have psych consult for failure to thrive or depression. There was a nurse's note dated 2/06/18 that indicated the nurse practitioner called and ordered a psych consult for Resident #7 related to previous statements by resident. There was no documentation in the medical record to indicate the psych consult was completed as ordered. An interview on 5/01/18 at approximately 11:28 AM with the Social Services Director (SSD) revealed the Medical Records Director (MRD) would be the person assisting in getting a psych consult for the resident. An interview on 5/01/18 at approximately 11:45 AM with the Medical Records Director (MRD) confirmed there was no documentation that the psych consult… | 2020-09-01 |
| 2837 | 2837 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 695 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, review of the facility's Oxygen Therapy General Policy and Equipment Rounds General Policy, the facility failed to ensure residents on oxygen received appropriate care and services for 3 of 3 sampled residents reviewed for respiratory care. Resident #7 and #62 with heavy white/beige substance that covered the front of the oxygen filter and Resident #31 with no documentation of checking oxygen saturation per shift as ordered. The findings included: The facility admitted Resident #7 on 11/08/17 with [DIAGNOSES REDACTED]. An observation during initial tour on 4/30/18 at approximately 9:22 AM revealed Resident #7 on an oxygen concentrator receiving oxygen at 2 liters by nasal cannula. There was an oxygen filter on both sides of oxygen concentrator that was noted with a heavy white/beige substance that covered the front of the oxygen filter. An observation on 4/30/18 at approximately 11 AM with another surveyor present revealed Resident #7 oxygen filters to be noted with a heavy white/beige substance on the front the oxygen filter. A chump of the white/beige substance was removed and felt gritty to the touch. An observation and interview on 4/30/18 at approximately 11:51 AM with LPN #2 revealed the facility did not have residents with oxygen concentrators with filters. LPN#2 further stated if there were any concentrators with filters, the filters would be cleaned as needed. In reviewing Resident #7 oxygen filters on his/her concentrator, LPN #2 confirmed the finding of the heavy white/beige substance on the filter. LPN removed the filter and the filter itself was noted to be black. The white/beige substance was dust, debris, lint, etc that had gathered during the use of the oxygen concentrator. LPN #2 stated the filter should have been cleaned before now. A review of the medical record on 5/01/18 at 11:09 AM revealed a Respiratory Flowsheet for the month of (MONTH) (YEAR) that indicated the nur… | 2020-09-01 |
| 2838 | 2838 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 745 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that quarterly medically related social services were provided for 2 of 2 resident reviewed to social services. Residents #9 and #28 with no documented social service notes for over 6 months or more. Resident #9 with no social services notes from (MONTH) (YEAR) until (MONTH) (YEAR). The findings included: The facility admitted Resident #9 on 10/30/18 with [DIAGNOSES REDACTED]. Review of the medical record on 5/01/18 at approximately 2:43 PM revealed the resident was on psych medications for behaviors. A review of a LifeSource Primary Care report dated 1/12/18 indicated the resident had been readmitted back into the facility. The report further indicated the resident was overmedicated and Plan of Care (P[NAME]) meeting with the daughter/son was recommended since the daughter/son was very insistent of giving patient higher doses. Review of social service progress notes revealed a note dated 10/31/17 that indicated the resident was admitted to the facility with plans to be discharged home. A social note dated 11/01/17 indicated the Power of Attorney could not attend care plan meeting. A social note dated 11/22/17 indicated the resident was readmitted back into the facility after having a significant health decline and will now be a long term care resident. There was no documentation in the social notes or nurse's notes related to meeting with daughter/son per recommendations in the 1/12/18 LIfeSource Primary Care report. An interview on 5/01/18 at approximately 11:30 AM with the Social Services Director revealed the social services progress notes in the chart are the only notes available. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Record review of the Social Worker notes on 5/2/2018 at 1:25 PM, revealed no notes or assessments related to the resident's psychosocial status or psychosocial needs, or monitoring of her/his psychosocial status, since 3/23/2017. T… | 2020-09-01 |
| 2839 | 2839 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 756 | D | 0 | 1 | FW0V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to identify medication irregularities in the drug regimen review for 1 of 5 residents reviewed for unnecessary medications. Resident #8 was ordered for PRN (as needed) [MEDICATION NAME] for over 14 days and the pharmacist failed to identify this irregularity. The findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's orders on 5/1/18 at approximately 9:25 AM revealed a 3/23/18 order for Quetiapine 50 mg every day PRN for agitation. Review of Resident #8's medication regimen review on 5/1/18 at approximately 9:30 AM revealed there were no irregularities identified in (MONTH) (YEAR). In (MONTH) (YEAR), the pharmacist identified an irregularity regarding [MEDICATION NAME] but did not identify the PRN [MEDICATION NAME] ordered for over 14 days. Review of Resident #8's medication administration records on 5/1/18 at approximately 9:45 AM revealed the PRN [MEDICATION NAME] was never administered. Interview with the Director of Nursing (DON) on 5/1/18 at approximately 11:03 AM confirmed PRN order for [MEDICATION NAME] on 3/23/18. The DON revealed the order was written during a hospitalization and carried over when the resident returned to the facility. | 2020-09-01 |
| 2840 | 2840 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-05-02 | 880 | E | 0 | 1 | FW0V11 | Based on observation and interview, the facility failed to ensure proper infection control protocols were followed during the observation of the laundry process. The findings include; On 5/2/18 at approximately 8:47 AM, an observation of the Laundry Aide revealed improper infection control procedures. During the observation of clean linen being removed from the washing machine and placed directly into the dryer, multiple items fell on to a soiled mat directly under the washer and dryer. The Aide proceeded to pick these items up from the floor and continued to place them into the dryer with the clean laundry. An interview with the Housekeeping Supervisor on 5/2/18 revealed his/her expectations would be for the linen that dropped onto the floor to be relaundered to ensure cleanliness. Review of the facility's policy titled Infection Control- The Laundry Process does not address transferring linen to the dryer in regards of cross contamination. An additional interview with the Regional Housekeeping Supervisor on 5/2/18 at approximately 11:00 AM, stated, it was his/her expectations the soiled linen placed in the dryer with the clean linen would not be harmful due to the high temperatures in the dryer that would kill the germs. | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );