cms_SC
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39 rows where "inspection_date" is on date 2020-01-16
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, complaint, standard, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 178 | 178 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 607 | D | 1 | 1 | FL9111 | > Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he … | 2020-09-01 |
| 179 | 179 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 609 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Residen… | 2020-09-01 |
| 180 | 180 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 625 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and [DATE] and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on [DATE] for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during December 2019. | 2020-09-01 |
| 181 | 181 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 908 | F | 1 | 1 | FL9111 | > Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine. | 2020-09-01 |
| 2024 | 2024 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 686 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of information from the National Pressure Ulcer Advisory Panel, the facility failed to accurately stage a pressure ulcer for one of one resident reviewed (Resident #6). The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review of the Wound Assessment Reports on 1/14/20 at approximately 1:47 PM revealed the following: -10/25/19-right buttock, .1 centimeters(cms) x .1 cm, Stage II, with scant, serous drainage, Slough [AGE]%, Granulation 20%; -1/6/20-right buttock, 1.8 cm x .8 cm, Stage II, serosanguineous, scant drainage, Granulation 100%; -1/13/20-right buttock, 1.5 x 1.2 cm, Stage II, sanguineous, scant drainage, Granulation 100%. During an interview with Registered Nurse #1 on 1/16/20 at 8:50 AM, s/he stated s/he had entered the role as Wound Care Nurse in September and would be going to more training related to wound care. S/he concurred the area on Resident #6's right buttock had been staged incorrectly and if slough was in the wound, the wound should have been staged as a Stage III pressure ulcer. Review of information from the National Pressure Ulcer Advisory Panel states the following: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis- . Granulation tissue, slough, and eschar are not present. | 2020-09-01 |
| 2025 | 2025 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 692 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Weight and Height Measurement, the facility failed to identify and implement additional interventions for one of 3 residents reviewed for nutrition. Resident #[AGE] with a documented weight loss of 11.28% at six months and a weight loss of 6.35% in one month. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Record review on 1/14/20 at 1:00 PM revealed a quarterly Minimum Data Set ((MDS) dated [DATE] listed Resident #[AGE] with impaired short and long term memory with severely impaired cognitive skills for daily living. Resident #[AGE] was coded needing extensive assistance-one person assist with eating. Review of the current physician orders revealed a Pureed diet, Ensure Plus daily, Magic Cup with lunch, evening snack, and a soft sandwich and nutty buddy as desired were ordered. Review of ordered medications revealed Resident #[AGE] had orders for [MEDICATION NAME] 40 mg daily and Potassium CL 10% (10 milliequivalants) every day. Review of the Medication Administration Records (MAR) for November 2019, December 2019, and January 2020 revealed with the exception of seven days Resident #[AGE]'s intake of Ensure was 100%. Intake for the Magic Cup varied from 0-100% during this time. Review of the meal percentage intake for three months revealed the resident's intake was 0-100%. Review of Resident #[AGE]'s weights revealed the following: 7/3/19- 133 pounds(lbs); 8/4/19-132 lbs; [DATE]-126 lbs; [DATE]-126 lbs; 12/11/19-118 lbs; 1/9/20-118 lbs; 1/16/20-122 lbs. Weight review revealed from [DATE]-12/11/19 there was a 6.35% weight lost and from 7/3/19-1/9/20 there was an 11.29% weight loss. Review of the Advanced Practice Registered Nurse (APRN) progress note dated [DATE] revealed a problem of loss of appetite with the onset of 7/19/18. Recorded weight by staff this month is back to 118 lbs. No further interventions were ordered. Revie… | 2020-09-01 |
| 2026 | 2026 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 759 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Nutrition Therapy, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 30 opportunities for error, resulting in a medication error rate of 6.67%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse (LPN) #1 on 1/15/20 at 12:33 PM revealed s/he crushed Sucrafate 1 Gram, [MEDICATION NAME] 20 milligrams (mgs), and [MED] 12.5 mg, placed each medication in individual cups and mixed each with water to help dissolve the medications. After administering medication through a [MEDEQUIP] tube to Resident #[AGE], LPN #1 was asked to show the medication cups to the surveyor. Residual medication was observed around the rim of the bottom of one cup and across the bottom of the second cup. The third cup appeared free of residual medication. During an interview with LPN #1 on 1/15/20 immediately after the observation, s/he confirmed there was residual medication in two of the cups and identified the medications as Sucrafate and [MED]. Review of the facility policy on 1/15/20 titled Enteral Nutrition Therapy, revealed the policy did not address residual medication. | 2020-09-01 |
| 2027 | 2027 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 812 | E | 0 | 1 | Z80E11 | Based on observations and interviews, the facility failed to ensure that ice machines in the main kitchen and the Cedar unit splash shield was free from stains, and that microwave ovens were free of dried stains on 2 of 3 units observed. The main kitchen ice machine splash shield was noted with dark stains, and the ice machine splash shield on Cedar unit was noted with stains. The microwave oven had dried on stains on inside top and bottom of microwave on Warley Unit and the microwave oven had dried stains on inside top on the Cedar Unit. The findings included: An observation and interview on 1/13/20 at approximately 10:08 AM with the facility's Chef confirmed the observation of the spots of black/brownish areas on the ice machine splash shield in the main kitchen. The Chef further stated that the spotted areas will not come out. The Chef stated it was the responsibility of maintenance to clean the ice machines. An interview on 1/13/20 at 11:33 AM with the Maintenance Director confirmed the blackened area on the ice machine splash shield in the main kitchen and stated the stains will not come out. The Maintenance Director stated he/she had to drain all the ice out of machine before cleaning the ice machines. An interview and observation on 1/13/20 at approximately 11:46 AM with the Maintenance Director confirmed the black/brownish stains on the ice machine splash shield on the Cedar Unit. Liquid was observed dripping from the splash shield to the ice in the machine. On 1/13/20 at approximately 4:19 PM, a review of the Unit Kitchen on Warley revealed the microwave had brown stains on inside top and bottom of the microwave oven. An observation and interview with Registered Nurse (RN) #2 confirmed the observation. RN #2 stated the stains at the bottom of the microwave occurred at lunch when coffee was heated. Reportedly, the housekeeping staff were responsible for cleaning the microwaves. On 1/13/20 at approximately 4:27 PM, a review of the Unit Kitchen/Staff Lounge on the Cedar Hall revealed the microwave had a thi… | 2020-09-01 |
| 2028 | 2028 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 849 | D | 1 | 1 | Z80E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to monitor for coordination of services by a Hospice Care provider for 1 of 2 sampled residents reviewed for Hospice (Resident #[AGE]). The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Record review on 01/14/20 at approximately 3:20 PM revealed Resident #[AGE] elected Hospice benefits and was admitted to Hospice Care by physician's orders [REDACTED]. Review of the Hospice communication book maintained at the facility revealed the certification of Hospice Services and Hospice Care Plan had not been updated since the initial certification period. In an interview on 01/14/20 at approximately 3:53 PM, the Hospice Nurse confirmed no updated information was in the communication book and stated s/he did not know why the documents were not there. In an interview on [DATE] at approximately 8:52 AM, the Director of Nursing stated s/he was not aware the documents were not in the facility and confirmed that no one from the facility monitored to ensure the contracted services were being provided as agreed upon. | 2020-09-01 |
| 2029 | 2029 | HERITAGE HOME OF FLORENCE INC | 425154 | 515 SOUTH WARLEY STREET | FLORENCE | SC | 29501 | 2020-01-16 | 880 | D | 1 | 1 | Z80E11 | > Based on observation, interview, and facility policies titled Hand Hygiene and The Laundry Process, the facility failed to follow infection control procedures for one of one observation of the laundry. Staff was observed to touch the washer door with a soiled, gloved hand; and did not sanitize or wash hands after removal of face shield, goggles, and gown. In addition, staff was observed removing clean items out of dryer during sorting of linen, and a soiled basket was touching a clean basket. The findings included: Observation of the laundry on 1/15/20 at 9:15 AM revealed during the loading of the washer, Laundry Staff #1 touched the washer door with his/her soiled, gloved hand. After removal of his/her face shield, goggles, and gown, Laundry Staff #1 did not sanitize hands or wash hands. In addition, staff was observed during the sorting of the linen, to remove clean linen out of the dryer. Further observation of the laundry revealed a dirty cart was touching a clean cart. During an interview with Laundry Staff #1 immediately after the observation, the above concerns were shared. Laundry Staff #1 did not dispute the findings and stated the washers were sanitized after every third wash. Review of the facility policy titled Hand Hygiene revealed it did not address handwashing after removal of face shield, goggles, and gown. Review of the facility policy The Laundry Process revealed it did not address the above concerns. | 2020-09-01 |
| 2841 | 2841 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2020-01-16 | 609 | D | 1 | 0 | 1I3M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to report an allegation of verbal abuse within 2 hours after the allegation was made for Resident #1, 1 of 3 sampled residents reviewed for Abuse. The allegation was reported to facility staff on [DATE]20 and reported to the State Agency on [DATE]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 1/15/2020 at 2:20 PM, revealed on [DATE] the facility received a phone call from a family member of Resident #1 alleging verbal abuse. As part of the investigation, the facility interviewed Resident #1 who stated the alleged verbal abuse occurred on the night shift on [DATE]. The facility also interviewed all staff members on duty at the time of the allegation as part of the investigation. Review of a hand written statement signed by Certified Nursing Assistant (CNA) #1 revealed Resident #1 reported the alleged verbal abuse to her/him on [DATE]20. Review of a signed statement by Registered Nurse (RN) #1 revealed RN #1 interviewed Resident #1 about the allegation on [DATE]. CNA #1 was present during the interview and stated Resident #1 reported the allegation to her/him on [DATE]20. During an interview with the Director of Nursing, on 1/16/2020 at 11:46 AM, the DON stated s/he also interviewed CNA #1 who confirmed Resident #1 had reported the allegation to her on [DATE]20. The DON stated staff are educated monthly and after any alleged violation about reporting potential abuse immediately to their supervisor. During an interview with RN #1, on 1/16/2020 at 1:45 PM, RN #1 confirmed her statement from [DATE] and stated CNA #1 said Resident #1 reported the allegation to her/him on [DATE]20. CNA #1 could not be reached by phone for interview. | 2020-09-01 |
| 3221 | 3221 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 609 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and policy review, the facility failed to report an allegation of misappropriation of resident property for Resident #82 to the State Survey Agency within the required timeframe of 24 hours. This failure was found for one (1) of seven (7) facility self-reported incidents reviewed during the survey. Findings include: Review of Resident #82's record indicated the resident's original admitted was [DATE]. The resident's [DIAGNOSES REDACTED]. According to Resident #82's Significant Change Minimum Data Set (MDS) assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Resident #82 required assistance with activities of daily living (ADLs). The Inventory of Personal Effects form completed on [DATE] indicated Resident #82 had a gold ring in his/her possession when s/he was admitted to the facility. Review of the Concern Grievance Form dated [DATE] and completed by the Director of Social Services revealed Resident #82's son reported the concern/grievance on [DATE]. The son indicated Resident #82's wedding ring was missing. The son and family did not know exactly when it went missing. Documentation on the Concern/Grievance Form revealed it most likely fell off Resident #82's finger without him/her realizing it. The Administrator, Director of Nursing and Housekeeping staff were notified of the missing ring on [DATE]. The family was asked for photographs of the ring. A search for the ring was conducted in Resident #82's room and bathroom, in the spa, and in the vacuum cleaner bag (went through its contents). The search did not result in finding the ring. The report indicated the plan also included checking the trap in the vacuum cleaner, checking the resident's robes, laundry washers and dryers, and his/her recliner. The ambulance transport company was contacted … | 2020-09-01 |
| 3222 | 3222 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 638 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for one (1) of 18 sample residents (Resident #82). Findings include: Review of Resident #82's record indicated the resident's original admitted was 12/22/15. The resident's [DIAGNOSES REDACTED]. According to the resident's Significant Change MDS assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Under the Mood Section, the resident was noted with tiredness/having little energy. She had no behavioral indicators. The resident required assistance with activities of daily living (ADLs). The MDS indicated the resident required extensive assistance from staff for transfers, dressing, and toilet use. Review of the clinical record revealed the last two (2) Quarterly MDS assessments with Assessment Reference Dates (ARD) of 9/12/19 and 12/5/19 were incomplete. The 9/12/19 and 12/5/19 Quarterly MDS sections were blank (no data entered) for the following sections: C - Cognitive Patterns and D - Mood. Section Z - Assessment Administration was not signed off. The 9/28/19 and 12/5/19 Quarterly MDS were incomplete as follows: Section C - The Cognitive Patterns section was blank for the Brief Interview for Mental Status (BIMs), the Staff Interview for Mental Status, and the [MEDICAL CONDITION] Section. There was no determination of the resident's level of cognition. Section D - The Mood section was blank for the Resident Mood Interview, Staff Assessment of Resident Mood, and Total Severity Score. There was no assessment of the resident's mood. The 9/12/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/16/2020 (as late as three (3) months after the ARD (annual review date). However, the overall assessment had not been signed of… | 2020-09-01 |
| 3223 | 3223 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 640 | E | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessments were encoded and transmitted to C[CONDITION] (Centers for Medicare and Medicaid Services) according to State and Federal time frames for five (5) of 18 sampled residents (Resident #2, Resident #82, Resident #132, Resident #133, and Resident #182). This deficient practice placed the residents at risk for having incomplete care plans and inadequate care and services resulting in physical and psychosocial decline. Findings include: Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected that the facility had not submitted assessment information into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System as required for the following residents. 1. Record review of Resident #2's face sheet revealed that Resident #2 was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 7/28/19 for Resident #2, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #2's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 2. Record review of Resident #82's face sheet dated reflected Resident #82 was admitted to the facility on [DATE]. Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of [DATE] for Resident #82, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #82's Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 3. Record review of Resident #132's face sheet dated reflected the resident was admitted t… | 2020-09-01 |
| 3224 | 3224 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2020-01-16 | 657 | D | 1 | 1 | GVI111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure care plans for two (2) of 18 sampled residents (Resident #2 and Resident #5) were updated when changes in condition occurred. This failure delayed a reduction in antipsychotic medication and possible lack of wound care and bleeding precautions. Findings include: 1. Record review of Resident #2's face sheet dated 1/26/2020 reflected that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted with medications including Quetiapine (an antipsychotic) and [MEDICATION NAME] (an antidepressant). Record review of the resident's Minimum Data Set ((MDS) dated [DATE] assessed the resident as having minimal cognition impairment as indicated the Brief Interview for Mental Status (BI[CONDITION]) score of 13. The resident was not documented as receiving hospice services or antipsychotic medications. Record review of Resident #2's active Care Plan dated 7/8/19-present reflected that Resident #2 was actively care planned for hospice services and care planned for monitoring of antipsychotic medication side effects. Care plan notes reflected a request for hospice consult on 8/15/19 by the family. Record review of a physician order [REDACTED]. The orders reflected a certification start date of hospice services dated 8/20/2019. The care plan was not updated/revised to reflect the physician orders [REDACTED]. During an interview on 1/15/2020 at 5:45 PM the facility Medical Doctor (MD) stated that he did not know that Resident #2 was no longer on hospice services. He stated that if he had known that he would have attempted a Gradual Dose Reduction (GDR) of Resident #2's antipsychotic if indicated. He stated that when a resident is on hospice care that he treats the resident very differently with respect to diagnostic orders because the resident is being followed by hospice, and if the resident comes off of hospice, then he would order primary care d… | 2020-09-01 |
| 3239 | 3239 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 656 | E | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, clinical record reviews and facility policies, the facility failed to create and implement comprehensive care plans for five (5) of 20 sampled residents (Residents #10, #22 #46, #55, and #[AGE]). The facility did not implement the care plan for restorative services for Resident #10 who was assessed to require passive range of motion restorative services. The facility did not develop a comprehensive care plan for the use of a Foley catheter for Resident #22. The facility failed to develop an individualized and comprehensive care plan for Resident #46's range of motion (ROM) services, catheter use, and pressure ulcer care. The facility did not update the care plan with the Wound Care Consultant (WCC) recommendations to keep Resident #55 incontinence brief unlatched when the resident was in bed. The facility did not develop a comprehensive care plan for the use of a Foley catheter for Resident #[AGE]. Findings included: Review of the policy titled, Person-Centered Care Plan Process dated 10/19/17 revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of Resident #10's clinical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had short and long-term memory problems and severely impaired decision-making skills. The MDS revealed Resident #10 had impairment on one (1) side of the lower extremity and did not use a mobility device. The MDS documented the resident did not receive therapy or restorative services. Review of Resident #10's care plan dated 11/6/19 for activities of daily living (ADL) function included the interventions, therapy as o… | 2020-09-01 |
| 3240 | 3240 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 657 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to ensure comprehensive care plans all residents were invited to care plan meetings. Resident #3 stated during an interview that he/she used to be invited to care plan meetings, but was no longer being invited to attend. An interview with the MDS (Minimum Data Set) nurses revealed they were responsible for inviting residents and family members to care plan meeting and they do not invite residents to their care plan meeting unless their cognitive status is assessed to be intact. The findings include: Review of the facility policy, with revision date of 10/17/19 Person Centered Care Plan Process, revealed the facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident in regard to daily routines and preferred activities. Residents will remain actively engaged in his or her care planning process through the resident's rights to participate in the development of the care plan and be informed in advance of changes to the care plan. Review of Resident #3's clinical record revealed an admitted to the facility of 7/9/12. The resident's [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Dysphagia, Hypertension, [MEDICAL CONDITION], Anxiety and Depression. Resident #3's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, was able to express ideas and wants, usually understands others and vision was adequate with c… | 2020-09-01 |
| 3241 | 3241 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 684 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interviews, and review of facility policy, it was determined the facility failed to follow the wound care consultant's (WCC) recommendation to keep the brief unlatched when in bed and failed to assess and measure the wound every week for one (1) resident. (Resident #55) Findings included: Review of the policy titled, Wound Evaluations revised 9/7/17 revealed an evaluation of wounds will be performed on admission, weekly and on discovery. Objective evaluation components included: location/type of wound; measurements; appearance; drainage; odor; presence of undermining/tunneling; healing; pain; [MEDICAL CONDITION]; presence of infection. Review of the clinical record revealed Resident #55 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Admission Observation form dated 12/13/19 and timed 5:47 PM revealed the resident had no alterations in skin, except for excoriation on the coccyx. Review of Resident #55's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, indicating intact cognition. The MDS revealed the resident required total assistance with transfers and personal hygiene. The resident was always incontinent of bowel and bladder, was at risk for developing pressure ulcers and had no skin alterations. Review of Resident #55's care plan dated 1/8/2020 identified the resident was admitted with excoriation to the sacrum and peri area. The interventions included nursing to do a full body audit weekly, preventative skin care as ordered, Certified Nurse Aides' (CNAs) to assess skin with activities of daily living (ADL) care and report any changes to nurse. Review of the Skilled Charting notes revealed: [DATE] at 6:49 PM the resident had no alteration in his skin. [DATE] at 2:35 AM and at 10:43 AM the resident had no alteration in skin. 12/30/19 at 10:43 AM the resident had no alteration in skin. 12/31/19 at… | 2020-09-01 |
| 3242 | 3242 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 686 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility policy it was determined the facility failed to provide appropriate wound care for one (1) of five (5) residents sampled for pressure ulcers. Resident #46. Findings included: Review of the policy titled, Indications For Glove Use, dated 11/27/17 documented, hands are washed immediately after gloves are removed, before contact with another resident or the environment and hands are washed or decontaminated prior to donning gloves. The facility did not provide a policy for the process and completion of dressing changes, upon request. Review of the clinical record for Resident #46 revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of Resident #46's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 14 (indicating intact cognition). The resident required total assistance of two (2) people with bed mobility, dressing, and toilet use and required total assistance of one (1) staff for eating, personal hygiene and bathing. The resident had one (1) Stage 3 and two (2) Stage 4 pressure ulcers. Review of Resident #46's care plan, dated 12/31/19, documented the interventions for impaired skin integrity as treatments per physician's orders and see Treatment Administration Record (TAR) for updated treatments. Review of the 1/2020 Physician Orders revealed an order dated [DATE] for two (2) times a day to cleanse the left exterior malleolus wound with Acetic Acid, apply a thin layer of Medi-Honey (used to treat wounds and has antibiotic in it), cover with [MED] (absorbent dressing), a dry dressing and secure with [MEDEQUIP]. The Physician's Orders also revealed an order dated 12/11/19 for two (2) times a day to clean the wound on the sacrum with Acetic Acid, apply a thin layer of Medi-Honey, and cover with [MED] and a dry dressing. Observation on 1/15/2020 at 11:47 AM during Resident #46's wound … | 2020-09-01 |
| 3243 | 3243 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 688 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation record review, interviews, and review of facility policy, it was determined the facility failed to provide restorative services for three (3) of seven (7) residents sampled for Range of Motion (ROM) services. (Resident #10, Resident #39, Resident #46) Findings included: Review of the policy titled, Joint Mobility/Range of Motion Program and Splinting-Initiating the Program dated 1/1/2020, documented a restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy. The restorative aide should review the care plan to determine the following: active or passive ROM, body parts to be exercised; number of repetitions; and special instructions. After the exercise session, the restorative aide should report any changes immediately, document any changes and document completion of the program and time. 1. Review of Resident #10's clinical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had short and long-term memory problems, had severely impaired decision-making skills and exhibited disorganized thinking that fluctuated. The resident required extensive assistance of one (1) with bed mobility, toileting, personal hygiene and dressing. The resident did not transfer from the bed or ambulate. The MDS revealed Resident #10 had impairment on one (1) side of the lower extremity and did not use a mobility device. The MDS documented the resident did not receive therapy or restorative services. Review of Resident #10's care plan dated 11/6/19 for activities of daily living (ADL) function included the interventions: therapy as ordered per physician's orders [REDACTED]. Review of the Physical The… | 2020-09-01 |
| 3244 | 3244 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 689 | D | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and clinical record review, the facility failed to ensure one (1) of three (3) residents (Resident #48) reviewed for accidents had devices in place to reduce injury in case of an accident. Resident #48 was to have a low bed and floor mats on both sides of the bed. Resident #48 was not in a low bed and had only one floor mat during four (4) observations. Findings included: Review of Resident #48's clinical record revealed an original admission on 4/16/19 and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's significant change Minimum Data Set ((MDS) dated [DATE] revealed she was usually understood and usually understands others. The MDS indicated she had severely impaired decision making. The MDS noted she needed extensive assistance of two people to move in bed and to transfer, extensive assistance of one person for locomotion on and off the unit, and had limited range of motion on one side of her body on both her upper and lower extremities. The MDS indicated she had two (2) falls with major injuries since the prior assessment. Review of Resident #48's comprehensive care plan updated [DATE] revealed she was at risk for falls related to her impaired balance during transitions, the use of antidepressant medication and cognitive impairment. The care plan noted she had a fall on 9/15/19. Interventions included floor mats on both sides of the bed. Review of Resident #48's 1/2020 physician orders [REDACTED]. Observations on 1/13/20 at 3:14 PM, 1/14/20 at 10:00 AM, 1/15/20 at 1:10 PM, and 1/16/20 at 11:39 AM revealed Resident #48 in bed. There was a floor mat on left side of bed and the bed was in a waist high position, not in the lowest position. In an interview on 1/16/20 at 05:26 PM, Unit Manager #1 stated Resident #48 should have floor mats on both sides of the bed. She confirmed there were orders for the resident to have the bed in a low position. The facility failed to ensure f… | 2020-09-01 |
| 3245 | 3245 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 690 | G | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, clinical record reviews and facility policy review, the facility failed to ensure three (3) of four (4) residents (Residents #22, #46, and #[AGE]) reviewed for catheter care received care and services for indwelling Foley catheters in a manner to prevent urinary tract infections. The facility failed to have current treatment orders for the Foley catheter and the catheter was not anchored, Resident #22 suffered blood in his urine and had three (3) bacterial infections that were not identified prior to surveyor intervention. This failure led to Resident #22 experiencing actual harm. 1. Resident #22's Foley catheter was not anchored to prevent pulling, had no current physician's orders [REDACTED]. The resident's catheter was not anchored to prevent pulling or injury. The facility staff was unaware of the red colored urine with sediment in the resident's drainage bag until pointed out by the surveyor. Therefore this standard is cited at harm level. 2. Resident #46's Foley catheter was not anchored or maintained in a dignity bag. 3. Resident #[AGE]'s Foley catheter was not anchored or maintained in a dignity bag. Findings included: Review of the policy titled, Catheter-Urinary Catheter, Cleaning and Maintenance dated 7/1/16 revealed the policy lacked documentation regarding the anchoring of the catheter tubing to the resident to prevent pulling on the urethra. 1. Review of Resident #22's face sheet dated 1/13/2020 revealed he/she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident sometimes understood others and was sometimes understood. Resident #22 had severely impaired cognition. The MDS noted Resident #22 had an indwelling urinary catheter. Review of Resident #22's comprehensive care plan updated 11/14/19 revealed he/she used a Foley catheter due to [MEDICAL CONDITION] bladder. Interventions included to change Foley/bag as… | 2020-09-01 |
| 3246 | 3246 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 759 | E | 1 | 1 | SMCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and review of facility policy, it was determined the facility failed to administer medication as ordered and/or following standards of practice for two (2) of four (4) residents of the sample. (Resident #24 and Resident #68) The medication error rate was 27.78 percent. Findings include: 1. Observation of the medication pass for Resident #24 on 1/14/2020 at 9:00 AM revealed Licensed Practical Nurse (LPN) #5 gave the resident [MEDICATION NAME] (used to treat too much acid production in the stomach) 10 milligrams (mg) by mouth. Review of the physician's orders [REDACTED]. Further review of the resident at 9:00 AM revealed Resident #24 had already had her breakfast. Review of the 1/2020 Medication Administration Record [REDACTED] Interview with LPN #5 on 1/14/2020 at 2:40 PM revealed the [MEDICATION NAME] should be given prior to breakfast. Interview with the Assistant Director of Nursing (ADON) on 1/14/2020 at 4:34 PM revealed the Unit Managers or the ADON are supposed to check the Physicians Orders against the MARs at the first of the month to ensure accuracy. Scheduling the [MEDICATION NAME] at 9:00 a.m. would be scheduling it for after breakfast. The time needs to be changed to prior to breakfast. The facility failed to administer the [MEDICATION NAME] per the physician's orders [REDACTED]. 2. Observation of the medication pass for Resident #68 on 1/14/2020 at 9:39 AM revealed Registered Nurse (RN) #5 prepared the following nine (9) medications: [REDACTED]. Further during the medication preparation revealed RN #5 placed an unmeasured amount of water into the plastic cup that contained the 30 milliliters (ml) of Critical Care. The mixture was thick like honey. The other medications were crushed and placed in a glass of water. RN #5 then entered the resident's room, turned off the [MEDEQUIP] feeding. She then checked the [DEVICE] for residual, attached the syringe and poured in the crushed pills … | 2020-09-01 |
| 3247 | 3247 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 803 | F | 1 | 1 | SMCX11 | > Based on observations, interviews, facility menu reviews and facility policy reviews, the facility failed to provide portions of food as required on the dietitian approved menu for one (1) of two (2) meals observed (lunch meal 1/15/20) Seventy-three residents ate food from the kitchen. 1. The vegetable lasagna was not portioned correctly for residents receiving regular and mechanical soft meals. 2. The vegetable lasagna was underserved for residents receiving a pureed diet. Findings included: 1. Observation on 1/15/20 at 12:00 PM revealed Cook #1 begin serving the lunch meal. Cook #1 took a spatula and cut the regular and mechanical soft vegetable lasagna into squares. She did not measure the portions of the lasagna, and the squares of lasagna were different sizes. She put one square on a plate. When the spatula did not cut the square completely, a layer of noodles would be pulled out and left in the tray. In an interview on 1/15/20 at 12:43 PM, Cook #1 stated she served one square of lasagna to each resident. Review of the menu printed 1/13/20 revealed residents receiving a regular diet and a ground/minced/moist were to receive 6 ounces of lasagna. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager (CDM) confirmed the lasagna was not portioned out. She said Cook #1 could have used a scoop to ensure the correct size was used. 2. Observation on 1/15/20 at 12:00 PM reveled Cook #1 serving lunch. Cook #1 scooped one (1) scoop of pureed vegetable lasagna for residents on a puree diet. In an interview on 1/15/20 at 12:43 PM, Cook #1 stated she used one (1) scoop of a #10 scoop (3.25 ounces) for the residents receiving a pureed diet. Review of the menu printed 1/13/20 revealed residents receiving a pureed diet were to receive a number six (#6) scoop (5.33 ounces) portion of lasagna. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager (CDM) confirmed a #10 scoop was too small a portion for residents receiving a pureed diet. Review of facility's Nutrition Policies and Procedures Foo… | 2020-09-01 |
| 3248 | 3248 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 804 | E | 1 | 1 | SMCX11 | > Based on observations, interviews, and facility policy reviews, the facility failed to provide flavorful and palatable food as required for one (1) of two (2) meals observed (lunch meal 1/15/20) Seventy-three residents ate food from the kitchen. The green beans served did not have any seasoning or flavor. Findings included: In a resident group interview on 1/14/20 at 10:47 AM, seven (7) of seven (7) residents said they felt the green beans were bland and did not taste good. Observation on 1/15/20 at 12:00 PM revealed Cook #1 begin serving the lunch meal. Cook #1 served green beans to residents on a regular and mechanical soft diet. A test tray of a regular diet meal was tasted on 1/15/20 at 1:06 PM with the Certified Dietary Manager (CDM). The green beans tested did not have any seasoning and tasted like green beans boiled in water. In an interview on 1/15/20 at 1:10 PM, the CDM confirmed the green beans needed seasoning, that they tasted like cooked frozen green beans. Review of facility's Nutrition Policies and Procedures Food Preparation revised 10/2/17 noted 5. Batch cook vegetables to conserve nutrient value and maintain flavor and color. | 2020-09-01 |
| 3249 | 3249 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2020-01-16 | 812 | F | 1 | 1 | SMCX11 | > Based on observations, interviews, and facility policy review, the facility failed to prepare and serve food in a sanitary manner for one (1) of two (2) meals observed (lunch 1/15/20). Seventy-three residents ate food from the kitchen. 1. Cook #1 wore a bracelet with charms that hung down while she prepared and served the lunch meal. 2. Cook #1, Dietary Aide #1, and the Certified Dietary Manager did not wash their hands or change gloves when touching other items in the kitchen and before serving the meal. 3. The Certified Dietary Manager did not sanitize a divided plate for the required amount of time that was used for service. Findings included: 1. Observation on 1/15/20 at 11:16 PM revealed Cook #1 preparing the lunch meal. On her right wrist, she wore a silver bracelet with charms that hung down. She then served the lunch meal. She wore gloves but the gloves did not cover the bracelet. In an interview on 1/15/20 at 12:46 PM, Cook #1 confirmed she wore a bracelet on her wrist. In an interview on 1/16/20 at 10:21 AM, the Certified Dietary Manager confirmed bracelets should not be worn in the kitchen. Review of facility's Nutrition Policies and Procedures Dress Code revised 10/2/17 noted 3. Neat and clean appearance. Limited jewelry: unadorned rings that are easily cleaned/removed during hand hygiene procedure, watch and non-dangling earrings only. Per the USDA Food Code, employees may not wear jewelry on their arms and hands during food preparations except for a plain ring such as a wedding band. 2. Observations on 1/15/20 of the lunch meal service revealed the following: - 12:06 PM, Dietary Aide (DA) #1 opened the kitchen door wearing gloves, removed her gloves, did not perform hand hygiene/wash her hands, donned new gloves and continued serving lunch onto trays. - 12:09 PM, Cook #1 opened the wooden oven doors with gloved hands, pulled out the lasagna, and closes the oven door. She continues serving without changing gloves or washing her hands. - 12:22 PM, the Certified Dietary Manager (CDM) picked up the bi… | 2020-09-01 |
| 4002 | 4002 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 550 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility documents, the facility failed to ensure one (1) of 20 sampled residents was provided dignity in the provision of services. Resident #61 requested not to be provided care by Certified Nursing Aide (CNA) #8. Responsible nursing staff did not provide follow-up to determine the cause of Resident #61's request. CNA #8 continued to enter Resident #61's room against the resident's request. The findings included: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to receive care from the center in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality .You have the right to reside and receive care in the center with reasonable accommodations of individual needs and preferences except when your health and safety or the health and safety of other patients/residents would be endangered .You have the right to receive care, treatment and services that are adequate and appropriate and provided: d. With respect for your personal dignity and privacy. Resident #61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had mild symptoms of depression and had no documented behavioral symptoms. Resident #61 require extensive assistive of one (1) staff person for bed mobility, dressing, toileting and personal hygiene. Resident #61 was always incontinent of bowel and bladder. Review of The Care Area Assessment (CAA) of the MDS revealed behavioral symptoms were not triggered and not moved forward to the comprehensive care plan. Review of Resident #61's Self-Care Deficit/Activities of Daily Living (ADL) care plan dated [DATE] revealed the resident had a self-care deficit due to impaired mobility and function… | 2020-09-01 |
| 4003 | 4003 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 655 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to develop and implement a baseline care plan for one (1) of 43 sampled residents that included the instructions needed to provide effective and person-centered care that met professional standards of quality care within 48 hours of the resident's admission for Resident #1. The findings included: The facility provided the policy titled Care Plans dated 12/31/96 which directed, It is the policy of the health care center for each patient/resident to have a person centered baseline care plan .Baseline care plan must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. 1. Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with other IDT (Interdisciplinary Team), the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required total assistance of one (1) staff for bathing, and the resident felt that it was somewhat important for him/her to choose between a tub bath, shower, bed bath or sponge bath, (although during interview, the resident stated nobody asked him/her about his/her preferences). The resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, d… | 2020-09-01 |
| 4004 | 4004 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 656 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a person-centered, comprehensive care plan was implemented for two (2) of 20 sampled residents (Resident #68 and Residents #[AGE]). Licensed nursing staff did not provide Resident #68 nail care as directed in the resident's plan of care. Observations on 1/13/20 and 1/14/20 of Resident #[AGE] revealed skin integrity care planned interventions were not followed related to suspending heels in bed and applying Prevalon boots to both feet when in bed. The findings include: Record review of the facility policy titled, 'Care Plans, dated 12/31/96, revealed it is the policy of the health care center for each resident to have a person centered comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the resident choice. Further review revealed the care plan approaches served as instructions for the resident's care and provides continuity of care by all partners. Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members. When approaches that involve the Certified Nursing Assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record. Review of Resident #68's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behavioral symptoms and required total assistance of staff for personal hygiene and bathing. Resident #68's Quarterly MDS dated [DATE] noted the resident required extensive assistance for personal hygiene and bathing. According to Resident #68's Activities of Daily Living (ADL) care plan date… | 2020-09-01 |
| 4005 | 4005 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 677 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy, it was determined the facility failed to provide the necessary services to provide and/or maintain activities of daily living (ADLs) related to personal hygiene and/or bathing for three (3) of 20 sampled residents (Residents #26, #34 and #68). Resident #26 requested but did not receive a shower between August 2019 and January 1, 2020. The resident was provided bed baths only. Resident #34 was assessed as extensive assistance with one (1) person for personal hygiene; however, staff failed to provide weekly showers as scheduled on Tuesday, Thursday and Saturdays. Resident #34 had not had a documented shower since 11/12/19 during the day shift. Resident #68 did not receive assistance with nail care when the resident's nails were long and jagged. The findings include: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to: c. Make choices about aspects of your life in the nursing center that are significant to you. Review of a policy entitled Documentation: Charting Activities of Daily Living (ADLs) (reviewed 10/24/18) revealed a policy statement that it is required for ADL care given by Certified Nursing Assistants (CNAs) and nurses to be documented using the CNA ADL Flow Sheet Form. For facilities with smart charting, all documentation will be completed using the smart charting system. During interview on 1/16/2020 at 3:47 PM, the Director of Health Services (DHS) stated the facility did not have a policy for bathing a dependent resident. Resident #26 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of Resident #26's annual Minimum Data Set (MDS) Assessment, dated [DATE] revealed a brief interview for mental status score of 13, indicating the resident was independent in cognitive skills for daily decision making. Resident #26 was identified on the assessment to have no sy… | 2020-09-01 |
| 4006 | 4006 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 684 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of facility policy, the facility failed to ensure two (2) of 20 sampled residents received services in accordance with professional standards (Resident #68 and Resident #[AGE]). Resident #68 did not receive therapy services to assess the resident for an appropriate-sized geri-chair. Facility nursing staff did not observe, assess, document and treat two (2) wounds for Resident #[AGE]. The findings included: Review of the facility's Therapy Evaluations policy last revised 9/3/15 revealed Therapy will foster an interdisciplinary approach to care by educating departments on safe transfer techniques, environmental adaptations, and patient/resident specific restorative nursing programs as indicated. Review of Resident #68's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behavioral symptoms and required extensive to total assistance of staff for all activities of daily living (ADLs). The resident had impairment of upper and lower bilateral extremities. According to the assessment, the resident did not utilize a device for mobility, and did not receive therapy services. Resident #68's Quarterly MDS dated [DATE] had not significantly changed from the annual assessment. Review of Resident #68's 4/24/19 comprehensive care plan, revealed Resident #68 had care areas that included: Resident #68's potential for skin breakdown due to decreased mobility, incontinence, [MEDICAL CONDITION] left side [MEDICAL CONDITIONS], [MED] dependent DM II. One approach to address this area was to turn and reposition frequently (4/24/19). Resident #68 was dependent with care givers in all ADL needs due to history [MEDICAL CONDITION] left [MEDICAL CONDITION]. Approaches included: anticipate and meet ADL needs, incontinent care needs and encourage resident to be up … | 2020-09-01 |
| 4007 | 4007 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 686 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents with pressure ulcers received necessary care and services to promote healing and prevent new ulcers from developing for one (1) of six (6) residents identified with pressure ulcers out of a total sample of 20 residents. Resident #[AGE]'s Certified Nursing Assistant plan of care directed staff to suspend the heels in bed and apply Prevalon boots (soft comfortable boot designed to keep the heel off the mattress to relieve pressure for individuals spending a lot of time in bed) to both feet when in bed for impaired skin integrity. However, observations on 1/13/2020 and 1/15/2020 revealed pillows under Resident #[AGE]'s calves and feet as well as the Prevalon boots were not on the resident's feet. The findings include: Review of the facility policy titled, Pressure Ulcer Prevention Program, dated September 2015, revealed a pressure ulcer prevention program is in place at each health care facility to identify residents at risk for developing pressure ulcers which is determined utilizing the Braden Scale for Predicting Pressure Score Risk. Any resident who is identified with a Braden score of 18 or below should be placed on the Pressure Ulcer Prevention Program. The Program consists of the following interventions: Reassess risk for all residents with specified intervals; inspect skin of all at risk residents daily with ADLs; manage moisture by providing incontinence care if indicated; optimize nutrition/hydration; minimize pressure by turning and repositioning, therapeutic support surface assessment, therapeutic seating surface assessment and tissue tolerance assessment; care plan should address resident interventions implemented when on the program; resident/family teaching regarding the program; and establish an interdisciplinary team when meets at least weekly to review resident care needs and outcomes. Review o… | 2020-09-01 |
| 4008 | 4008 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 692 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility policy, the facility failed to initiate approaches to prevent further weight loss for one (1) of 20 sampled residents (Resident #66). Resident #66 had a 4.4% weight loss in 10 days and the Nurse Practitioner and Registered Dietician recommendations to address the weight loss were not initiated. The findings were: Review of the facility's Weight Monitoring Program last revised 6/13/18 noted residents who experience significant weight loss will be weighed weekly and reviewed weekly for a minimum of four (4) weeks until weight is stable or increasing .A significant weight change is identified as: 5% weight loss or gain in one month; 7.5% weight loss or gain in three months; and 10% weight loss or gain in six months .All disciplines should be aware of all patients/residents who are on a weight monitoring program. Resident #66 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired and required total assistance of staff for eating. According to the assessment the resident was 58 inches in height and weighed 112 pounds (lbs), during the assessment period. Review of Resident #66's Nutrition care plan dated [DATE], Resident #66 was at risk for decline in nutritional status related to increased nutrient needs for wound healing, dependent on staff for feeding, has poor appetite and low [MEDICATION NAME] with [DIAGNOSES REDACTED]. Approaches - follow colored napkin protocol; provide supplements as ordered; provide diet as ordered; ST (speech therapy) to evaluate and treat per physician's (MD) order; weigh and observe result, notify MD/IDT (interdisciplinary team) of significant weight changes. Review of Resident #66's History & Physical (H&P) dated 9/18/19 noted that the resident entered the facility with severe protein malnutrition. Review o… | 2020-09-01 |
| 4009 | 4009 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 697 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to assess pain and provide pain relieving measures for one (1) of 43 sampled residents, Resident #1. The findings included: The facility provided the policy titled, Pain assessment dated [DATE] directed, At all levels of health care, the standard for performing a complete pain assessment is: on admission .with any self-report of pain or evidence of pain .whenever a pain score is above 0 (zero) . Complications: When left untreated, pain can have negative consequences, including multisystemic complications and the development of chronic disabling pain, which may seriously impact the patient's functioning, quality of life, and well-being . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] recorded Resident #1 had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #1 had impairment on both upper extremities. The MDS recorded the resident had occasional pain and rated the intensity as four (4) of 10, with 10 being the worst pain. The MDS recorded Resident #1 Received prn (as needed) pain medication or was offered and declined. Resident #1's clinical record lacked a baseline care plan for pain. The care plan developed on 1/14/20 for pain included the following interventions: Administer pain medications per physician's orders [REDACTED]. Monitor effectiveness of pain medication Provide comfort measures (no specific comfort measures listed) Report to physician if resident does not experience reduction or relief of pain after receiving interventions through next 30 days Complete Pain Observation on admission and as needed Review of the Admission Pain Interview and Obse… | 2020-09-01 |
| 4010 | 4010 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 698 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and facility policy review, the facility failed to assess and monitor the fistula access port for [MEDICAL TREATMENT] for one (1) of two (2) residents sampled for [MEDICAL TREATMENT]. Resident #1. The findings included: The facility provided the policy titled, [MEDICAL TREATMENT] Care - Pre and Post [MEDICAL TREATMENT] dated 5/25/18 which directed, Pre-[MEDICAL TREATMENT]: Verify Physician Orders. Take and record patient/resident blood pressure and pulse and observe shunt access (AV shunt or Permacath) prior to patient/resident transport to [MEDICAL TREATMENT]. Post [MEDICAL TREATMENT]: Verify Physician Orders. Upon return from [MEDICAL TREATMENT], take and record patient/resident blood pressure, pulse and observations of the dressing at the access site. Palpate for evidence off thrill and auscultate bruit before and after [MEDICAL TREATMENT], documenting both as appropriate and notifying physician if they are absent . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] for Resident #1 recorded the resident had intact cognition, and no [MEDICAL CONDITION], mood problems, [MEDICAL CONDITION] or behaviors. The MDS recorded the resident required extensive assistance of one (1) staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #1 had impairment on both upper extremities. The MDS recorded the resident received [MEDICAL TREATMENT] in the last 14 days, before admission, and since admission to the facility. Resident #1's clinical record lacked a baseline care plan for [MEDICAL TREATMENT] or for monitoring his/her fistula. The [MEDICAL TREATMENT] care plan developed on 1/15/20 (12 days after admission) included the interventions: Monitor for thrill and bruit every shift left upper arm Monitor left upper arm and report to MD (Medical Doctor) signs of localized infection (localized… | 2020-09-01 |
| 4011 | 4011 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 725 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide sufficient nursing staff to provide care and services for two (2) of twenty (20) sampled residents (Resident #26 and Residents #34). Seven (7) residents in a group interview reported incidents of lack of care due to insufficient staff available to answer call lights. Resident #26 received bed baths only and did not receive a shower, as requested, only four (4) times during a six (6) month period. Resident #34 received bed baths only and did not receive a shower, as requested, for approximately two (2) months. The findings include: An interview was conducted on 1/14/20 at 10:00 AM with seven (7) members of the resident council. When questioned regarding staff response to call lights and the provision of care and services needed all the residents expressed having concerns with these issues. The residents went on to report call lights are not being responded to in a timely manner, reporting that sometimes at night it takes up to an hour for staff to respond. At times, the nurse will eventually enter the room, report there is no Certified Nursing Assistant (CNA) available on the hallway, and the nurse has to change us (referring to incontinence care). There are times when a CNA will enter the room in response to a call light, turn the light off, and state I'm not your CNA. The CNA will tell them they will report their request for service to the assigned CNA. However, no one ever comes back. The residents reported when their assigned CNA does answer the call light, they will turn the light off and tell the resident they are making rounds right now and cannot tend to their need until finish rounds. The residents are told they can't come out of sequence. The residents stated they observed staff sitting at the nursing station, sitting on the counter, as call lights were not being responded to. Some residents would ye… | 2020-09-01 |
| 4012 | 4012 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 804 | E | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined the facility failed to ensure food was palatable by maintaining the temperature of the food at the point of delivery for one (1) of four (4) kitchenettes, affecting 66 residents. Observation of the test tray from the lunch meal on 1/13/2020 on the Killian hall, revealed point of service temperatures for hot foods were below 135 degrees Fahrenheit (F) which was not in accordance with facility policy. The findings include: Review of the facility Policy titled, Food Temperatures, revised date 3/24/16, revealed all foods served from the steam table must be held at or above 135 degrees and all potentially hazardous cold foods must be held at 41 degrees or less. Exempt hot foods include bacon, pancakes, waffles, toast, French toast, no temperature check is indicated. Continued review of the policy revealed food should not be heated/cooked on the steam table for it may foster bacterial growth and delete nutritive value and quality of food. Hot food should be heated using direct heat of the oven, stove, steamer, etc. Once heated above 135 degrees, hot food may be transferred to the heated steam table for serving. Food should be transferred to the steam table no more than 30 minutes prior to resident serving time. If the food item is not within acceptable range, it must be removed and reheated to 165 degrees for 15 seconds and food will be served at palatable temperatures. Continued policy review revealed ways to maintain temperature tips included deliver carts immediately to units when complete, do not portion out food ahead of time, make sure all equipment is in proper working condition, and stir hot foods from the middle to the outside to maintain an even temperature throughout the meal service. Review of the facility's policy titled, Meal Delivery, revealed all foods leaving the kitchenette is to be served to residents in their rooms covered, hot food items will be served with… | 2020-09-01 |
| 4013 | 4013 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 812 | F | 1 | 1 | YEP811 | > Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observation on 01/13/20, during the tour of the dry food storage area, revealed food items had been opened and not labeled with the use by date. The findings include: Review of the facility's policy titled, Labeling, Dating and Storage, reviewed date 10/18/17, revealed all food and beverage items would be properly labeled with the name of the item, and a use by date. Foods would be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. Observation of the dry food storage area in the kitchen, on 1/13/2020 at 9:30 AM, revealed the following food items opened, wrapped in film with no opened and use by date: one (1) 36.8 ounce (oz) box of Quick 5-Minute Quaker Grits; one (1) 24 oz bag of French's Crispy Fried Onions; one (1) 16 oz bag of Domino Confectioner's Sugar; two (2) bags of White Cake Mix, one (1) 32 oz bag of Pie Filling Mix; one (1) 1.5 pound (lb.) bag Sysco Home Style Old Fashioned Biscuit Gravy Mix; and one (1) 16 oz bag of Frito Lay Corn Chips. Interview on 1/13/2020 at 9:55 AM with Dietary Cook #1, revealed that all food items should have a label on them with the received date, opened date, and use by date when they are stocked in the dry food storage area. He/she stated that it's important to dispose of the items by the use by date to prevent the residents from getting sick from old food. Interview on 1/13/2020 at 10:04 AM with the Dietary Manager, revealed that it's the responsibility of all staff to stock the food in the dry food storage area. Continued interview revealed that staff should print and place a label on the food item with the received, opened and use by date. Additionally, he/she stated that he/she ensures that all the food items are sealed, labeled and d… | 2020-09-01 |
| 4014 | 4014 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 880 | F | 1 | 1 | YEP811 | > Based on interview and review of facility policy it was determined the facility failed to implement protocol to ensure an ongoing Infection Prevention and Control Program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. The findings included: Review of a policy entitled Infection Prevention and Control Program Overview (revised on 1/15/16, last reviewed on 4/20/17) revealed it was policy of the facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and partners. The policy specified it was the Administrator of the facility that was responsible for the Infection Control Program. Procedures established to implement the policy included: Patient/resident infection cases are monitored and documented by the Infection Preventionist (IP). The IP reviews cases of infections, including tracking and analysis of the findings and develops an action plan to resolve identified concerns. A report of resident infections is reported monthly to the Administrator and Director of Health Services (DHS) and quarterly to the Infection Control Committee. The IP completes the Infection Control Committee Quarterly Summary Form and submits to the Infection Control Committee. Partner (staff) infections are reported by the partner to the partner's supervisor, then to the IP. The IP completes the Partner's Infection Report Form and report is submitted: (1) Monthly to the Administrator, (2) Quarterly to the Infection Control Committee; (3) Quarterly to the Senior Nurse Consultant. Compliance with Infection Control Practices are monitored and documented by: (1) Staff Competency; (2) Observation of practices. The IP, DHS, and Department Managers review the compliance monitoring and initiate appropriate corrective measures, if indicated. Review of a second policy entitled Infection Prevention and Control Surveillance (Revised 11/21/17) re… | 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 );