cms_SC
Data source: Big Local News · About: big-local-datasette
10,300 rows sorted by inspection_date
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date ▼ | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10250 | 10250 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 157 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated… | 2014-02-01 | ||
| 10251 | 10251 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 281 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility provided policy for documentation, the facility failed to meets professional standards of quality. Resident # 11 was documented as having a rapid onset of illness with elevated temperature and foul smelling emesis at 2:45PM. At 6PM, a facility staff member documented the effect of medications administered. There was no further documentation of the resident until 355AM, the following morning when the resident was mottled, with unstable vitals signs and transferred to acute care. A History and Physical completed by the attending physician failed to address a complete assessment of the resident. The findings included: The facility admitted Resident # 11 on [DATE]. The resident's [DIAGNOSES REDACTED]. On [DATE], a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on [DATE] at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. Licensed Practical Nurse # 1 documented she administered [MEDICATION NAME] two times that day (at 8:30AM and 2PM) and Tylenol at 2PM for and elevated temperature. The last documented complete physical assessment of the resident was at 2:45PM on [DATE]. Review of the 24 hour report and nursing worksheet contained no additional information. Licensed Practical Nurse # 2 documented on the back side of the Medication Record that Tylenol and [MEDICATION NAME] were repeated at 6PM and were "effective." No further documentation of the resident's condition was found. The next documentation of an assessment of the resident's condition occurred at 3:55AM on [DATE] when the resident was transferred to acute care and admitted to the hospital. The admission History and Physical obtained from the hospital stated the resident was to be admitted with [DIAGNOSES REDACTED]. The resident expired while in the hospital on [DATE]. The Discharge summary s… | 2014-02-01 | ||
| 10252 | 10252 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 428 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the consulting pharmacist failed to identify that Resident # 11 with known bradycardia was not having a pulse taken prior to administration of the medication. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having known Bradycardia. The resident was ordered by the physician to receive Metoprolol 12.5 milligrams daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pharmacist was questioned as to why there had not been a previous recommendation to take the resident's pulse prior to the administration of the medication, especially since she had acknowledged the resident's known bradycardia. The pharmacist stated that some facilities had policies which required a pulse be obtained prior to the administration of this class of drug, but this facility did not. On 10/25/10 at 5PM, during an interview with the attending physician, he stated he was not aware the resident's pulse was not being taken prior to the administration of the medication. The Nursing Drug Handbook 2011 Edition available as a resource for the nurses on the nursing unit, stated on page 383: "Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately." There was no documentation found that the resident's pulse was being obtained prior to the administration of the Metoprolol or that the consulting pharmacist had reported the irregularity to the physician. | 2014-02-01 | ||
| 10253 | 10253 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 156 | B | M5SK11 | On the days of the survey, based on record review and interview, the facility failed to provide timely Notice of Medicare Provider Non-Coverage notification for 4 of 5 residents reviewed for Change in Pay Source. The findings Included: Review of residents files for change in pay source revealed four of five residents had not received timely notification of Medicare Provider Non-Coverage. Resident A's Notice of Medicare Provider Non-Coverage indicated that effective 1/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until 1/11/2010. Resident B's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/10. Resident C's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/2010. Resident D's Notice of Medicare Provider Non-Coverage indicated that effective 1/14/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 1/14/2010. During an interview with the Business Office Manager (BOM) on 10/25/10 at approximately 3:30 PM he/she stated " They wanted to go home that day, so we did not have time to give notice". The medical records for residents B and C showed a form titled Notification of Therapy Change which was dated 6/2/10 for resident C. (7 days in advance). and Resident B's form was dated 6/7/10. (4 days in advance). The BOM stated when asked what this form was for, "that is how they let us know the time is ending." | 2014-02-01 | ||
| 10245 | 10245 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 157 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician and family promptly of a change in condition which potentially required physician intervention. Resident #4, one of four residents reviewed for notification, had a temperature of 103.2 without timely physician/family notification of a change in condition. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes on 10/27/10 at 10:20 AM revealed a note dated 7/20/10 at 1:50 PM that stated "130/76, 100.3, 78, 18. Prn (As needed) Tyl(enol) admin(istered) (with) f/u (follow up) temp (temperature) of 98.8. Pt (Patient) total care continues. Up in w/c (wheelchair) daily max assist (with) mech(anical) lift. Skin warm-tx (treatment) to sacral area continues. Moderate drainage noted (with) scant odor. Will cont(inue) to monitor...". The next note was dated 7/21/10 at 3 AM and stated "At 1 AM resident had rapid breathing, skin warm & moist. VS (Vital Signs) as follows 103.2, 98, 24, 136/92. PRN (As Needed) Tylenol given for (increased) temp. Recheck temp @ 3 A(M) (down) to 99.9. Respiration(s) even + nonlabored...". There was no mention that the physician or family had been notified of the change in condition for this resident when her temperature, heart rate, and respiratory rate increased at 1 AM. The next entry was dated 7/21/10 at 10:40 AM and stated "@ 9 am, pt alert, responsive-meds (medications) given per g-(gastrostomy) tube (without) difficulty. g tube patent (with no residual). HOB (Head of Bed) elevated per norm. Tyl(enol) PRN admin(istered) @ this time prior to wound care tx (treatment). @ 9:55 called to pt rm (room) d/t (due to) pt lethargic et facial drooping upon assessment noted pt (with) L(eft) side facial drooping, open mouth breathing-labored respirations @ 26. Lungs full, SpO2 @ 90% RA (Room Air… | 2014-02-01 | ||
| 10246 | 10246 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 166 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interview, and review of the policy provided by the facility entitled "Grievances & Complaints", the facility failed to actively work towards resolution of a complaint/grievance for one of one sampled residents with a grievance. Family member concerns regarding the care of Resident #4 were not addressed by the facility. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. A complaint faxed to DHEC (Department of Health and Environmental Control) Certification was reviewed on 10/26/10 prior to the survey. The complaint included a letter dated 7/29/10 addressed to the Admissions Director and Marketing Director of Springdale Health Care Center. It contained the following: "Gentlemen: (Resident #4) is back at Springdale, as you know, and I'd like to review with you the matters regarding her care that we discussed recently. (Marketing Director) informed us that she would be placed on the "100" wing/hall with different nurses/staff caring for her. (Admissions Director) addressed personally taking care of/supervising her wound care, including the "wound vac". To prevent dehydration, her feeding tube is to be flushed multiple times daily. Insuring that the feeding tube area remains clean. Monitoring excessive therapy (exercise) on her left arm. To make sure that she isn't sitting on the affected area for prolonged periods, and that she is turned on a regular basis. That someone communicates with Dr. --, myself and/or my (other family member) for any change in her condition or care. FYI, her home caregiver --, will continue to make regular visitations with (Resident #4). I am optimistic that the "situation" that occurred last week has been resolved, corrected, and that (Resident #4's) care will be the best that Springdale has to offer. Please contact me immediately if any of the foregoing is incorrect or mis… | 2014-02-01 | ||
| 10247 | 10247 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 253 | D | K6DC11 | On the days of the complaint inspection, based on observation, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 6 resident rooms observed. Soiled and malodorous carpets were observed in 3 of 6 resident rooms on Unit 2. The findings included: Observations on 10/26/2010 at 10:10 AM of room 209 revealed 3 large grayish brown spots on the floor under the tube feeding pole and pump; room 213 was noted with a large amount of clothes piled on a chair and a pair of bedroom shoes on the floor; both room had a musty odor throughout. Observations on 10/26/10 at 12:02 PM revealed a fly light position on the floor in room 212B near the window, the ionizer contained approximately 15 dead flies on the base, under the light. There was also a musty odor noted throughout the room. The tan carpet on the floor was worn and had stains along with darker areas that looked like black scuff marks. At 12:24 the Director of Nursing verified the findings but stated she could not smell any odors. She stated that there might be an odor, but that she smoked and didn't have a good sense of smell. | 2014-02-01 | ||
| 10248 | 10248 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 279 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review and interview, the facility failed to development comprehensive plans of care, which addressed the needs of 1 of 6 sampled residents. Resident #3 with a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #3 on 10/15/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/26/2010 for Resident #3 revealed a Interdisciplinary Progress Note dated 10/23/2010 at 1:00 PM that stated, "Res (resident) noted with nephrostomy valve leaking. Supervisor notified and MD made aware. MD order given to tape around valve to seal and to monitor until Monday and let nephrologist address then. Urine draining in nephrostomy bag without problems..." A care plan dated 10/25/2010, noted the following problem area: "Is at risk for injury related to falls as evidence by...has nephrostomy with drng (drainage) bag and suprapubic cath (catheter)"; "Admits related to weakness from acute hospital stay...suprapubic cath and groin pain"; "Potential for pain related to [DIAGNOSES REDACTED]. staff for ADL's (activities of daily living) related to: suprapubic cath in place..." The care plan identified the left nephrostomy tube as a suprapubic catheter. The plan of care did not document that Resident #3 had a left nephrostomy tube in place or the need to monitor on a routine bases the care of the tube and insertion site. The Director of Nursing verified the resident was not care plan for a left nephrostomy tube. | 2014-02-01 | ||
| 10249 | 10249 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 309 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observation, the facility failed to assure each resident received care and services in accordance with the plan of care as ordered by the physician. Resident #1 had current physician orders [REDACTED]. Resident #3 with an order documented in the Interdisciplinary Progress Notes for a follow-up with the nephrologist related to a leaking nephrostomy tube that was not transcribed and carried out. (2 of 6 sampled residents reviewed for care and services related to following physician orders.) The findings included: The facility admitted Resident #1 on 10/04/2010 with [DIAGNOSES REDACTED]. As a result of a complaint the closed medical record for Resident #1 was reviewed on 10/26/2010, a physician's orders [REDACTED].#1 complained of loose stools through the night and the standing order for Immodium was initiated, there was no further documentation related to loose stools until 10/10/2010. A late entry dated 10/12/2010 at 8:00 PM for 10/10/2010 4:00 PM stated, "Resident c/o (complains of) loose stool. Medicated with Immodium, ineffective continues to have loose stool. MD aware n/o (new order) received: obtain stool sample, decrease TF (tube feed) 50 cc/hr (centimeters/hour); have dietician assess." On 10/10/2010 the Resident #1 was transferred to the hospital at the request of the family due to their concerns related to her having loose stools. Review of the Activities of Daily Living (ADL) Flow Record showed Resident #1 had extra large stools on all three shifts 10/08/2010; had no stool on the 11-7 shift, an extra large stool on the 7-3 shift and a small stool on the 3-11 on 10/09/2010; had extra large stools on all three shift on 10/10/2010. Review of the 24 hour report from 10/08/2010 thru 10/10/2010 documented on 10/08/2010 for the "Day" shift (7-3) "c/o loose stools, initiated s.o. (standing order) Immodium..."; the 24 hours reports revealed no further documentatio… | 2014-02-01 | ||
| 10242 | 10242 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2010-10-29 | 225 | D | CXO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of facility files related to an allegation of abuse and misappropriation of resident property, the facility failed to report the allegation to the State survey and certification agency for 1 of 1 allegation reviewed. On 5/5/10, Resident #1's [MEDICATION NAME] ([MEDICATION NAME]) patch was missing. All staff on duty were drug tested that day. Laboratory test results reported to the facility on [DATE] confirmed the presence of the drug in Certified Nursing Assistant (CNA) #1's system. The findings included: Resident #1 arrived at the facility on 1/22/03. His [DIAGNOSES REDACTED]. The resident suffered from chronic pain and received [MEDICATION NAME] 25 micrograms per hour via [MEDICATION NAME]. The patch was changed every 72 hours. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the investigative materials revealed LPN #1 went to the resident on the morning of 5/5/10 and applied a new [MEDICATION NAME]. She secured the patch with a dated piece of tape. The LPN was unable to find the old patch for removal. LPN #1 tried to find the old patch again at approximately 10 AM and could not. She made another attempt at 12 noon only to discover the 8 AM patch was missing. A search of the resident, his bed, and his room failed to locate the [MEDICATION NAME]. LPN #1 reported her findings to Administration. The facility conducted searches of all employees on duty. The employees were also held for drug testing. Only one employee's drug test returned with positive results for [MEDICATION NAME], CNA #1. The Bureau of Drug Control was called to investigate. CNA #1 was terminated on 5/29/10. The facility could not provide any evidence showing they reported this incident to the State survey and certification agency. | 2014-02-01 | ||
| 10206 | 10206 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 323 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to provide residents and staff with adequate supervision to ensure it's system for safe transfer of residents was followed by Hospice and facility staff members for 1 of 1 resident reviewed who sustained injury from an inappropriate transfer (Resident #1). Resident #1 was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to [DATE] because of acute renal failure and congestive heart failure exacerbation. Several medications were discontinued on his return to the facility including the Prednisone the resident had taken for years. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to osteoporosis, risk for falls, risk for complications due to CVA with left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as n… | 2014-03-01 | ||
| 10207 | 10207 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 282 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews the facility failed to ensure that care plans were followed for Resident #1, 1 of 3 sampled residents care planned for a mechanical lift with transfers, was transferred from bed to chair on [DATE] by manual lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to [MEDICAL CONDITION], risk for falls, risk for complications due [MEDICAL CONDITION] left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical … | 2014-03-01 | ||
| 10208 | 10208 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 225 | D | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Resident #1, 1 of 1 sampled resident that sustained an injury during a transfer, was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift, as care planned, by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the ax… | 2014-03-01 | ||
| 10204 | 10204 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 323 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review, interviews, review of the facility's policy on Falls, and review of the facility's inservices, the facility failed to assure each resident was free of accidents as was possible for 1 of 6 sampled residents. Resident #1 sustained 3 falls in 3 days without new interventions implemented. Resident #1 fell on ,[DATE], 7/30 (sustained injuries to the face and mouth) and on 8/1/2010, no interventions were implemented until 8/2/2010. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as needing extensive 1 person assistance with transfers and bed mobility and completely dependent for locomotion on and off the unit. Resident #1 was also coded as dependent for eating, dressing, hygiene, and bathing with no behaviors coded as occurring during the assessment period. The resident was coded as receiving Hospice services. Resident #1 was not coded as having any accidents within 180 days. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8… | 2014-03-01 | ||
| 10205 | 10205 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 280 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews, the facility failed to assure 1 of 6 resident's care plans were reviewed and revised appropriately. Resident #1's care plan was not reviewed and revised with each fall. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8/2/2010 at 11 AM, the nurses' note indicated an order was obtained for a bed alarm and 1/2 lap tray. Review of the care plan revealed a risk for injury (falls) related to weakness, history of [MEDICAL CONDITION], dementia and [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "observe frequently, call light within reach..., provide assistive devices for mobility, provide assistance with mobility, review circumstances of how falls occur to try to eliminate further falls, keep floor/pathway free of debris, notify MD/hospice PRN (as needed)." The care plan was updated on 7/29/2010 with a handwritten note to "observe res(ident) frequently when up." The care plan was not updated with the 7/30/2010 fall or the 8/1/2010 fall. On 8/2/2010 the bed alarm was written on the care plan, however the lap tra… | 2014-03-01 | ||
| 10209 | 10209 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2010-11-10 | 280 | D | 0LRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection, based on observations, interviews and record reviews, the facility failed to ensure that Resident #4's care planned was review and revised regarding one-to-one supervision by the staff (1 of 4 sampled reviewed with behaviors). The findings included: The facility admitted Resident #4 on 10/23/09 with [DIAGNOSES REDACTED]. Review the of Nurse's Progress Notes dated 10/03/10 at 1250 documented at 1145 the staff was paged to the facility's canteen and that Resident #4 was in the canteen area and he threw a chair at a snack machine, hit a visiting family member of another resident and slammed a nurse's finger in a cabinet. The Nurse's Note further indicated that once the resident calmed down he requested to call law enforcement. At 1245 physician's orders [REDACTED].#4 returned to the facility from the hospital; at 1930 Resident #4 was noted running his wheelchair into people and things. The resident later calmed down and went to bed. A Nurse's Note dated 10/04/10 at 2330 indicated the staff was at the bedside with no behaviors noted. A Nurse's Note dated 10/05/10 at 0830 indicated the staff was at the bedside with no behaviors noted; at 2145 the resident became agitated and talked about hitting the vending machine on 10/03/10. Nurse's Note date 10/06/10 indicated that a staff member was at the bedside and in attendance when family and friends visited the resident. A Nurse's Note dated 10/07/10 at 1340 indicated Resident #4 was in the facility lobby with a staff member when he knocked over a table in the front lobby and tried to hit a staff member with a chair. The resident was return to the unit and given 5 mg (milligrams) of [MEDICATION NAME] IM for combativeness. An observation on 11/03/10 at 11:10 AM, 1:30 PM and 2:10 PM revealed staff seated in the room with the resident. There was nothing in the chart to indicate why a staff was seated in the room with the resident. There was no care plan to indicate … | 2014-03-01 | ||
| 10239 | 10239 | ANCHOR HEALTH & REHAB OF AIKEN | 425311 | 550 EAST GATE DRIVE | AIKEN | SC | 29803 | 2010-11-15 | 280 | D | RSFH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review and interviews, the facility failed to review and revise one of four resident's care plans. Resident #1 had a significant weight loss that was not identified or updated on the care plan. The care plan also did not reflect the resident's diarrhea. The findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded the resident's weight as 157 pounds with no weight changes. The Medicare 14 day MDS dated [DATE] coded the resident weight was 152 pounds with no weight changes. Review of the daily weights revealed her admission weight of 151.6 pounds on 7/13/2010. On 7/17/2010 Resident #1 weighed 148.4 pounds. On 7/25/2010 she weighed 140.2 pounds. Resident #1 had a steady rapid weight loss during that week of 8.2 pounds in 8 days. On 8/2/2010 she weighed 135.6 pounds. On 8/5/2010 she weighed 134.8 pounds. A total weight loss of 15.4 pounds or an 11.4% weight loss in 3 weeks. Review of the Physicians Orders revealed an order to "Notify MD (medical doctor) of weight change > (greater than) 5 pounds." Review of the care plan revealed expected weight loss related to diuretic therapy was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "dietician to evaluate nutritional status, weigh per order..." The care plan had not been updated with the actual significant weight loss, or the supplements that had been added. During an interview on 11/15/2010 at 1 PM, the Care Plan Coordinator confirmed that Resident #1's care plan was not updated to reflect the resident's significant weight loss. She also confirmed that interventions should have been put in place to address the weight loss. She stated that she routinely updated care plans, h… | 2014-03-01 | ||
| 10235 | 10235 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 157 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to notify the physician, or failed to notify the physician timely, of changes in status for 3 of 11 residents reviewed for notification. The facility failed to notify the physician of a positive stool hemoccult test for Resident #1 and failed to notify the physician timely of complaints of pain for Resident #11. In addition, the facility failed to notify the physician of blood noted in Resident #9's brief and also failed to notify the family of the blood or of an order for [REDACTED]. The findings included: At 5:28 PM on 11/15/10, record review for Resident #9 revealed a physician's orders [REDACTED]." Review of the Progress Notes revealed a note by the FNP (Family Nurse Practitioner) dated 9/27/10 regarding debridement of eschar from the right heel wound. On 11/16/10 at 9:29 AM review of the Nurse's Notes revealed a note dated 9/27/10 at 2:00 PM that the wound had been debrided per the FNP. No documentation of family notification of the FNP evaluation or debridement was found in the record. On 11/16/10 at 9:29 AM, record review for Resident #9 revealed a Nurse's Note dated 9/22/10 of a late entry for 9/21/10 at 3:40 PM stating "noted dark red blood on brief + (and) penis size of quarter." Review of the physician's orders [REDACTED]. No new orders were initiated. The Nurse's Notes also revealed a note dated 9/24/10 at 12:00 noon "Res(ident) had another episode of small amt (amount) of dark rusty blood p (after) he voided clear urine." There was no documentation of physician notification of the second episode of blood in the resident's brief and there was no documentation that the family was notified of either episode. During an interview at 1:47 PM on 11/16/10, LPN (Licensed Practical Nurse) #4 confirmed there was no documentation that Resident #9's family was notified of the evaluation and debridement of his wound or of the blood in his brief. She also ver… | 2014-03-01 | ||
| 10236 | 10236 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 225 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interviews and review of the facility's Abuse policy, the facility staff failed to immediately report an allegation of abuse to the administrator of the facility. Resident #11 reported an injury to her ankle on 9/23/2010 to her Certified Nursing Assistant (CNA). The CNA failed to report the injury to the nurse. An allegation of abuse was made to the Licensed Practical Nurse (LPN) the next morning. The LPN waited 6 hours before contacting the administration of the allegation. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: "This nurse (LPN (Licensed Practical Nurse #1) brought to the DON (Director of Nurses) office by res(ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, "the CNA was rough with me last night." Then res stated the CNA offered to use lift to stand resident. Res states, "I said hell no." Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated "ok" and seemed pleased." A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated "Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray." At 5:00 PM a nurses note documented "Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle." Review of the Incident Report dated 9/24/2010 at 9:15 AM revealed "res stated to this nurse "the CNA was rough with me last night." Then resident stated the CNA offered to use lift t… | 2014-03-01 | ||
| 10237 | 10237 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 280 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to assure that 1 of 11 residents reviewed had their care plans reviewed and revised to reflect the care needs of each resident. Resident #11's care plan did not reflect the specific transfer devices needed. Resident #11 was recommended to use a sliding board, rolling walker and gait belt for safe transfers. The care plan did not reflect the recommendations. The findings include: Review of the medical record revealed Resident #11's was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 10/1/2010 indicated that the Nurse Practitioner and the Physical Therapist assessed Resident #11's decreased Range of Motion and functional ability of the left ankle and recommended it was "safest for res. to use slide board to transfer and use BSC (bedside commode) after standing from w/c." Review of the Physical Therapy notes revealed on 10/1/2010 "...sliding board transfer to w/c and standing pivot transfer with walker for w/c recliner transfer. No more toilet transfer and used bedside commode..." A Physical Therapy inservice was conducted with 4 CNA's related to safe transfers for Resident #11. The inservice indicated the staff was to use a gait belt and rolling walker for transfers. Another Physical Therapy inservice was conducted with the Ambustar staff related to safe transfers for Resident #11. The education provided indicated the resident was to be transferred using a gait belt and rolling walker with "no ankle lock on floor." Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive." T… | 2014-03-01 | ||
| 10238 | 10238 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 323 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview, the facility failed to assure Resident #11's range of motion was appropriately assessed and the appropriate interventions were put in place related to safe transfers. Resident #11 did not have a current range of motion assessment in place, did not have documented the safe handling devices that were recommended by the nurse practitioner and the physical therapist and staff were not consistent/aware of the recommendations for safe transfers. The findings included: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #11 as needing extensive one person assist with bed mobility, transfers, walking in and out of the room and locomotion on the unit. Resident #11 also needed extensive one person assist with toileting, hygiene, bathing and dressing. Resident #11's functional range of motion was coded as one sided partial loss of the leg. Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive." There were no approaches related to the type of transfer devices needed or what was the safest way to transfer the resident. The CNAs used the same care plan as the nurses. The care plan was located in the resident's chart at the nurse ' s station. There was no documentation on the resident's care plan that indicated what the specific care needs of Resident #11's were (i.e. slide boards, rolling walker, gait belt etc) Review of the Nurses' Progress Notes da… | 2014-03-01 | ||
| 10210 | 10210 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 241 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation of meal service, the facility failed to provide services that respected resident's dignity during a random observation of a meal. Resident # 5 and 2 other unidentified residents were not served their meal in a timely manner. The findings included: The facility admitted Resident # 5 on 10/30/06 with [DIAGNOSES REDACTED]. On 11/16/10, at 12:20 PM, the lunch trays were delivered to the dining room. Resident # 5 was observed along with two other residents sitting in the dining room facing the other residents. Meal trays were served and the other residents ate or were assisted with their meals. Resident # 5's meal tray was noted to be on the cart. Resident # 5 and the other two residents were not assisted to a table or served the meal until 1:00 PM. This observation was shared with the DON during sharing. The facility admitted Resident # 3 on 6/23/10 with [DIAGNOSES REDACTED]. Prior to observation of wound care on 11-16-10 at 1:35 PM, Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #5 entered the room without knocking. During the course of the treatment from 1:35 PM until 2:55 PM, the LPN left the room two times to obtain needed supplies and reentered without knocking. The nurse entered the shared bathroom to wash her hands four times without knocking to ensure that residents from the adjoining room were not using the commode. At 2:30 PM, when the nurse entered the bathroom for the fifth time (without knocking) to wash her hands, she walked in on a resident who was using the commode. After this incident, the nurse continued to enter the bathroom door three more times without knocking while completing the wound care. The privacy curtain was not closed at the foot of the resident's bed during the entire treatment. During an interview with LPN # 3 on 11-17-10 at 12:40 PM, the nurse verified that she had failed to knock when entering the room and each time she entered the ba… | 2014-03-01 | ||
| 10211 | 10211 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 250 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, no medically related social services were provided for Residents #21 and #26 related to behaviors. ( 2 of 6 residents reviewed for specific medically related social services.) The findings included: The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed numerous nurse's notes documenting sexually inappropriate behaviors towards staff and residents and wandering into other resident rooms. This was also confirmed on 11/16/10 at 1:30 PM by 4 of 4 residents who attended group meeting. These residents stated they had been touched on the arms, toe, and asked "give me some sugar." Nurse's note on 5/18/10 documents " CNA (Certified Nursing Assistant) - resident touching and rubbing her leg - won't quit." On 5/25/10 " MD (Medical Doctor) in today for touching staff inappropriately. CNA reported resident asked for a kiss." On 5/26/10 note documents " CNA makes resident hold to side rails to keep him from reaching for her." Nurses notes continue: 6/12/10- touches staff inappropriately at times; 6/14/10 - started on Lexapro 10 mg (milligrams) r/t (related to) inappropriate sexual disinhibition; 6/16/10 - continues to enter resident rooms, continues to attempt to touch staff and residents- redirect as necessary; 9/1/10 CNA and PT (Physical Therapist) reported resident made inappropriate gestures and sexual comments. Resident attempted to enter other resident's rooms without permission; 9/4/10 - inappropriate sexual remarks at staff at times; 10/17/10 - staff and residents reported resident has been making inappropriate comments "give me some sugar and I want a lick." staff will continue to monitor behavior. On 11/16/10 resident approached a surveyor and asked "when can we meet" and made an explicit sexual gesture. Only two physician progress notes [REDACTED]. Review of Social Service Notes revealed a note on 4/22/10 -Resident has been not… | 2014-03-01 | ||
| 10212 | 10212 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 281 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide nursing services that met professional standards of practice. The facility nurse failed to transcribe Resident # 7's medication order correctly and multiple nurses administering medications to the resident failed to clarify the entry on the MAR (Medication Administration Record) for [MEDICATION NAME] as needed on Monday, Wednesday and Friday, resulting in a medication errors. The findings included: The facility admitted Resident # 7 on 11/10/10 with [DIAGNOSES REDACTED]. On 11/16/10, review of the resident's medical revealed a physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) revealed that the order had been transcribed incorrectly to the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. On 11/16/10 at approximately 4:00 PM interview with RN (Registered Nurse) # 4 revealed that she had transcribed the order incorrectly. She stated that the computer system being used will not recognize Monday, Wednesday, Friday orders unless entered as a prn order. She stated that she had failed to mark out the PRN as needed when the MAR indicated [REDACTED]. | 2014-03-01 | ||
| 10213 | 10213 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 279 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a plan of care which addressed the non compliance of Resident # 21 with safety regulations within the facility and failed to address the resident's non compliance with fluid restrictions. (One of one sampled resident known to be noncompliant with smoking regulations and one of one sampled resident reviewed with a fluid restriction reviewed for the development of care plans) The findings included: Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. On 11/14/10, at 6:50PM, the resident was observed to be out of bed sitting near the nurses station and in the dining room. The resident was observed to obtain glass(es) of water from a drinking cooler three times during the observation which lasted approximately one hour. No staff intervened or spoke with the resident about his fluid consumption. During an interview with the unit manager, when asked if the resident was compliant with the fluid restriction, she stated "no." The unit manager further verified that the resident's plan of care did not address his non-compliance or the facility plan to address the concern. Further record review revealed the resident had been noncompliant with the facility smoking regulations which had been addressed by the facility Administrator. On August 21, 2009 and on September 10, 2010, the resident had received a letter from the facility addressing his non-compliance. Nursing notes also revealed that on 9/16/10, two cigarette lighters had been removed from the resident's room. When the Administrator was questioned if he was aware of the 9/16/10 occurrence, he did not respond. Further review of the resident's comprehensive plan of care did not reveal any concern/plan related to the residents non-compliance with the facility safety/non-smoking regulations. A copy of the smoking policy (7/06) stated; "All residents are prohibited from keeping any type of smo… | 2014-03-01 | ||
| 10214 | 10214 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 309 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide physician-ordered care and services for one of two residents reviewed with orders for Hospice services and one of one residents reviewed for provision of [MEDICAL TREATMENT]. There was no evidence of implementation of a 10-6-10 hospital transfer order for Hospice for Resident #17. Intake and output was not monitored to ensure compliance with a fluid restriction order for Resident #21. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following a hospitalization from [DATE] to 10-6-10. Record review on 11-15-10 at 12:45 PM revealed a hospital Patient Transfer Form dated 10-6-10 which was noted as faxed to the facility on the same date. Instructions on the cover page of the form included to "Arrange hospice". Additionally, the same Discharge Instruction was listed as a line item on an attached Order Confirmation Report. There was no evidence in the medical record that the order had been implemented. During an interview on 11-15-10 at 3:30 PM, the Director of Nurses reviewed the transfer document and confirmed the order for Hospice. She stated she "did not see" and had not been aware of the order until 10-26-10, the date of the resident's death. During an interview on 11-16-10 at 11:35 AM, Registered Nurse (RN) #6 also confirmed the Hospice order and stated that she had been unaware of the Hospice order until after the resident's death when she "found the Hospice note". The RN stated that the transfer information usually came from the hospital in a packet and that the nurse who received the resident should have written the order for the referral. She stated that, when she became aware of the order, she questioned the nursing staff and they "said they never saw the order". The nurse further stated that the admitting nurse "should have made the referral". Resident # 21 was recently readmit… | 2014-03-01 | ||
| 10215 | 10215 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 314 | G | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, facility policy on care and assessment of Pressure Ulcers, and interview, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four of seven sampled residents reviewed for pressure ulcers. Resident # 23 was admitted [DATE] with a known pressure ulcer. treatment for [REDACTED]. Resident # 22 with a known red area to the back, receiving treatment, was not assessed weekly for changes in the area and effectiveness of treatment. Resident #1 failed to have ongoing documentation available of a pressure ulcer as it was treated to allow staff to accurately determine response to the treatment and the need for possible changes in treatment. During a pressure ulcer treatment observed on Resident #3 the licensed staff failed to implement infection control techniques to ensure healing. The findings included: The facility admitted Resident # 23 on 3/6/10 with [DIAGNOSES REDACTED]. On the weekly skin documentation form dated 3/6/10 the resident was documented by nursing to have a black area to the right heel with no further description/measurement noted. On 3/15/10 the area was documented as "soft and black." There was no physician order for [REDACTED]. ... He has a large decubitus over the right heel. It is covered by skin" . He previously had a blister and nursing staff reported that this has drained and there is some serosanguineous type drainage....Small area in the plantar surface of the right foot that is measuring approximately .5cm (centimeter) in diameter Wound bed in this area is pink, moist. This again is a very superficial area ..." The NP at this time ordered vitamin C, Prosource and Vitamin with Minerals, treatments to both areas, continued use of Podus boots, and floating of the heels while in bed. The physician saw the resident on 3/23/10 and made no change… | 2014-03-01 | ||
| 10216 | 10216 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 367 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide the diets as ordered by the physician for two of seven sampled residents reviewed for therapeutic diets. Resident #17 was provided solid foods on a mechanically-altered (pureed) diet and an order for [REDACTED]. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following hospitalization from [DATE] to 10-6-10 for Aspiration Pneumonia, Dehydration, and [MEDICAL CONDITION]. Additional/chronic [DIAGNOSES REDACTED]. Record review on 11-15-10 at 12:45 PM revealed that Resident #17 was on a "Puree diet with nectar thick liquids for pleasure" prior to hospitalization and received an "egg salad sandwich c (with) ea(ch) meal" per a physician's orders [REDACTED]. The hospital Patient Transfer Form dated 10-6-10 noted "Instructions" for a Discharge Diet of "TF (tube feeding)". The hospital Discharge Summary noted that the resident was to receive "[MEDICATION NAME] 1.5 at 80 ml (milliliters)/hour for 18 hours, start at 3 PM, off at 9 AM." physician's orders [REDACTED]. There was no evidence in the record that the sandwiches had been reordered. A copy of a Diet Order & Communication form dated 10-7-10 was found in the medical record. Pureed Texture and Nectar-Like Thickened Liquids were checked to indicate the type of diet to be provided. During an interview on 11-15-10 at 4 PM, the Speech Language Pathologist (SLP) reviewed the Rehabilitation Screen form she had completed on 10-8-10. She stated that the resident had been on caseload prior to the 9-26-10 hospitalization , but had reached a plateau. He had received the sandwich with meals prior to hospitalization and was "safe" with it. Upon readmission, she stated that the resident was uncooperative with the screening process for oral motor assessment and noted that the resident was "WFL (within functional limits) for puree". She did not request a… | 2014-03-01 | ||
| 10217 | 10217 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 156 | C | JNTL11 | On the days of the survey, based on record review and interview, the facility failed to provide Liability Notices to 3 of 3 residents reviewed for notification of Medicare Provider Non- Coverage. The facility did not utilize form or any of the 5 denial letters to inform residents or their responsible party of the items and services expected to be denied under Medicare Part A. The findings included: On 11/17/10 at 10:20 AM, a review of 3 random Medicare Non-Coverage Notices revealed that there were no Liability Notices included in the information given to the resident or responsible party. An interview with the Admission Coordinator revealed that she had not been aware until yesterday that Liability Notices were required. According to information provided by the Admission Coordinator, Resident A had used 50 days and his last covered day was 10/27/10 due to therapy being discontinued. Resident B had used 64 days and no longer required skilled services. His last covered day had been 9/2/10. Resident #8 had used 36 days and her last covered day had been 8/20/10 due to her therapy having been discontinued. | 2014-03-01 | ||
| 10218 | 10218 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 159 | D | JNTL11 | On the days of the survey, based on record review and interview, the facility co-mingled personal funds with facility funds for 2 of 5 residents reviewed with Resident Trust Fund Accounts. Resident D had personal funds withdrawn from her Trust Fund Account and deposited into the facility account. Resident E had retirement checks deposited into the facility account instead of being deposited into her Trust Fund Account first. In addition, there was no evidence of notification of balances that would jeopardize Medicaid eligibility for Resident D. The findings included: Review of Resident D's Trust Fund Account record on 11/17/10 at 1:42 PM revealed a Care Cost Payment dated 9/17/10 of $3.04, a second Care Cost Payment dated 10/7/10 for $11.28, and a third Care Cost Payment dated 11/5/10 for $30.06. When asked about what these payments were for, the Business Office Manager stated that she withdrew these amounts from the resident's Trust Fund Account and deposited the monies into the facility account since the resident had reached her $1800.00 limit in which she would need to start spending down her account since she was a Medicaid recipient. According to the Business Office Manager, the monies deposited into the facility account would go towards payment of any remaining balances the resident might have. When asked if the resident owed a balance, she stated "no". She stated the facility account was not interest bearing. When asked if she had contacted the family of the resident to try to see if they could spend down her account she stated she had never seen the family and hadn't recently tried to get ahold of them, but she would try now. Review of the Resident Fund Management Service reports revealed that these funds had been withdrawn from the resident's Trust Fund Account and had been deposited into the facility account. During the funds interview on 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that when a Medicaid resident's account reached #1800.00, she told the resident or responsible pa… | 2014-03-01 | ||
| 10219 | 10219 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 160 | D | JNTL11 | On the days of the survey, based on record review and interview, one of five resident records reviewed for conveyance of funds revealed disbursement of funds without written authorization. The findings included: On 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that Resident #19 had $30.00 in the Resident Trust Fund Account that had been sent to the funeral home at the family's request after her death. According to the Business Office Manager, the family wanted the cash money, however, she told them she could send it to the funeral home or the estate. The family requested the money sent to the funeral home. According to the Business Office Manager, there was no Power of Attorney in effect over the resident's financial matters. Review of the Admission Agreement revealed a "Beneficiary Designation:" section that was not filled out and did not designate a person to receive the resident's personal funds. | 2014-03-01 | ||
| 10220 | 10220 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 167 | C | JNTL11 | On the days of the survey, based on observations, the facility failed to post the most recent survey report within the facility. The facility failed to post the most recent complaint survey with citations from 9/16/10 and failed to post a complaint survey with citations from February 2010. The findings included: Observation on 11/15/10 at approximately 5:00 PM revealed a plastic holder mounted on the wall in the hallway near the front lobby. Observation of the contents of the holder revealed a labeled notebook containing the annual recertification survey report from September 2009. The complaint surveys with citations from 9/16/10 and February 2010 were not posted as required. On 11/17/10 at approximately 4:30 PM, the surveyor reviewed the contents of the notebook with the Administrator. The Administrator confirmed that the complaint surveys were not posted at that time. | 2014-03-01 | ||
| 10221 | 10221 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 282 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the care plan was not followed related to pacemaker checks for Resident #9 and analysis of causative factors of behavior for Resident # 26. ( 1 of 2 residents reviewed with pacemakers and 1 of 1 resident reviewed for socially inappropriate behaviors.) The findings included: The facility admitted Resident #9 on 5/13/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 revealed the resident to have a pacemaker. The Physician's History and Physical listed a [DIAGNOSES REDACTED]. Dates of 5/14/09, 9/3/09, 12/17/09 and 3/4/10 were listed on the sheet as to when checks should be done. The only documentation of testing in the medical record was dated 9/03/09. No other documentation could be found. There was no physician order to do pacemaker checks. The care plan for pacemaker also documented pacemaker check as ordered q 3 months ( every 3 months). An interview with RN # 1 (Registered Nurse) and the Unit Manager revealed that the nurse did not know the resident had a pacemaker. She was unable to find any information in the record related to the checks other than the one report of 9/03/09. RN #1 placed a call to the Clinic and found that a check had been done on 9/03/10. There were no other reports sent at this time. The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem which stated, "Resident exhibits socially inappropriate behaviors IE: wandering into others room, touching peers and staff inappropriately, pulling fire alarm. Under approaches were listed: assess resident's understanding of the situation, monitor resident frequently, analyze key times, places, circumstances, triggers, and what de-escalates behavior, and Psychiatric evaluation as indicated. An interview with the Unit Manager of 100 unit and Social Services on 11/17/10 revealed that no one had done an analysis, and no psychiatric evaluation had b… | 2014-03-01 | ||
| 10222 | 10222 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 441 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to provide evidence that all personal laundry was effectively cleansed/sanitized to destroy microorganisms. Also, based on observations and interviews, the facility failed to follow a procedure whereby expired topical agents, irrigation trays, and wound care supplies were removed from current stock and were available for daily use in two of four medication rooms reviewed. The findings included: During observation of the laundry on [DATE] at 10:15 AM, two home-type washers were noted (in use) not to be connected (via the chemical dispensing system) to any type of sanitizing agent. Bleach was set up to be dispensed on an automatic dispensing system to a third commercial-type washer. A sign was noted on the wall above a dryer indicating "no bleach" formula to be used on given wash cycles. When asked at this time, the Laundry Aide confirmed that bleach was not used for some personal laundry. She stated that the water temperature ranged from 120 to 160 degrees and was monitored by maintenance. She was unaware if any type of sanitizer was used and deferred to the Housekeeping Supervisor. During an interview on [DATE] at 2 PM, the Maintenance Supervisor provided laundry water temperature logs for review. Water temperatures ranged from 129 to 141 degrees Fahrenheit over the previous six month period. When informed that personal laundry was being washed without bleach, or water temperatures over 160 degrees, the Housekeeping Supervisor stated that he could provide no information to verify use of any other type of sanitizing agent. During an interview at 2:35 PM on [DATE], a second maintenance employee stated that he had checked the dispensing mechanism on the two home-type washers and that the commercial bleach product had not been connected. At that time, the Housekeeping Supervisor verified that he could provide no information on use of any type of sanitizing agent, … | 2014-03-01 | ||
| 10223 | 10223 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 164 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility protocol entitled "Survey Readiness", the facility failed to provide privacy to 1 of 3 residents observed for wound care and 1 resident randomly observed in the bathroom during the same wound care procedure. Resident # 3 was exposed during wound care to the buttock when a Certified Nursing Assistant (CNA) entered the room without knocking. The Licensed Practical Nurse (LPN) entered an occupied bathroom without knocking during this same treatment. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During observation of wound treatment for [REDACTED].#3 entered the room through the closed bathroom door without knocking, left the bathroom door open while she got the lift and then left the room through the same bathroom door. The wound care treatment was in progress with Resident #3's buttock exposed and the privacy curtain was not pulled at the foot of the bed. During observation of the same wound treatment for [REDACTED].#3 entered the bathroom to wash her hands and did not knock. A resident was using the bathroom at the time when the nurse entered without knocking. During an interview with LPN #3 on 11-17-10 at 12:40 PM, the nurse verified that she did enter the occupied bathroom without knocking. She also verified that CNA #3 entered the room without knocking while Resident #3 was exposed. On 11-17-10 at 1:05 PM, the Staff Development Coordinator (SDC) provided a document entitled "Survey Readiness" which stated: "Remember Privacy: Knock on each door, close the door, pull the privacy curtain, and close the blinds." The SDC stated that she goes over this information with new hires and periodically as needed. During a discussion with the Director of Nursing (DON) related to privacy issues identified during treatments on 11-17-10 at 1:00 PM, the DON said she had in-serviced the staff on closing blinds, pulling curtains… | 2014-03-01 | ||
| 10224 | 10224 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 315 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review, review of the facility policy entitled "Suprapubic Catheter Care", and review of the training manual "Assisting in Long Term Care, Second Edition", the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infections for 2 of 4 sampled residents reviewed with indwelling catheters. Resident #3 had the catheter anchored inappropriately during catheter care causing a potential for trauma. Resident # 14's catheter tubing was on the floor throughout catheter care observation. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. On 11-17-10 at 10:45 AM during observation of suprapubic catheter care for Resident # 3, Licensed Practical Nurse (LPN) #3 anchored the catheter tubing approximately 4 inches away from the insertion site and cleansed the tubing from the insertion site in an outward motion causing potential trauma. Review of the facility policy entitled "Suprapubic Catheter Care" step # 12 stated: 'With the third wipe, clean the catheter tubing about 4 inches, while holding the catheter securely." The facility admitted Resident # 14 on 6/12/09 with [DIAGNOSES REDACTED]. During observation of suprapubic catheter care by Registered Nurse (RN) # 5 on 11-17-10 at 10:30 AM, the catheter tubing was noted to be lying on the floor upon entering the room and remained there during the entire procedure. After completion of the procedure, RN #5 was questioned about the cloudy character of the urine. The nurse stated that the resident was currently being treated for [REDACTED]. Record review revealed a Physician's Telephone Order dated 11/14/10 which stated: "Keflex 250 mg. (milligrams) po (by mouth) TID (three times daily) X 10 days for positive urinalysis." RN # 5 confirmed that the tubing was on the floor during an interview held on 11-17-10 at 12:30 PM. The nurse verified that she was aware that the t… | 2014-03-01 | ||
| 10225 | 10225 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 225 | D | PITJ11 | On the day of the inspection, based on record review and review of facility files, the facility failed to ensure that all allegations of neglect were reported within twenty-four hours to the State survey and certification agency for 1 of 1 allegation of neglect reported (Resident #1). The findings included: On 10/22/10, after Resident #1 complained of pain in her right ankle, the physician found a dressing dated 9/27/10 on her ankle. The dressing had originally covered a callus. When the physician removed the dressing, he found the resident's ankle red and swollen with an open and infected ulcer. Review of the medical record revealed the resident was to have a DuoDerm dressing to the site, changed every three days. The facility reported this allegation of neglect to the State survey and certification agency on 10/25/10, which exceeded the twenty-four hours allowed. | 2014-03-01 | ||
| 10226 | 10226 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 281 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, interviews, and review of facility files, the facility failed to ensure that services provided by the facility met professional standards of quality for 1 of 1 resident who developed redness, swelling, pain, and an open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). Facility staff failed to ensure the resident's treatment order was carried forward to the new month, and failed to thoroughly assess and accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician found an occlusive dressing on the right lateral ankle dated 09/27/10. There was pus underlying the dressing and an infected open area measuring 1 X 1 cm (centimeter) surrounded by a 3 by 3 cm area of [MEDICAL CONDITION]. The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. Review of the medical record and the facility's investigative materials revealed none of the staff providing care to the resident (five nurses and thirteen nursing assistants), from 9/27/10 to 10/22/10, noticed the unchanged dressing and the developing decline in the resident's skin condition. CNAs (Certified Nursing Assistants) doing daily skin inspections noted the resident's skin was "clear." Licensed staff documented on the weekly body audits that the resident had a callus on her right ankle. The licensed staff failed to update the monthly cumulative orders for October 2010 to show the dressing change order for DuoDerm to the right ankle every three days. This order was initiated on 6/30/10. Licensed staff failed to realize the omission of the order and therefore, failed to provide the resident with the treatment. The staff also failed to provide the appropriate care and ongoing assessment required to manage the resident's skin care. Cross refer to F-314 related… | 2014-03-01 | ||
| 10227 | 10227 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 314 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review and interview, the facility failed to ensure that a resident received treatment to promote healing, prevent infection, and prevent new sores from developing for 1 of 1 resident reviewed who developed an infected sore when facility staff left a protective dressing in place from 9/27/10 to 10/22/10 (Resident #1). The resident did not have her dressing changed because the treatment order was omitted from the October 2010 orders and treatment record. Facility staff failed to recognize the omission. As the resident's ankle declined in condition, the staff failed to thoroughly assess and accurately document her condition in the medical record. The daily skin inspection and weekly body audit documentation showed no changes in the condition of the resident's ankle. These failures lead to a lack of appropriate interventions. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician's progress note, dated 10/22/10 and signed on 11/18/10, stated he found an occlusive dressing on the right lateral ankle "which was dated 09/27 and had pus underlying the dressing." Under the dressing was "a 3 X 3 cm (centimeter) stage 2 ulceration and a 1 X 1 cm stage 3 ulceration with surrounding [MEDICAL CONDITION]." The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. According to the physician's progress note, it was his understanding the Wound Care team was assessing this wound at least weekly. The physician wanted to know why the dressing had "apparently not been changed for 23 days." He showed the wound to the Unit Manager and wanted to know why the dressing had not been changed. The facility began an investigation to answer the physician's questions. Review of the medical record revealed the resident had an ulcer on her right lateral ankle in February 2010. The pressure ulcer was treated with antibiotics for tw… | 2014-03-01 | ||
| 10228 | 10228 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 514 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident who developed an infected open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). On 11/18/10, the physician's progress note of 10/22/10 was not on the record. Facility staff failed to ensure monthly cumulative orders were complete related to treatments ordered, and failed to accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 10/22/10, the resident complained to the physician of pain in her ankle. While examining the resident, the physician found a DuoDerm dressing on the ankle 9/27/10. Under the dressing was an open and infected ulcer. Review of the resident's medical record on the morning of 11/18/10 failed to show a physician progress notes [REDACTED]. The physician signed and sent his progress note for 10/22/10 via facsimile on the afternoon of 11/18/10. Review of the Nurse's Notes for 10/22/10 showed no descriptive documentation of the resident's right ankle. The redness, swelling, and open area found by the physician was not included in the nurse's note. The pressure ulcer's characteristics were documented in the Skin Condition Report, but other than the physician's progress note, the medical record did not show that a dressing dated 9/27/10 was found on the resident on 10/22/10. Facility staff failed to note the omission of the DuoDerm treatment order on the printed cumulative orders for October 2010. Therefore, the order was not listed on the Documentation Sheet for treatments and the resident did not receive the DuoDerm treatment 10/1-22/10. Review of the CNA Daily Skin Inspection Record and the Body & Skin Audits done by the nurses on a weekly basis revealed documentation for September 2010 and up to October 22, 2010 showing no changes in the resident's condition alt… | 2014-03-01 | ||
| 10232 | 10232 | UNIHEALTH POST ACUTE CARE - AIKEN, LLC | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2010-11-22 | 153 | G | 6LCC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of … | 2014-03-01 | ||
| 10233 | 10233 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2010-11-23 | 225 | D | FIPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interview, the facility's "Patient/Resident Incident/Accident Investigation Worksheet" and review of the facility's policy on Abuse and Neglect, the facility failed to report injuries of unknown origin to the State survey and certification agency related to Resident #1. Resident #1 with injuries of unknown origin; a bruise to her right lower jaw on 10/27/2010 and a bruise to her left knee/leg on 11/04/2010 that were not reported to the state agency. (1 of 3 sampled residents reviewed) The findings included: The facility admitted Resident #1 on 5/09/1907 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that indicated the resident had short and long-term memory problems with severely impaired cognitive skills for daily decision-making. Range of motion showed limitation on both side for neck, arm, hands and leg with partial voluntary movement. Review of a 10/27/2010 "Patient/Resident Incident/Accident Investigation Worksheet" indicated "2 cm (centimeter) bruise noted to RT (right) v (lower) jaw. doesn't flinch when touch. Unable to communicate to tell what happened D/T (due to) mentality." Review of an 11/04/10 "Patient/Resident Incident/Accident Investigation Worksheet" indicated "8 AM called to Room CNA (Certified Nurse Aide) states every time I move her left leg she hollers. In to exam Resident noted to have light purple bruise appx (approximately) 3x (times) 3 in (inches) area (just above left outer knee)..." In an interview with the surveyor on 11/23/2010 at 11:50 AM the Director of Nursing (DON) revealed she did not report the 10/27/2010 or the 11/04/2010 incidents to State survey and certification agency. An interview on 11/23/10 at 12: 20 PM with the Interim Administrator revealed the unwitnessed incidents were not reported because he believed the facility had within 24 hours to determine the cause of the incide… | 2014-03-01 | ||
| 10234 | 10234 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2010-11-23 | 323 | D | FIPL11 | On the day of the compliant inspection, based on an observations, interviews and record reviews, the facility failed to ensure that Resident A received adequate assistive devices to prevent accidents. Resident A had padded side rails; the pads did not cover the entire length of the side rails and were not securely attached to the side rails. The findings included: An observation and interview on 11/23/10 at 11:15 AM with the DON (Director of Nursing) revealed Resident A had padded side rails, the pads did not cover the entire length of the side rails and were not stable. The DON showed how easily the padded side rails moved back/forth and confirmed the pad would not protect the resident from injury if she rolled against the uncovered side rails. | 2014-03-01 | ||
| 10229 | 10229 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 225 | D | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review, interviews, and review of the facility's policy on Abuse and Neglect, the facility failed to provide evidence that an incident involving the care of Resident #1 was thoroughly investigate. The facility failed to interview and obtain witness statements from the Certified Nursing Aide (CNA) assigned to Resident #1 at the time of the incident and the Registered Nurse (RN) on duty at the time of the incident; Resident #2's family's concern about his eye was not investigated and reported to the state agency. (2 of 5 sampled residents reviewed). The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the facility investigation file revealed a facility accident/incident report dated 11/08/2010 at 11:22 AM Section One: To be completed by person reporting/witnessing the incident. CNA #1 described the incident as follows: "staff turn back and res (resident) rolled over and hit head on closet. Section Two: To be completed by a licensed nurse dated 11/08/2010 at 1500 under Corrective/preventive measures RN #1 stated, "Resident receiving AM care staff turned and resident rolled OOB (out of bed) struck head on closet. Orders written to pad closet and nightstand to prevent this type of injury. Matts were on floor..." The facility investigation included incident witness statements from three staff members who stated they were unaware of the incident; there were no credentials/job titles to identify the three witnesses. The facility failed to obtain interview statements from CNA #1 and RN #1. In an interview on 11/17/2010 at 10:40 AM the Director of Nurses confirmed there were no witness statements completed by CNA #1 and RN #1. The facility admitted Resident #2 on 11/29/2004 w… | 2014-03-01 | ||
| 10230 | 10230 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 282 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews the facility failed to ensure that care plans were followed for 1 of 5 sampled residents reviewed. Resident #1 care planned as a total assist with two care givers with bathing, dressing and grooming, was injured on 11/08/2010 when Certified Nurse Aide #1 provided care unassisted. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around "to grab things" while providing care. CNA #1 stated, "I turned away for a few seconds and the resident rolled out of bed." CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA … | 2014-03-01 | ||
| 10231 | 10231 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 323 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews the facility failed to ensure that Resident #1's environment remains as free of accident hazards as possible. Resident #1 injured on 11/08/2010 when a Certified Nurse Aide (CNA) bathed him alone, was care planned to have two people with bathing. The review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. Following the injury the care plan was updated on 11/09/2010 to include padded edges to the nightstand and closet, observation on 11/17/2010 revealed no padded edges. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." On 11/09/2010 the care plan was updated with an intervention to include "Pad night stand and closet." Review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned aroun… | 2014-03-01 | ||
| 10141 | 10141 | SUNNY ACRES | 425093 | 1727 BUCK SWAMP ROAD | FORK | SC | 29543 | 2010-12-01 | 225 | D | 07P711 | On the day of the inspection, based on review of facility concern forms and interview, the facility failed to ensure that all allegations of misappropriation of resident property were reported to the State survey and certification agency for 2 of 2 allegations reviewed (Resident A). The findings included: Review of the concerns filed with facility administration since the last recertification survey revealed two allegations of misappropriation from Resident A. On 8/12/10, the resident reported $12.00 missing. Facility staff searched for the money but it was not found. The facility reimbursed the resident. On 9/1/10, Resident A reported $50.00 missing, two twenty dollar bills and other money totaling fifty dollars. A search revealed some one dollar bills in the resident's coat, but she stated this was not part of the $50.00 she had put in her purse. The facility reimbursed the resident by depositing the money in her fund account. The Administrator and Director of Nurses were asked at 4 PM on 12/1/10 if these allegations had been reported to the State survey and certification agency. After researching their files, no evidence was discovered to show the allegations of misappropriation of resident property were reported. | 2014-04-01 | ||
| 10146 | 10146 | LANCASTER CONVALESCENT CENTER | 425155 | 2044 PAGELAND HWY | LANCASTER | SC | 29721 | 2010-12-01 | 225 | D | DFSK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, interview, review of the facility's grievance log and review of the facility's policy on Abuse and Neglect, the facility failed to report an injury of unknown origin. On 10/14/2010 a large, dark purple bruise was noted on Resident #5's back and left side of his chest; he was unable to state how the injury happened. There was no documentation to indicate the facility reported the incident as an injury of unknown origin. (1 of 5 sampled residents reviewed) The findings included: The facility admitted Resident #5 on 2/07/2009 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS (Minimum Data Set) dated 7/12/2010 indicated the resident had no memory problems with moderately impaired cognitive skills for daily decision-making. Review of the Nurses' Note dated 10/14/10 at 1:30 PM stated, "large dark purple bruise note L (left) side of chest and back. Res (resident) stated, I don't know it happened..." Review of the "Incident/Accident Report" form signed 10/18/2010 revealed a date of 10/15/2010 as the date a large, dark purple bruise was noted on the left side of the chest and back of Resident #5. The incident report included the statement, "I don't know what happened." There was no documentation that a referral was made to the State Survey Agency. An interview on 12/01/2010 at approximately 10:38 PM with the Administrator and Director of Nursing (DON) confirmed the findings. The Administrator stated they did not feel the bruises were significant enough to make a report. The Administrator further stated it was the facility practice to determine the cause of the bruise instead of reporting. | 2014-04-01 | ||
| 10123 | 10123 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 463 | J | R87Z11 | On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to ensure that all components of the nurse call system were operational. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light to room 712 was blinking on and off with no sounds. The call light to room 715 was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights to rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room 715 to turn off the call light for room 701. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms 718 and 719, located in a corner, not readily visible to the staff from the halls. When asked how long problems existed on the unit with the call lights CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room 701 called for a CNA to go to room 717 due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room 717 was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:25 PM Licensed Practical Nurse (LPN) #1 reveale… | 2014-04-01 | ||
| 10124 | 10124 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 490 | J | R87Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey and the facility administrative staff was aware of problems with the call lights. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light for room [ROOM NUMBER] was blinking on and off with no sounds. The call light for room [ROOM NUMBER] was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights for rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room [ROOM NUMBER] to turn off the call light for room [ROOM NUMBER]. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms [ROOM NUMBERS], located in a corner, not readily visible to the staff from the halls. When asked how long problems with the call lights had existed on the unit CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observe… | 2014-04-01 | ||
| 10125 | 10125 | UNIHEALTH POST-ACUTE CARE - COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-12-07 | 280 | D | R87Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review the facility failed to assure a resident's care plan was reviewed and revised to reflect the current status of one of one resident reviewed with socially inappropriate behaviors. Resident #1 alleged that a new Certified Nurse Aide (CNA) hit him in the eye. Resident #1's care plan was not updated to reflect the allegation and no new interventions were initiated to attempt to address the behaviors. The findings included: The facility admitted Resident #1 on 11/14/2007 and readmitted him on 11/14/2008 with [DIAGNOSES REDACTED]. During record review for Resident #1 on 12/06/2010 the Nurse's Notes dated 11/11/2010 stated, "Resident called nurse to room and states, 'look what the new CNA did to me'. Nurse asked what did CNA do resident states 'CNA punched me in the face'. SA (screening assessment) done noted bluish injury to (R) (right) eye..." Review of the resident's care plan dated 08/17/2010 identified Socially inappropriate/disruptive behavior and Resistance to care, restlessness, crawling on the floor, history of combative behavior...w (with) potential for self-inflicted injury as problems. The care plan had not been updated following the 11/11/2010 incident related to the allegation that the CNA punched him in the face. No new interventions were initiated to address the resident's behavior or the alleged response of a staff member to the continuing behaviors. The care plan included a statement under the problem area dated 11/12/2010 "continue problem x 3 months". | 2014-04-01 | ||
| 10143 | 10143 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 365 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observations, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 3 sampled residents with an order for [REDACTED]. The findings included: The facility admitted Resident #14 on 4/28/08 with [DIAGNOSES REDACTED]. Review of the medical record on 12/07/10 revealed a current physician's orders [REDACTED]." Review of the physician's telephone orders dated 11/19/10 indicated, "D/C prev. diet. Mech (mechanical) soft, gr (ground) meats...for better tolerance." Review of the Nurses Notes dated 11/19/10 at 1:00 PM indicated, "Difficulty chewing pork chop at lunch - given gr mts (meats) (with) better tolerance." Review of the Dietary Progress Notes dated 11/23/10 revealed, "The resident's diet consistency was downgraded to mech soft (11/19/10)..." Observation on 12/07/10 at approximately 12:30 PM revealed Resident #14 sitting at a table in the dining room in the process of eating lunch. Observation of the resident's plate revealed fish which was cut into pieces. Observation of the diet card on the lunch tray indicated, "Diet regular Texture regular." Observation on 12/07/10 at approximately 5:45 PM revealed Resident #14 resting in bed, and staff was observed to deliver the dinner tray to Resident #14's room. Observation revealed the dinner plate contained sliced roast beef with gravy, and observation of the tray card again revealed "Diet regular Texture regular." The surveyor asked Licensed Practical Nurse (LPN) #3 to review the current orders related to diet, and LPN #3 confirmed that the order was for ground meat. LPN #3 observed the dinner plate at that time and confirmed that Resident #14's meat was not ground. LPN #3 informed staff to hold the dinner plate and stated that another meal with ground meat would be obtained for Resident #14. On 12/08/10 at approximately 10:30 AM, LPN #3 was asked about the process of communicating diet orders to the dieta… | 2014-04-01 | ||
| 10286 | 10286 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 441 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of facility policies, the facility failed to develop and maintain an infection control program which prevented the spread of infection. During three of four pressure ulcer treatment observations, concerns were identified related to glove use or handwashing. (Resident's # 1, #2, and #5) During observation of three of three gastric tube flushes, the nursing staff failed to clean the stethoscope either before or following the treatment. (Resident's #2, #3, and #8) In two of three medication rooms, supplies were found stored beyond the manufacturer's expiration date. (One hundred and three hundred units) The findings included: The facility last admitted Resident # 1 with [DIAGNOSES REDACTED]. On [DATE] at 10:45AM, Licensed Practical Nurse (LPN) # 5 was observed performing wound care for the resident. LPN # 5 was observed to remove the soiled dressing from the residents left hip area, and without changing gloves proceeded to clean the wound using clean supplies. The facility last admitted Resident # 5 with [DIAGNOSES REDACTED]. On [DATE] at approximately 11AM, Licensed Practical Nurse # 5 was observed performing pressure ulcer care. LPN # 5 removed the soiled dressing from the residents sacrum and without changing gloves proceeded to clean the Stage IV pressure area with clean supplies. After cleaning the area with normal saline and drying the area, LPN #5 removed her gloves, washed her hands and donned clean gloves. The nurse then skin prepped the perimeter of the wound, fanned the area dry, applied Santyl to the areas containing slough, wet a dressing with saline, unfolded it, folded it into a smaller size and placed it directly onto the wound. A cover dressing was applied. LPN #5, continuing to wear the same gloves, reached into her uniform pocket, removed a pen and tape which were used to initial and date the dressing. After moving the bedside table away from the bed, the nu… | 2014-01-01 | ||
| 10287 | 10287 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 520 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to fully identify quality concerns related to restraints. Resident # 2 with a known restraint, had no quarterly assessment to determine if the restraint was the least restrictive device and whether or not the restraint continued to be necessary. The facility conducted weekly restraint quality assurance reviews and failed to fully identify missing documentation related to the restraint. The findings included: The facility admitted Resident # 20 with a primary [DIAGNOSES REDACTED]. During the initial tour of the facility on 12/6/10 the resident was identified as wearing a hand mitt restraint, "at the families request." The resident was observed with an oven mitt with a splint applied over the mitt on the right hand. On 12/8/10, record review revealed an order was written on 2/2/10 for: "Oven mitt to right hand(with) left hand Spica. Remove for ADL's (Activities of Daily Living) + (and) check skin integrity Q (every) shift d/t (due to) restlessness, Dementia, playing in feces and self scratching." Further review revealed a Quarterly Restraint Review dated 1/8/10 (before the restraint order) which stated: ' Continue current restraint order. ...Look for alternative to mitt that is less restrictive." The quarterly physical restraint review was completed thirteen times, each time recommending the continued use of the restraint. On 12/8/10 from 10AM to approximately 11:15AM, interviews were conducted with the Director of Rehabilitation who stated she was responsible for restraint documentation and the Physical therapist. It was questioned what follow up was done to obtain an alternative which was less restrictive and or whether the resident still required the use the use of the restraint. In reviewing the nurses notes, there was no documentation of the resident scratching or attempting to play in feces when the restraint was released for ADL's. The last… | 2014-01-01 | ||
| 10288 | 10288 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 164 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to ensure 1 of 3 residents received privacy during wound care. (Resident # 2) The findings included: The facility admitted Resident # 2 on 12-30-08 with [DIAGNOSES REDACTED]. During observation of wound care on 12-7-10 at approximately 1:30 PM, the Licensed Practical Nurse (LPN # 1) entered the room, pulled the privacy curtain between the beds to the foot of the bed, and asked the room mate if she wanted to leave the room while care was being given to Resident # 2. The room mate declined to leave the room, and was moving around her side of the room in her wheelchair. The privacy curtain which could have surrounded Resident # 2's bed was left at the head of her bed and not pulled around her bed. During the treatment LPN # 1 used up all of the supplies and stated to this surveyor, that he needed to leave the room to obtain more supplies to complete the treatment. At that time, Resident # 2 was lying on her side facing the door, with her brief unfastened and her entire backside exposed to view. When LPN # 1 left the room, the door was left ajar and unidentified persons were noted to be walking in the hall past the door. | 2014-01-01 | ||
| 10289 | 10289 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 315 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the South Carolina Nurse Aide Candidate Handbook, and review of the facility policy on catheter care, the facility failed to provide appropriate treatment for 1 of 1 resident observed for catheter care. During observation of catheter care for Resident # 7, the Certified Nursing Assistant failed to secure the catheter close to the meatus to prevent tension or pressure on the bladder wall when cleaning the catheter tubing. The findings included: The facility admitted Resident # 7 on 6-7-10 with [DIAGNOSES REDACTED]. ,During observation of catheter care on 12-7-10 at approximately 10:00 AM, Certified Nursing Assistant (CNA # 1) knocked, entered the room, provided privacy, washed hands and gloved. CNA # 1 then set up the supplies on the over the bed table: 3 separate cups, one containing soapy water and gauze wipes, one containing clear water and gauze wipes, and the third containing dry gauze wipes. After Resident # 7 was positioned for the treatment, CNA # 1 again washed hands and gloved. CNA # 1 then positioned her left hand to separate the labia and secure the catheter. Using her right hand she used a soapy gauze wipe to clean around the left side of the labia, and discarded the gauze wipe, then repeated the procedure on the right side. CNA # 1 then used the third soapy gauze wipe to clean the catheter, beginning at the entry point of the catheter into the body, she wrapped the gauze around the catheter and pulled away from the body to where the fingers of her left hand secured the catheter (about 4 inches from the body). Tension was observed when the catheter was being cleaned. This entire process was repeated with the clear water rinse, and in drying. Review of the facility policy revealed the following: "Female residents: Separate labia with one hand. With the soapy gauze, cleanse from front to back one stroke down one side, discard the used gauze then stroke down the ot… | 2014-01-01 | ||
| 9951 | 9951 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 363 | F | 0 | 1 | KWBU11 | On the days of the survey, based on observation, interview, and facility policy related to Emergency Food Supply, the facility failed to maintain a separate emergency food supply to met the nutritional needs of the residents. The findings included: During a tour of the main kitchen on 12/8/10 from 10:30 AM to 11:45 AM, a request was made to observe the emergency food supply. The Food and Beverage Director stated that they had a 72 hour supply of food as part of their regular stock and he understood that was sufficient. He further stated that they could also order more food from their food purveyor in Columbia if needed. The plan for Emergency Food Supply was requested. The policy dated 3/15/10 documented "A three day supply of staple food items will be kept on hand at all times. All foods are either canned or non-perishable and may be served without heating. Food for emergency menu is kept in a marked special area in the storage room." | 2014-09-01 |
| 9952 | 9952 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 372 | F | 0 | 1 | KWBU11 | On the days of survey, based on observation and interview, the facility failed to ensure garbage and refuse was disposed of properly in outside storage receptacles. The findings included: The compactor and cardboard and recyclable dumpsters were observed during the tour of the main kitchen on 12/8/10 at approximately 11:30 AM. There was a large amount of paper and plastic trash under the wooden steps leading up to the compactor as well as trash around the three containers. There was also trash scattered in the woods behind this area. An interview with the Food and Beverage Director indicated dietary was not responsible for keeping the area clean and trash-free. | 2014-09-01 |
| 9953 | 9953 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 362 | F | 0 | 1 | KWBU11 | On the days of survey, based on Dietary observations and identified concerns and interview, the facility failed to ensure sufficient personnel were employed to carry out the functions of the dietary service. The findings included: The Food and Beverage Director was interviewed on 12/8/10 at 2:10 PM regarding the concerns related to the sanitary conditions in the Main and Health Care kitchens. When asked about sufficient staff, he stated that all employees had been on an eight hour furlough per week for the last two months. He also stated there was a hiring freeze and he had 8 positions to be filled, 6 dietary under staff and 1 Health Care Center Dining Room Manager, and 1 Sous Chef. | 2014-09-01 |
| 9954 | 9954 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 371 | F | 0 | 1 | KWBU11 | On the days of survey, based on observations, interview, and facility documentation, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. The main kitchen that cooked for the entire campus including the Health Care Center as well as the serving kitchen in the Health Care Center were inspected and found to have numerous areas of unsanitary conditions. The current monitoring systems for cleaning/sanitation in both areas were not being utilized based on the findings. The findings included: During the initial tour of the kitchen on 12/7/10 at 8:40 and the extended tour on 12/8/10 from 10:30AM to 11:40 AM accompanied by the Food and Beverage Director the following conditions were found: A large grey plastic trash container uncovered by the kitchen door containing trash. Kitchen floor with dust, dried spills, and food remnants. Dust, black matter on 1/2 of the metal filters over the cooking area on both sides. Dust on the fan and mechanical parts behind the oven. During the extended tour of the main kitchen on 12/8/10 from 10:30AM to 11:40 AM accompanied by the Food and Beverage Director the following conditions were found:, Heavy grease build-up on the convection ovens inside and outside. Metal splash guard around the stove with soiling. Stored pots and pans over the pot and pan sink with soiling. Dried food spills/food crumbs/and or black substance around the floor drain rim, behind a majority of the cooking equipment, stainless steel shelving, drawers in the food preparation area near the meat slicer, table under the meat slicer, spice storage shelf, rice, sugar, and flour plastic bins, #10 can rack, shelves in cooler, black plastic bins holding lids, potato chip and croutons and the ceiling of the freezer. The floor throughout the kitchen, including under the pot and pan sink, behind tilting kettle, cooler, and freezer was observed with trash, dust, and dried food. Radios on shelves in kitchen and dishroom. Frozen fish was observed in a large plastic container on the f… | 2014-09-01 |
| 9955 | 9955 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 280 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to periodically review and revise the care plan for 1 of 9 residents reviewed. (Resident #1 was exhibiting behaviors of refusing care and diet which was not addresssed in the plan of care.) The findings included: The facility admitted Resident #1 on 9/10/09 with [DIAGNOSES REDACTED]. Record review on 12/7/10 revealed that the resident exhibited behaviors of refusal of meals, supplements, refused periods of rest and personal hygiene. Review of the Minimum (MDS) data set [DATE] listed the resident's cognitive status as a short term memory problem and moderately impaired cognitive skills for daily decisionmaking. The resident's weight chart revealed that the resident had lost weight over the past months and also had three Stage II pressure sores. Further review of the resident's care plan revealed that although the behaviors had been added to the care plan, interventions for the exhibited behaviors had not been incorporated into the resident's plan of care. During an interview with the Care Plan Coordinator on 12/8/10 at 10:35 AM, she stated that when the resident exhibited behaviors, the facility staff would call the resident's son or ask staff that had a good rapport with the resident to talk with him. At the time of the interview, the Care Plan Coordinator confirmed that she had not updated the resident's care plan to include interventions for the behaviors exhibited. | 2014-09-01 |
| 9956 | 9956 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 315 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, interview, and review of facility policy for Perineal Care, the facility failed to ensure appropriate perineal/incontinent care was provided for 1 of 1 residents observed for perineal/incontinent care. During perineal/incontinent care, the Certified Nursing Assistant(CNA) did not cleanse the perineal area properly, cleanse the resident's buttocks, and did not wash her hands during the procedure. (Resident #6) The findings included: The facility admitted Resident #6 on 11/15/02 with [DIAGNOSES REDACTED]. On 12/8/10 at approximately 4:40 PM, CNA #2 was observed providing perineal/incontinent care for Resident #6. After CNA #2 donned gloves, the resident's brief was unfastened and the resident was rolled to the left side. CNA #2 removed her gloves and donned new ones, a brief was placed, and the resident was rolled onto her back. CNA #2 changed her gloves and using different wipes, cleansed the creases of the right leg and then left leg. CNA #2 changed gloves and attempted to spread the resident's labia. Using a wipe, she wiped down the middle of the perineal area. CNA #2 changed gloves and repeated the cleansing process. After drying the resident, CNA #2 changed gloves and reapplied the resident's brief. CNA#2 removed her gloves and washed her hands. Review of the facility policy titled "Perineal Care, General" listed the following in the guidelines: " e) Female: Wash perineal area (from pubis toward perineum) with disposable wipes. Discard disposable wipes after one use in trash liner/bag. g) Remove perineal pad. h) Dry perineal and anal areas. Apply clean dry perineal pad or under garments. Assist resident to comfortable position. i) Discard disposable items. Remove gloves and wash hands thoroughly." CNA #2 was asked during an interview on 12/8/10 at 5:50 PM if she could identify anything that the surveyor may have been concerned during the treatment. She stated that she had done… | 2014-09-01 |
| 9957 | 9957 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 367 | E | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide the physician prescribed diet for 2 of 6 sampled residents reviewed for therapeutic diets. During the survey meal observations, Resident #1 did not receive Ensure with meals and Resident #6 did not receive whole milk with meals per physician orders. The findings included: The facility admitted Resident #1 on 9/10/09 with [DIAGNOSES REDACTED]. Record review on 12/7/10 revealed a physician's orders [REDACTED]. Further review of the Minimum Data Set(MDS) listed the resident's cognitive status as a problem with short term memory and moderately impaired cognitive skills for daily decision making. Review of the care plan noted the resident as refusing meals, supplements, periods of rest, and personal hygiene. An intervention listed on the care plan related to pressure sores was to adjust diet/supplements as indicated to reduce the risk of skin breakdown. Also, the care plan for potential weight loss related to poor po(oral) intake of meals listed as an intervention to provide nutritional supplements as ordered by physician and provide diet as ordered by physician Review of the nurse's notes listed only one time on 11/23/10 that the resident had received/or refused the Ensure supplement. Review of the nutritional assessment dated [DATE] listed significant weight loss and pressure ulcers as problems identified with recommendations to consider liberalizing diet to Regular Mechanical Soft with chopped meets and to change supplements to between meals rather than at mealtime to improve intake at meals. On 9/3/10, the Dietician again recommended to liberalize diet and to give supplements between meals. On 12/6/10, the Dietician recommended to continue diet and supplements. Review of the resident's weights were as follows: 1/10 -139.8, 2/10 - 154.5, 3/10 - 149.2, 4/10 - 139.4, 5/10 - 161, 6/10 - 159.2, 7/10 - 156, 8/10 - 157, 9/10 - 144, 10/10 - … | 2014-09-01 |
| 9958 | 9958 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 176 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews the facility failed to follow a procedure to ensure that an individual resident had been assessed by an interdisciplinary team for self-administration of drugs. The findings included: On 12/7/10 at approximately 9:38 AM during observation of medication pass, Licensed Practical Nurse (LPN) # 1 allowed Resident A to self-administer inhalations from a [MEDICATION NAME] Inhaler. Resident A did not shake the container as specified by the manufacturer and waited approximately 5 seconds between inhalations, instead of one minute as specified in Facts and Comparisons. During medication reconciliation, there was no physician's order for self-administration and there was not record of an assessment for self-administration. On 12/7/10 at approximately 3:30 PM, LPN # 1 stated that the resident was alert and oriented and was always allowed to self-administer the [MEDICATION NAME] Inhaler and that in spite of encouragement did not wait between inhalations. During an interview on 12/8/10 at approximately 9:25 AM, LPN # 2 (Care Plan Coordinator) stated that no assessment for self-administration had been completed on Resident A. During an interview on 12/8/10 at approximately 5:00 PM LPN # 4 stated that she did not allow Resident A to self-administer [MEDICATION NAME] Inhaler and that she waits one minute between inhalations. | 2014-09-01 |
| 9959 | 9959 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 425 | E | 0 | 1 | KWBU11 | On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 1 of 1 medication rooms. The finding included: On 12/7/10 at approximately 12:25 PM, inspection medication room revealed the following: -An undated, opened foil pouch containing eleven vials of Xopenex Inhalation Solution 1.25mg. (milligram)/3ml. (milliliter) was found on the bottom shelf of the refrigerator. -An undated, opened foil pouch containing six vials of Xopenex Inhalation Solution 0.63mg. /3ml. was found on the bottom shelf of the refrigerator. The manufacturer label on each of the foil pouches stated: " Once the foil pouch is opened, the vials should be used within 2 weeks ". -Four Povidone Iodine Prep Pads, Lot 5B94, expiration 2/08 were found atop the treatment cart. -One Povidone Iodine Prep Pad, Lot 3M11, expiration 12/06 was found atop the treatment cart. On 12/7/10 at approximately 12:35 PM LPN (Licensed Practical Nurse) # 5 stated that all nurses used products from the treatment cart and confirmed that the Xopenex vials and Povidone Iodine Prep Pads were expired. | 2014-09-01 |
| 9960 | 9960 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 332 | E | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of a medication error rate of five percent or greater. The medication error rate was 7.3% (percent). There were 3 errors observed out of 41 opportunities for error. The finding included: -ERROR # 1: On 12/7/10 at approximately 9:38 AM, during observation of medication pass on Sweet Bay, Licensed Practical Nurse (LPN) # 1 handed a [MEDICATION NAME] Inhaler to Resident A without shaking the inhaler or providing instruction to Resident A. Resident A took two puffs from the inhaler with approximately 5 seconds between puffs. During medication reconciliation on 12/7/10 at approximately 2:00 PM, the physician's order [REDACTED]. However, the Drug Facts and Comparisons states that the [MEDICATION NAME] Inhaler should be shaken for 10 seconds before administration and in reference to administration technique for aerosol inhalers: " Allow greater than or equal to 1 minute between inhalations (puffs). " On 12/7/10 at approximately 3:30 PM LPN # 1 verified that the [MEDICATION NAME] Inhaler had not been shaken, that no instruction had been given to Resident A and that Resident A had not waited a sufficient amount of time between inhalation. During an interview on 12/8/10 at approximately 5:00 PM, LPN # 4 stated that she administers [MEDICATION NAME] Inhaler to Resident A and that she waits a minute between inhalations. -ERROR # 2: On 12/7/10 at approximately 4:47 PM, during observation of medication pass on Sweet Bay, LPN # 2 stated that she would not administer [MEDICATION NAME] 6.25 mg. (milligrams) to Resident B due to a low blood pressure reading of 102/61. During medication reconciliation on 12/7/10 at approximately 5:00 PM, the physician's order [REDACTED]. During an interview on 12/7/10 at approximately 5:10 PM, the Director of Nursing stated that a medication hold o… | 2014-09-01 |
| 9961 | 9961 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 441 | D | 0 | 1 | KWBU11 | On the days of the survey, based on observation and interview, the facility failed to assure Personnel must handle, store soiled linens so as to prevent the spread of infection. Soiled linen was observed stored uncovered and over-flowing the storage container. The findings included: During initial tour on 12/7/10 at approximately 8:40 AM a white overloaded soiled linen container was observed in the Sweet Bay Soiled Utility Room. The soiled linen container was uncovered and over-flowed approximately 18-inches above the top of the container. Repeated observations on 12/7/10 at approximately 11:30 AM, 12:45 PM, 3:10 PM and 3:55 PM found that the overloaded soiled linen container remained uncovered and had not been removed from the Soiled Utility Room. During interviews on 12/8/10 at approximately 6:50 PM, the DON (Director of Nursing) stated that soiled linen containers should be covered and the Administrator stated that the Laundry is responsible for removing soiled linen daily at 8:00-8:30 AM and 1:30-2:00 PM. | 2014-09-01 |
| 9962 | 9962 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 156 | C | 0 | 1 | KWBU11 | On two days of the survey, based on observations, interview, and review of "Residents Rights" in the facility's Admission Packet, the facility failed to prominently display written information on how to receive refunds for previous payments of Medicare benefits. The findings included: On two days of the survey, written information of how to receive refunds for previous payments covered by Medicare benefits had not been prominently displayed. Random observations on 12-07-10 and 12-08-10 of a posting observed on the bulletin board in the facility entrance foyer revealed no information on how to receive refunds for previous payments covered by Medicare. During an interview on 12-08-10 at approximately 1:40 PM with the Director of Social Services, she revealed she did not know refund information for previous payments of Medicare benefits had to be prominently displayed. Review of "Residents Rights" in the facility's Admission Packet stated,"The facility must prominently display in the facility written information and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits". | 2014-09-01 |
| 9963 | 9963 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 279 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to develop an Initial Care Plan that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 new residents. Resident #4 did not have an Initial Care Plan developed. The findings included: The facility admitted Resident #4 on 12-01-10 with [DIAGNOSES REDACTED]. Record review on 12-08-10 at approximately 1:00 PM revealed an Initial Care Plan had not been developed. During an interview on 12-08-10 at 1:15 PM with Licensed Practical Nurse (LPN) #2, she, after record review, confirmed an Initial Care Plan had not been developed. She further revealed she was responsible for developing the Initial Care Plan and stated, "I'll write one right now". | 2014-09-01 |
| 9964 | 9964 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 281 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to clarify an allergy discrepancy for 1 of 9 residents reviewed for admission criteria. Professional standards of quality were not met for admission criteria for Resident #4 when nursing failed to identify The findings included: The facility admitted Resident #4 on 12-01-10 with [DIAGNOSES REDACTED]. Record review on 12-07-10 at 5:25 PM of Resident #4's record revealed the record did not have an allergy sticker. Review of the Face Sheet revealed in the Allergy section "No allergies". Record review of the History and Physical dated 12-01-10 revealed documentation of allergies to [MEDICATION NAME] ([MEDICATION NAME]), Horse Serum, and Anti-Depressants. During an interview on 12-07-10 with the Assistant Director of Nursing (ADON), she, after chart review, confirmed the allergies were not listed on the Face Sheet. Record review of the Patient Transfer Form dated 12-01-10 revealed documentation in the section "Important Medical Information" of allergies to Horse Serum and Antidepressants. Additional record review revealed documentation of allergy to [MEDICATION NAME] on the ...... Regional Medical Center Transfer Medication Summary dated 12-01-10. Record review on 12-08-10 at 4:00 PM of the Treatment Record and Medication Administration Record [REDACTED]. During an interview on 12-08-10 at 4:00 PM with the ADON, she, after chart review, confirmed the above findings. She further stated she was responsible for ensuring allergies were listed correctly on the Face Sheet. The ADON proceeded to put an allergy sticker on the chart with documentation of all of Resident #4's allergies and to update the Face Sheet for allergies. | 2014-09-01 |
| 9965 | 9965 | THE PRESTON HEALTH CENTER | 425325 | 87 BIRD SONG WAY | HILTON HEAD ISLAND | SC | 29926 | 2010-12-09 | 325 | D | 0 | 1 | KWBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status related to body weight. The facility failed to document the percentage of snack intake daily for Resident #2 with trending weight loss. The findings included: The facility admitted Resident #2 on 11-19-10 with [DIAGNOSES REDACTED]. Record review on 12-07-10 at approximately 3:21 PM of the physician's orders [REDACTED]. Record review of the Dietary Progress Notes dated 11-24-10 revealed "5 Day Assessment. Weight 136.9 pounds (#) at admission. Per os (PO) 25-50 percent (%). Per nursing-not eating well". Record review of the Nutrition Risk assessment dated [DATE] revealed Skin Condition as "Stage 2: Coccyx, Sacrum area". The Nutrition Risk Assessment further noted current body weight as 132.1 # and usual body weight as 136.9# at admission. The Weight Trend revealed a trend of "Weight Loss". The Comments section noted "Per os (PO) limited. Weight (wt) trending down. Noted alteration in skin integrity". Record review of Resident #2's Nutrition assessment dated [DATE] revealed "Weight Goal: prevent further loss". In the Nutrition [DIAGNOSES REDACTED]. The Nutrition Assessment further noted in section "Nutritional Goals: Weight decreased 3.5% since admission. Interventions in place for wounds, poor appetite-on [MEDICATION NAME], receiving Multivitamins and Med Pass. Record review on 12-08-10 at 11:15 AM of the Medication Administration Record [REDACTED]". The following was revealed: 12-03-10: no documentation, 12-04-10: no documentation, 12-05-10: no documentation, and 12-06-10: no documentation. During an interview on 12-08-10 at 12:45 PM with the ADON, she, after chart review, verified the above findings and stated, "I'll check into this". | 2014-09-01 |
| 10168 | 10168 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 281 | K | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on chart reviews, interviews, review of The South Carolina State Board of Nursing Advisory Option # 9 B, and review of the facility policies, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident reviewed with a PICC (Peripheral Inserted Central Catheter) line (Resident # 11). The facility nurses failed to clarify with the Physician a discontinued order related to flushing a PICC line. In addition, LPNs (Licensed Practical Nurses) documented that they administered medications through the PICC line with no documentation of advanced training and there was no RN (Registered Nurse) on site when the LPN administered the medications via the PICC line. The facility nurses failed to document consistently that they were flushing the PICC line and failed to note medications used for the flush were taken from a container of expired [MEDICATION NAME] Lock Flushes with a large number of expired [MEDICATION NAME] syringes. In addition the facility nurses failed to recognize signs and symptoms of infection of a surgical wound in a timely manner for Resident # 11, which delayed treatment. The findings included: The facility originally admitted Resident # 11 on [DATE] and after a brief hospital stay readmitted Resident #11 on [DATE] with diagnoses, which included Aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. On [DATE], review of the progress notes revealed that on [DATE] at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On [DATE] at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On [DATE] at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. Th… | 2014-04-01 | ||
| 10169 | 10169 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 425 | J | GN4K12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, the facility failed to ensure that expired medications were not stored with medications readily available for resident use resulting in expired Heparin Lock Flush available for use. Seventy Five of 79-3 millimeter Heparin Lock Flushes, were observed in the medication room with expiration dates prior to the survey, an additional 30 were found 12/13/2010 in the bio-hazard container with an expiration date of 8/1/2010 and 2 used Heparin 3 millimeter syringes were found in the sharps container on 12/13/2010 with expiration dates of 8/1/2010 and 11/1/2010. One of one resident sampled with a Peripherally Inserted Central Catheter (PICC), Resident #11, had a IV flush daily with a Heparin Lock Flush ordered. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on 11/16/2010 with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc Heparin Once a Day at 8PM, start date 11/16/2010". On 12/8/2010, during observation of the facility's medication room, expired supplies were noted to be in the same area as the supplies used for resident care. The medication room contained 14-3 ml. Heparin Lock Flush syringes expired 8/1/2010; 60-3 ml. Heparin Lock Flush expired 11/1/2010 and 1-3 ml. Heparin Lock Flush syringes expired 10/20/2010. The Heparin Lock Flushes were observed to be in an open brown cardboard box, sitting on a cart to the right as you entered the medication room. At 10:45 AM on 12/8/2010, expired items (Heparin Lock Flushes) in the medication room were verified by LPN #1 who then removed them from the medication room. LPN #1 stated all nurses were responsible for ensuring any expired meds were removed from the medication room, but there was no system in place to determine when it sh… | 2014-04-01 | ||
| 10170 | 10170 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 490 | K | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Surveys based on observations, interviews and full and/or limited record reviews, the facility's administrator failed to assure that the facility established and maintained services in the building that met Professional Standards of Practice. The administrator failed to develop a system to ensure that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. The findings included: Cross refers to the following citations: 483.20 (k)(3) Professional Standards F281, with a scope and severity of "K" due to facility failure to clarify orders for Peripherally Inserted Central Catheter (PICC Line) Flushes, Licensed Practical Nurses (LPNs) administering Intravenous (IV) medications via PICC Line and [MEDICATION NAME] Flushes without evidence of advance practice certification. 483.30 (b) Nursing Services F354 with a scope and severity level of "F" due to failure to ensure an (RN) Registered Nurse was working 8 consecutive hours every day and the facility employs a full time Director of Nurses not to be shared with another facility. 483.60 Pharmacy Services F425 with a scope and severity level of "J" due to the facility's failure to ensure that expired medications were not stored with medications available for resident use. 483.75 (l) Clinical Records F514 with a scope and severity of "J" due to inaccurately documenting Medication Administration Records (MARs). Interview with the Nursing Home Administrator was held on 12/8/2010 and again on 12/13/2010. The Nursing Home Administrator confirmed the Director of Nursing was shared with the Senior Community Assisted Living Facility. Time sheets were provided to the surveyors and did reveal there were dates without 8 consecutive hours of RN coverage. The NHA also confirmed that there was not a security feature on the electronic records and if the nurse did not completely log off before … | 2014-04-01 | ||
| 10171 | 10171 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 514 | J | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on full and/or limited record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to "Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc [MEDICATION NAME] Once a Day at 8PM, start date [DATE]". On [DATE], review of Resident #11's Medication Record (MAR) revealed 4 dates, [DATE], [DATE], [DATE] and [DATE], which indicated that Licensed Practical Nurses (LPNs) had administered IV antibiotics and IV flushes via a Peripherally Inserted Central Catheter (PICC) Line. During an interview with one of the LPN's that signed off the MAR indicated [REDACTED]'s antibiotic and both saline and [MEDICATION NAME] flushes through the resident's PICC line and that she had advanced training and certification to allow her to administer medications via a PICC Line. On [DATE], during an interview with the facility's Administrator, the Administrator stated that there was a "glitch" in the e-mar (electronic) record keeping system that inserted the wrong nurse's initials onto the MAR. She stated that if the nurse did not log out completely when the shift ended there was no security system that would log them out after a certain time had passed with no activity on the part of the staff member. The Administrator did state the nurses were just not taking the time to log out completely and that when medications were given it would be documented as the wrong nurse having administered the medication. She did state t… | 2014-04-01 | ||
| 10172 | 10172 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 272 | D | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review, interview and review of the facility's policies entitled Smoking, the facility failed to assess for safety in a timely manner Resident #3. Resident #3 was 1 of 1 sampled resident observed while smoking. The findings included: The facility admitted Resident #3 on 9/28/2009 and readmitted her on 11/14/2009 with [DIAGNOSES REDACTED]. On 12/7/2010 at 3:00 PM, during the review of Resident #3's medical chart, the smoking assessments were reviewed. The chart contained a smoking assessment dated [DATE]. The surveyor could locate no other assessments related to smoking. When the surveyors asked Licensed Practical Nurse (LPN) #3 if staff accompanied residents outside to smoke, she stated no. When asked if the residents kept their smoking materials with them, LPN #3 stated that the smoking materials were locked in the Medication Room and that the residents asked for them when they went outside to smoke and returned them to the nurses when they came back inside. At 3:55 PM on 12/7/2010, during an interview with the Director Of Nursing (DON), she verified that there had been no smoking assessment completed on Resident #3 since 10/6/2009. Review of the resident's medical chart revealed that on 8/4/2010 her cognitive status was assessed as 0100 and on 11/2/2010 as 0110 indicating a change in cognitive status. The DON also stated that the facility policy does not require assessments unless the resident has a change in condition. Review on the facility's policy entitled "Smoking" revealed no information related to smoking assessments. | 2014-04-01 | ||
| 10173 | 10173 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 441 | F | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on record reviews, interviews, review of the facility's Infection Control Logs and the facility's policy and procedure entitled Infection Control Program, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility also failed to ensure that expired [MEDICATION NAME] Lock Flushes (3 millimeter (ml), 100 unit (u)/ml (75 of 79), Intravenous (IV) supplies (3 start kits), 1 Biopatch Antimicrobial Dressing, and Vacutainer's (3) were not stored in an area away from resident use items. The findings included: On 12/7/2010, review of the facility's Infection Control Logs revealed that the facility logged resident's who were prescribed antibiotics (Abt.). On 12/8/2010 at 12:45 PM, during an interview, the Director of Nursing (DON) was asked if the facility logged Gastrointestinal illness (vomiting and diarrhea) and Multi Drug Resistant Organisms (MDROs). The DON stated that the facility only logged residents on Abt. (antibiotic) therapy. When asked if the facility tracked and trended to recognize outbreaks and potential educational needs, the DON stated no. Review of the facility's policy and procedures entitled Infection Control Program revealed "I. GOALS: The goals of the Infection Control Program are to: A. Decrease the risk of infection to residents and personal. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection control practices. D. Insure compliance with state and federal regulations relating to infection control. II. Scope of the Infection Control Program. The Infection Control Program is comprehensive in that it address detection, prevention and control of infections among residents..." On 12/8/2010, during observation of the fa… | 2014-04-01 | ||
| 10174 | 10174 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 500 | C | GN4K11 | On the days of the Recertification and Extended Survey, based on record reviews and interviews, the facility failed to provide a contract for emergency dental services for the residents. The findings included: On 12/9/2010, review of the facility's required contracts, the facility failed to provide a contract for emergency dental services. In an interview with the Nursing Home Administrator, the Administrator stated that the facility did not have a dental contract. No signed dated contract for dental services was provided prior to the survey team exiting the facility on 12/13/2010. | 2014-04-01 | ||
| 10175 | 10175 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 156 | C | GN4K11 | On the days of the Recertification and Extended Survey, based on observations and interview, the facility failed to post how to apply for Medicaid and how to apply for refunds from Medicare. In addition, the facility failed to post how to contact the Department of Environmental Control (DHEC). The findings included: On 12/7/2010 and 12/8/2010, observations revealed that the facility failed to post how to apply for Medicaid and how to apply for a refund from Medicare. In addition there was no posting related to how to contact DHEC. Interview with the facility Administrator on 12/8/2010 at approximately 5:00 PM, revealed that she was unaware that the facility did not have the information posted. She confirmed that the information was not posted. The Administrator stated that the information must have been taken down during renovations of the facility and not re-posted. | 2014-04-01 | ||
| 10176 | 10176 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 157 | G | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to notify the attending Physician of the signs and symptoms of an infected surgical wound for one of one resident reviewed with an infected surgical wound. (Resident # 11) The findings included: The facility admitted Resident # 11 on 11/1/2010 with diagnoses, which included aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. Resident #11 was re-admitted [DATE] after a hospital stay. On 12/8/2010, review of the progress notes (nurses notes) revealed that on 11/4/2010 at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On 11/5/2010 at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On 11/6/2010 at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on 11/8/2010 LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On 11/8/2010 an order for [REDACTED]." Interview with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on 11/5/2010 and that the resident's MD (in addition to the resident' attending physician this was also the facility's Medical Director) had not been notified of the change of condition of the wound until 11/8/2010 which resulted in a delay in treatment. On 11/12/2010 the resident was transferred to the hospital at 5:00 AM for Incision and Drainag… | 2014-04-01 | ||
| 10177 | 10177 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 159 | D | GN4K12 | On the days of the Recertification and Extended Survey, based on review of the facility's petty cash fund and interview, the facility failed to adhere to acceptable accounting practices for three of three resident's funds that were reviewed. The findings included: On 12/8/2010, interview with the facility's Business office person # 1, revealed that the facility accepted monies of "less than $50.00 dollars" and kept this in petty cash. Review of the accounting for the funds revealed that Resident # 1's account did not accurately reflect the amount of money that the resident had in petty cash. Review of Resident # 5 accounting of funds, revealed that a receipt from Walgreen ' s for $1.06 however there was no request/authorization for the funds to be spent from the resident/responsible party.Review of Resident A's accounting of funds revealed a receipt for Walgreen ' s for $17.00 dollars and no request/authorization for the funds to be spent from the resident/responsible party.Business office person # 1 confirmed this. | 2014-04-01 | ||
| 10178 | 10178 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 315 | E | GN4K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record reviews, observation and review of the facility procedure for suprapubic catheter care, the facility failed to provide appropriate catheter care for two of two residents reviewed for catheter care. During Residents' # 2 and # 4 suprapubic catheter care, the facility staff failed to provide treatment in a manner that would prevent possible infection and failed to follow Physician orders [REDACTED]. The findings included: The facility readmitted Resident # 2 on 2/8/2008 with diagnoses, which included Urinary Tract Infection, [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 12/8/2010 at approximately 3:00 PM, LPN (Licensed Practical Nurse) # 2 was observed to perform suprapubic catheter care on resident # 2. The nurse failed to wash her hands prior to donning gloves and was observed to use her gloved hand to turn on the faucet and run water into a basin. She placed the basin on the resident's overbed table, returned to the bathroom and using her right gloved hand dispensed soap onto a hand towel touching the trigger of the wall soap dispenser. LPN # 2 draped the resident with a towel. There was no dressing around the insertion site and the left side of the insertion site was observed to have a small amount of red tinged drainage. Using the hand towel, LPN # 2 cleaned around the catheter insertion site with a back and forth motion without changing position of the hand towel. Next LPN # 2 cleansed down the catheter tubing. LPN # 2 placed the hand towel back into the hand basin filled with water and was observed to use the same towel and again used a back and forth motion around the insertion site without changing position of the hand towel and then wiped down the catheter tubing. Bright red tinged drainage was observed on the right side of the catheter site. LPN # 2 returned the hand towel to the basin and picked up the towel she had used to drape the resident and using the sid… | 2014-04-01 | ||
| 10179 | 10179 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2010-12-13 | 354 | F | GN4K12 | On the days of the Recertification and Extended Survey, based on observation and interviews, the facility failed to have a RN (Registered Nurse) on duty for eight consecutive hours daily. In addition, the facility failed to employ a full time DON (Director of Nurses). The findings included: Review of the facility staffing revealed that on the following days that the facility failed to have a RN on duty for eight consecutive hours daily:10/23/ 1/6/ 1/13/ 1/20/ 2/4/2010 Interview with the facility administrator and the DON on 12/8/10 confirmed that the facility did not have the correct RN coverage on the above dates. In addition, the Administrator stated the DON did not work full time for the skilled area; that she also had duties for the Assisted Living area. | 2014-04-01 | ||
| 9925 | 9925 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2010-12-15 | 225 | D | 0 | 1 | GFU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to assure an allegation of physical/verbal abuse was thoroughly investigated and reported to the appropriate state agency. Resident #3, (1 of 6 residents reviewed for abuse and neglect) reported an alleged incident of physical/verbal abuse. There was no evidence the allegation was thoroughly investigated and reported to the appropriate state agency. The findings included: The facility admitted Resident #3 on 5/5/10 with [DIAGNOSES REDACTED]. On 12/1510 at 11:15 AM, an individual interview was conducted with Resident # 3 by this surveyor. During the interview, Resident #3 stated a facility staff member had been rude, yelled at her and had "jerked" her during care. During a subsequent interview with the Administrator on 12/15/10, she stated that the Ombudsman had visited with residents and that Resident #3 had reported to the Ombudsman the alleged incident which occurred around three months ago. The Administrator also stated that after talking with Resident #3, she was able to determine what staff member could have been involved. The staff member was employed only on an "as needed" basis. After speaking with the Director of Nursing, it was decided not to schedule that particular staff member again. When asked if the incident had been reported to the State Survey Agency - Certification, the Administrator stated, "No." Review of the facility policy titled "Abuse Investigations" listed the following: Policy Statement - "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 3) The Director of Nursing will complete and submit the Resident Abuse Report Form to the Office of Certification within 24 hours or next business day." | 2014-09-01 |
| 9926 | 9926 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2010-12-15 | 441 | D | 0 | 1 | GFU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview and review of facility policy for handwashing, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. During observation of a pressure sore treatment for [REDACTED]. Additionally, after placing biohazard material in the biohazard room, the staff member did not wash her hands. The findings included: The facility admitted Resident #1 on 11/29/10 with [DIAGNOSES REDACTED]. During observation of a pressure sore treatment on 12/14/10 at 11:27 AM, Registered Nurse (RN) #1 was observed to reach into a paper container of 4 x 4"s with her soiled gloved hand, thereby contaminating the clean dressings. After the treatment was completed, RN #1 bagged the trash in a biohazard bag, entered the biohazard room and discarded the contents. RN #1 exited the biohazard room, entered the resident's room and began to transport the resident to an activity without washing her hands. During an interview with RN #1 on 12/15/10 at 12:25 PM, she stated that hand sanitizer was used after tying up the soiled bag, but could not remember if she had washed her hands before entering the patients room after exiting from the biohazard room. The facility provided policy for Hand Hygiene stated: "Hand hygiene continues to be the primary means of preventing the transmission of infection.....some situations that require hand hygiene.....before and after direct resident contact...." | 2014-09-01 |
| 9927 | 9927 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2010-12-15 | 156 | C | 0 | 1 | GFU911 | On the days of the survey, based on review of residents' funds and interview, the facility failed to complete 3 of 3 mandated Liability Notices in a timely manner. The findings included: During review of residents' funds on 12-15-10 at approximately 2:45 PM with the Minimum Data Set (MDS) Coordinator, she confirmed 3 of 3 mandated Liability Notices reviewed had not been completed. | 2014-09-01 |
| 10137 | 10137 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 502 | D | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on limited record review, and interview the facility failed to provide laboratory services to meet the needs of its residents in a timely manner for 1 of 3 residents reviewed for laboratory services. Resident #1 with documented [MEDICAL CONDITION] of the external genitalia; waist and legs had a physician's orders [REDACTED]. The CMP and BMP were not drawn. The findings included: Resident #1 admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed nurses' notes dated 10/06/2010 at 11:00 AM which stated, "...increased [MEDICAL CONDITION] notified Dr. ... N.O. (new order) 40 mg (milligrams) [MEDICATION NAME] IM (intramuscularly) now then 80 mg [MEDICATION NAME] PO (by mouth) BID (twice a day) x 1 week then resume 80 mg [MEDICATION NAME] PO QD (daily), CMP BMP on 10-13-10..." In a telephone interview with the Director of Nurses on 12/15/2010 at approximately 10:00 AM she stated that the CMP and BMP were not drawn, that she thinks the nurse who took the order failed to transfer it to a lab requisition. | 2014-04-01 | ||
| 10138 | 10138 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 157 | G | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review and interview the facility failed to consult the resident's physician regarding persistent pain and swelling following an injury to Resident #2 left arm/hand/wrist. The resident fell on [DATE], the facility notified the physician and an order was obtained for an x-ray of the hand/wrist. Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The findings included: Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NA… | 2014-04-01 | ||
| 10139 | 10139 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2010-12-15 | 309 | G | OVIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, interview and record review, the facility failed to provide care and services to maintain the highest practicable physical well being for 1 of 3 residents reviewed for a change in condition. Resident #2 injured her left arm/hand/wrist on 11/24/2010, and was not treated for [REDACTED]. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: "11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to … | 2014-04-01 | ||
| 10162 | 10162 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 281 | K | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies for Change of Condition and Laboratory Services, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.20 F-281 at a scope and severity of "K", starting 9/12/10. The facility Nursing staff repeatedly failed to identify a delay in the receipt of laboratory tests and subsequently failed to contact the attending physicians in a timely manner to obtain further medical direction for the assessment, monitoring and treatment of [REDACTED]. Residents # 1, 4, 5, 6, 7, 14, 15, 21,and 29 were 9 of 22 sampled residents reviewed for professional standards related to physician notification of laboratory results who were found to be affected by the deficient practice. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no… | 2014-04-01 | ||
| 10163 | 10163 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 505 | K | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.75 F-505 which was identified at a scope and severity of "K" which began on 9/12/10. The facility failed to assure laboratory test results were returned to the facility in a timely manner and promptly provided to the physician to use for assessment, diagnoses, treatment and initiation of appropriate infection control practice. The systematic failure to provide lab services and notify the physician promptly placed residents at risk for serious harm. The immediate jeopardy was not removed upon exit from the facility. Residents #'s 1,4,5,6,14,15,21 and 29 who were 8 of 22 sampled residents reviewed for Physician notification of lab services were identified with concerns related to physician notification resulting in a delay of treatment. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16… | 2014-04-01 | ||
| 10164 | 10164 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 153 | G | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers rega… | 2014-04-01 | ||
| 10165 | 10165 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 225 | D | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey and complaint investigations, based on review of the facility's investigation into allegations of abuse and/or neglect, the facility failed to thoroughly investigate 2 of the 5 allegations reviewed (Residents #24 and #26). The findings included: Resident #24 with [DIAGNOSES REDACTED].#4. A day shift CNA reported that same day that the resident was found on several mornings with soaked and/or stained linens. The facility obtained statements from the resident's roommate, the accused CNA, and one other CNA assigned to provide care to the resident on one of the "several" 11-7 shifts. The facility failed to investigate to determine the exact dates of the alleged verbal abuse and the exact dates of the alleged neglect of the resident. Their investigation failed to show evidence that other staff members were interviewed concerning the allegations in an effort to identify other potential perpetrators or witnesses to the alleged abuse and neglect. Resident #26 was admitted with [DIAGNOSES REDACTED]. Review of the facility's "Initial 24-Hour Report" dated 12/02/10 and the "Five-Day Follow-Up Report" dated 12/08/10 revealed the alleged perpetrator CNA (Certified Nursing Aide) #13 was not interviewed related to allegation of abuse. Further review of the completed investigative report submitted by the facility revealed that no one at the facility attempted to interview CNA #13. Review of the facility policy on Abuse and Neglect in the "INVESTIGATING" under page 1 of 3 #1 *"Investigation documentation will include, but not be limited to, the following: "Date and time of the alleged occurrence. Patient/resident's full name and room number. Names of the accused and any witnesses. Names of the healthcare center/agency staff who investigated the allegations. Any physical evidence and description of emotional state of patient/resident (s). Details of the alleged incident and injury. Signed statements from pertinent parties." On page 2 … | 2014-04-01 | ||
| 10166 | 10166 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 498 | F | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, review of staff development records, review of the facility policy entitled "NURSING: PERINEAL CARE" (revised 4/07),the facility provided policy for Handwashing and review of the South Carolina Nurse Aide Candidate Handbook (January 2010), the facility failed to ensure that nurse aides were able to demonstrate competency related to implementation of infection control precautions in the provision of incontinent care. Nurse Aides failed to provide appropriate care and services to prevent infections for 13 of 20 residents (Residents #1, #5, #14, #15, #16, #17, #18, #19, #20, #30, #31, #32, #34) during 14 observations for incontinent care. Deficient practice and substandard quality of care was identified (CFR F- 315) during provision of incontinent care by nine of eleven Certified Nursing Assistants (CNAs) on two of three shifts and on three of three nursing units. The findings included: The facility admitted Resident #20 on 11-27-09 with Chronic [MEDICAL CONDITION] and multiple cormorbidities. During observation of incontinent care on 12-13-10 at 5:10 AM, after Certified Nursing Assistants (CNAs) #9 and #10 washed their hands and applied gloves, CNA #10 uncovered the resident from waist to feet and detached his incontinent brief. CNA #9 was unable to locate supplies at the bedside to provide incontinent care. She removed her gloves and left the room to obtain disposable wipes. CNA #9 reentered the room, applied gloves without washing her hands, and proceeded to provide care to the resident who had been incontinent of urine and feces. CNA #9 used one disposable wipe to cleanse both upper inner thighs and groin areas, then the penis, without changing the position of the cloth. When cleansing the penis, the CNA wiped down the shaft, toward the urethra, then cleansed the glans penis. The resident was positioned onto his right side and the CNA proceeded to cleanse the perianal area and but… | 2014-04-01 | ||
| 10167 | 10167 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 441 | F | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the facility policy and procedure related to Infection Control, the facility failed to establish and maintain an effective Infection Control Program. The facility failed to maintain accurate records of infections to determine tracking and trending by resident and organism. (Resident # 30) The facility failed to initiate transmission based precautions in a timely manner for Resident # 21 with a known drug resistant respiratory infection who was located in a multi-bed room; Resident personal equipment was not labelled for individual use; Oxygen equipment was not maintained in a sanitary manner for Resident # 32; and 1 of 3 housekeeping staff was not knowledgeable in housekeeping procedures required to clean resident room who were on isolation. The facility failed to ensure staff used appropriate handwashing during resident care. The facility failed to handle soiled linen in a way which prevented the spread of infection as observed during resident care and observation of the laundry process. The findings included: During Initial Tour of the facility on 12-13-10 at approximately 5:05 AM, this surveyor observed Certified Nursing Assistant (CNA) # 7 coming out of room # 117 with a bag of soiled linen. CNA # 7 went into the soiled utility room, placed the linen in a linen barrel, left the room, and went into the clean linen room. She then proceeded to obtain clean linen and returned to room # 117 to make up the bed. CNA # 7 did not wash her hands after disposing of the soiled linen and before she handled the clean linen. At approximately 6:00 AM, CNA # 7 entered room # 113 in response to a call light, and assisted a resident into the bathroom. On the counter beside the sink in the room were two used urinals with no resident identification. CNA # 7 put each urinal into separate bags and set them in the bathroom, The room was occupied by 2 male residents, but the C… | 2014-04-01 | ||
| 10134 | 10134 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 224 | G | 5SHE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record reviews, interviews and review of the facility's Abuse and Neglect policy, the facility failed to assure 3 of 5 sampled residents were free from neglect. Resident #1 and #3's dressings were not changed per the physician's orders [REDACTED]. Resident #2's wound was observed to have a yellow center with dried blood. The findings included: Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. The Annual MDS coded Resident #1 as totally dependent for hygiene, bathing and toileting. Resident #1 was coded as needing extensive assistance with transfers, dressing and eating. No behaviors were coded as occurring during the assessment period. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. The interventions that were in place prior to the incident were "abuse and neglect addressed 10/1/2010 by staff development coordinator." The interventions taken by the facility to prevent future abuse were "facility continues to stress no tolerance for abuse or neglect. Reeducation of staff on abuse/neglect." LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx (treatment) on the opposite hall, and stayed over on Sunday n… | 2014-04-01 | ||
| 10135 | 10135 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 315 | D | 5SHE12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the follow up inspection based on observations, interviews and review of the facility policy on Peri (perineal)-care, Certified Nursing Assistant #1 failed to provide for the dignity of Resident #6 and failed to appropriately provide peri-care for Resident #6. One of two residents observed for peri-care. The findings include: The facility admitted Resident #6 on 12/18/2008 with [DIAGNOSES REDACTED]. During peri-care observation on 2/7/2011, CNA #1 was observed in Resident #6's room removing the resident's pants. The blinds were left open. The curtains were observed to be open as well. The resident's roommate was in bed awake. A grabber was observed in the bed lying along side the resident's left leg. The CNA exposed the resident and wiped the resident's groin and then wiped once down the middle. CNA #2 then closed the blinds and pulled the curtain. CNA #1 then retrieved a clean brief from the resident's closet using the soiled gloves. CNA #1 rolled the resident over onto the metal grabber and placed the clean brief under the resident. CNA #1 still using soiled gloves fastened the brief and dressed the resident. During an interview on 2/7/2011, CNA #1 stated that she did not close the blinds or pull the curtain to provide for the resident's dignity. She also stated that she "forgot" to clean the resident's bottom. CNA #1 confirmed that she did not change her gloves prior to placing a new brief on the resident. CNA #1 stated that she did not recall the last time she was checked off on peri-care competency. Review of the facility's plan of correction revealed that CNA#1 was checked off on competency on peri-care on 1/6/2011. No concerns were noted at that time. Review of the facility's policy on Peri-Care revealed the following:..."3. Provides for privacy. 17. Asks resident to lower legs and assume side lying position. Assists as necessary." | 2014-04-01 | ||
| 10136 | 10136 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2010-12-20 | 314 | G | 5SHE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to 3 of 5 sampled resident's wounds. Resident #1 and #3 did not have their dressings changed as ordered. Resident #2 had a dressing on her right lower leg dated 12/6/2010; the dressing was observation on 12/20/2010. The findings included: The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. On 11/22/2010 LPN #3 removed dressings from Resident #1's coccyx and right inner ankle dated 11/19/2010; daily dressing changes were ordered. LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she "had done all of my treatments. I done (sic) some extra tx on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse." LPN #3's facility obtained statement dated 11/22/2010 stated, "On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10." Review of the physician's orders [REDACTED]." T… | 2014-04-01 | ||
| 10180 | 10180 | NHC HEALTHCARE - MAULDIN | 425359 | 850 E. BUTLER RD. | GREENVILLE | SC | 29607 | 2010-12-21 | 332 | D | 7CTK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews, the Drug Facts and Comparisons book (updated monthly) and the Drug Information Handbook for Nursing, 8 th Edition, 2007, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The medication error rate was 6.5 percent. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 12/20/10 at 4:29 PM, during observation of medication pass, Licensed Practical Nurse (LPN) #3 was observed to instill one drop of [MEDICATION NAME] Ophthalmic Suspension into each eye of Resident A without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug." During an interview on 12/20/10 at 4:48 PM, LPN #3 confirmed she did not shake the [MEDICATION NAME] Ophthalmic Suspension before instillation into the resident's eyes and further stated that she knew that [MEDICATION NAME] should be shaken. Error #2: On 12/20/10 at 4:53 PM, during observation of medication pass, LPN #4 was observed to prepare and administer 1 [MEDICATION NAME] 150 milligram (mg) tablet and one other medication to Resident #23. Review of the current physician's orders [REDACTED]. [MEDICATION NAME] 150 MG TABLET TAKE 1 THREE TIMES DAILY - REC. (record) PULSE PER POLICY-" LPN #4 was not observed to take the resident's pulse prior to administering the medication. Review of the facility's policy revealed that antiarrhythmic drugs (which included [MEDICATION NAME]) required a daily pulse. During an interview on 12/20/10 at 6:23 PM, LPN # 4 confirmed she had not taken the resident pulse and that there was no place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the pharmac… | 2014-04-01 | ||
| 9639 | 9639 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2011-01-13 | 309 | E | 0 | 1 | CL1611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to administer medications as prescribed by the physician for 1 of 1 residents reviewed with orders for [MEDICATION NAME] (Resident # 2) and 1 of 1 residents reviewed receiving [MEDICATION NAME]. (Resident # 9) The findings included: The facility admitted Resident # 2 on 11-20-05 with [DIAGNOSES REDACTED]. Upon viewing Resident # 2 during the initial tour on 1-12-11 at approximately 1:30 PM, this surveyor noted a large amount of drool on the clothing of the resident. Resident # 2 also had protective clothing to prevent soiling, which staff stated had been supplied by the resident's family. Subsequent review of the Medical Record revealed a physician's orders [REDACTED]. [MEDICATION NAME] Liquid 25 mg (milligrams) via PEG (gastric tube) @ HS (at bedtime)." Review of the MAR (Medication Administration Record) for the months of September and October, revealed that the medication was only documented as having been administered on September 29th, and 30th. The order was not carried forward onto the October MAR, and there was no documentation that the order had been discontinued. On 1-12-11 at 3:30 PM, during an interview with Licensed Practical Nurse (LPN) # 3, she stated that Resident # 2 was not currently on [MEDICATION NAME], but that she had been receiving it prior to a hospitalization in September. Further chart review revealed Resident #2 was in the hospital from 8-31-10 to 9-3-10. During an interview with Resident # 2's Physician on 1-13-11 at approximately 1:45 PM, she stated that she was not aware that Resident # 2 was not receiving the [MEDICATION NAME] as ordered, and she would address the oversight immediately. The facility admitted Resident # 9 on 6-18-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 1-12-11 at approximately 3:45 PM, revealed that the resident had gone to the hospital for treatment of [REDACTED]. The hospital … | 2015-02-01 |
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 );