CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8241 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 225 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interview and record review, the facility failed to report an injury of unknown origin to the appropriate State agency for 1 of 1 sampled residents reviewed with an injury of unknown origin. (Resident #5) The findings included: Resident #5 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 2/27/12 at approximately 2:15pm revealed a nursing note dated 1/3/12 which indicated that the resident was seated in wheelchair in doorway of room with skin tears to arms, knot noted on back of head - sent to ER (emergency room ). Review of Incident report on 2/28/12 at approximately 10:30am indicated that a nurse and CNA (Certified Nursing Assistant) entered room after a loud noise was heard. When asked what had happened, the resident stated he was trying to go downstairs to put out the fire. The incident report did not indicate where in the room the resident was located when found. Review of the resident's most recent Minimal Data Set of 2/14/12 indicated a BIMS (Brief Interview for Mental Status) of 7. A BIMS score of 0-7 indicates severe cognitive impairment. Interview on 2/28/12 with the Administrator indicated that the incident had not been reported any State agency. Communication with the Bureau of Certification Compliant Intake Officer verified that the incident had not been reported to the agency. Based on the information in the nursing notes and the incident report, the occurrence met the definition of an injury of unknown origin. Therefore, it should have been reported to the appropriate State agency within 24 hours of its occurrence and a further investigation should have occurred and been documented. | 2016-06-01 |
| 8242 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 280 | E | 0 | 1 | 5WM211 | **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 review and revise care plans for 4 of 13 resident care plans reviewed. The facility failed to revise the CNA (Certified Nurses Aide) care plan to reflect implemented interventions to prevent falls for Resident #6, failed to update the comprehensive care plan to reflect a fall for Resident #6, failed to update the comprehensive care plan for Resident #5 to reflect implemented interventions to prevent falls, and failed to revise the care plans for Resident #9 and Resident #13 to reflect treated infections. The findings included: The facility admitted Resident #6 on 12/11/07 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 8/22/11 at 5:55 PM indicated Resident #6 sustained a fall to the floor after rolling out of bed. Review of the fall data provided by the facility entitled Falls Screened by Therapy PAR (Patients at Risk) committee revealed that recommendations following the fall included, Recommend resident not be left alone for meals. Further review of the Nurse's Notes dated 11/18/11 at 11:05 AM indicated Resident #6 was found on the floor in front of the wheelchair. The notation stated, Res (resident) appeared to have slide (sic) out of w/c. Record review indicated Resident #6 sustained a [MEDICAL CONDITION] tibia and fibula as a result of the incident. Review of the Therapy Screen dated 11/22/11 indicated interventions included recommend checking regularly for repositioning needs and Recommend Hoyer lift transfer to protect fx. Review of the Falls Screened by Therapy PAR committee data revealed Recommend not leaving resident alone but in-sight of caregivers to identify repositioning needs .Recommend also Hoyer transfers were recommended interventions to prevent further falls. Review of the Nurse's Notes dated 1/07/12 at 8:30 AM indicated, CNA was transferring res from wheelchair to bed when Res slipped and slid to ground on top of CNA. The Therapy Screen following the incident indicated, Recommend Hoyer transfer. Review of Resident #6's comprehensive care plan revealed the fall on 1/07/12 was not documented and was not included under the problem area entitled Falls. Review of Resident #6's KARDEX contained in the CNA Notebook revealed the recommendations following the falls on 8/22/11 and 11/18/11 were not documented on the KARDEX. These recommended interventions included not leaving the resident alone for meals, checking regularly for need of repositioning, and use of Hoyer lift for transfers. Further review indicated the KARDEX form indicated transfer assistance for Resident #6 was Assist of 1. During an interview on 2/29/12 at approximately 3:00 PM, CNA #3 was asked how CNA staff know what type of assistive device or assistance a resident requires for transfers. CNA #3 stated that this information is documented on the CNA KARDEX located in a notebook at the Nurse's Station. CNA #3 reviewed the KARDEX with the surveyor and confirmed that Assist of 1 was documented under Transfer assistance. CNA #3 stated that Resident #6 was to be transferred using a Hoyer lift and referred to a pink, laminated page in the resident's section of the notebook which contained this information. This signage contained no date to indicate when this information was included in the CNA Notebook. During an interview on 2/29/12 at approximately 11:10 AM, the Director of Nursing (DON) and MDS Coordinator were asked to review Resident #6's KARDEX. Both staff members confirmed that the KARDEX indicated Resident #6 was a transfer assist of 1. In addition, both staff members confirmed that the KARDEX did not include information that Resident #6 was not to be left alone for meals, should be checked frequently for repositioning needs, and should be transferred via a Hoyer lift. The DON and MDS Coordinator were asked to review the page in the CNA Notebook which indicated Resident #6 was to be transferred via a Hoyer lift. When asked when this information was included in the CNA Notebook, the DON stated that this information was included after the fall on 1/07/12 but was not included prior to this incident. During an interview on 2/29/12 at approximately 2:45 PM, the MDS Coordinator was questioned about the process for updating care plans. The MDS Coordinator indicated that information is obtained from physician's orders [REDACTED]. The MDS Coordinator indicated that both the comprehensive care plans and CNA care plans are updated using this information. Resident #5 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 2/27/12 at approximately 2:15pm indicated the resident had fallen on 1/3/12, 1/4/12, 1/6/12, 1/10/12, and 1/30/12. Review of the current Care Plan revealed that it did not reflect that the falls had occurred or the interventions that were put into place to prevent further falls. Resident #9 was re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review on 2/28/12 at approximately 10:10am revealed a physician's orders [REDACTED]. A second physician's orders [REDACTED]. Review of current Care Plan revealed that it did not reflect the infection or the interventions put into place. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 2/28/12 at approximately 4:10pm revealed a physician's orders [REDACTED]. A second physician's orders [REDACTED]. A third physician's orders [REDACTED]. Review of the current Care Plan revealed that it did not reflect the infections or the interventions put into place. Interview on 2/29/12 at approximately 11:10am with the MDS Coordinator and Director of Nursing indicated that the above three Care Plans had not been updated to reflect the changes in the residents status or the interventions put into place to correct or prevent future occurrences. | 2016-06-01 |
| 8243 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 315 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview and review of the facility's policy Catheter Care, the facility failed to ensure that 1 of 3 residents received appropriate catheter care. For Resident #3, Certified Nurse Assistant (CNA) failed to separate and cleanse the labia. The finding included: The facility admitted Resident #3 on 1-7-09 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. On 2-29-12 at 11:38 AM, during an observation of Resident #3's Foley catheter care, CNA #4 anchored the catheter tubing at the urinary meatus with her left hand. She then used 3 sanitary swabs to wipe only the catheter tubing. The CNA did not separate the labia to assure thorough cleansing. On 2-29-12 at 11:49 AM, during an interview, CNA #4 verified she had only cleaned the catheter tubing. Review of the facility policy entitled Catheter Care states under Procedure, Female Residents: Spread the labia, using the first swab cleanse down the one side of the labia, second swab cleanse down the other side, use third swab, starting at the urinary meatus and clean down catheter tubing rotate swab and clean opposite side of the tubing. | 2016-06-01 |
| 8244 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 322 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interview and record review, the facility failed to administer the amount of tube feeding formula and water flush as ordered for 5 feedings over a 2 day period for Resident #2, 1 of 2 residents sampled for Percutaneous Gastrostomy Tube (PEG) feedings. The findings included: The facility admitted Resident #2 on 12/13/11 with [DIAGNOSES REDACTED]. On 2/28/12 at 9:52 AM, Licensed Practical Nurse (LPN) #3 was observed administering the tube feeding and water flush to Resident #2. After checking the Medication Administration Record, [REDACTED]. After washing her hands, donning gloves and verifying placement, the LPN flushed the PEG tube with 30 ml of water. She poured 60 ml of Glucerna 1.5 into the syringe and allowed to flow via gravity. She then poured an additional 60 ml into the syringe and allowed to flow, added an additional 5 ml of formula then followed with an additional 30 ml of water to flush the tube. Record review on 2/28/12 at 3:40 PM revealed a Physician's Telephone Order dated 1/31/12 that read Per Dietary Rec(ommendation) - (Change) TF (tube feeding) to bolus 1 can Glucerna 1.5 @ (at) 9A, 1P and 6P and follow with 125 cc (cubic centimeters) H2O (water) flush. Further review revealed the order had been carried over to the February 1-29 monthly physician's orders [REDACTED]. During an interview on 2/28/12 at 4:45 PM, LPN #3 confirmed that she had given a total of 125 ml of tube feeding and a total of 60 ml of water to flush. After reviewing the MAR indicated [REDACTED]. | 2016-06-01 |
| 8245 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 369 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation, the facility failed to provide adaptive feeding equipment for 1 of 1 sampled residents with orders for adaptive equipment. The facility did not provide Resident #6 with the angled spoon per physician's orders [REDACTED]. The findings included: The facility admitted Resident #6 on 12/10/07 with [DIAGNOSES REDACTED]. Review of the February 2012 physician's orders [REDACTED]. Further record review revealed a Physician's Telephone Order dated 5/23/11 for an angled spoon. Review of the Nutrition Risk assessment dated [DATE] indicated an angled spoon was listed as an adaptive device to be used for Resident #6. Observation of the lunch meal on 2/28/12 at approximately 12:30 PM and the dinner meal on 2/28/12 at approximately 5:45 PM revealed Resident #6 sitting at a table eating in the dining room. Observation indicated that Resident #6 was provided a built-up fork for both meals. This was the only eating utensil provided by staff for both of the meals. Review of the dietary tray card revealed a photo of adaptive equipment which did not include an adaptive spoon. On 2/29/12 at approximately 4:00 PM, the Certified Dietary Manager (CDM) reviewed the dietary card and order for angled spoon. The CDM confirmed that the dietary card did not correctly indicate that the angled spoon was to be provided. | 2016-06-01 |
| 8246 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 425 | D | 0 | 1 | 5WM211 | 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 in 1 of 3 medication rooms. The findings include: On 2/27/12 at approximately 10:45 AM, inspection of the Riverside (D Wing) medication room refrigerator revealed the following: -One opened vial of Novolog Insulin 100 U (units)/1 ml (milliliter), Lot AZF0366, Prescription 848, dispensed 1-19-12 and belonging to Resident A had not been labelled as to the date it was opened. -One opened vial of Novolog Insulin 100 U/1 ml, Lot AZF0333, Prescription 976, dispensed 12/15/11 and belonging to Resident B had not been labelled as to the date opened. These findings were verified by LPN (Licensed Practical Nurse # 2) who stated that they should have been dated when opened. The manufacturer, Novo Nordisk, states in the package insert that Novolog Insulin should be discarded 28 days after opening. | 2016-06-01 |
| 8247 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 441 | E | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record review, the facility failed to implement all components of the infection control program. The facility failed to have a process to comply with State Laws and Regulations for reporting communicable diseases and outbreaks and failed to monitor that staff observed transmission based precautions. The facility also failed to ensure that expired instant hand sanitizers were not being stored in 2 of 3 medication rooms and were not being used during patient care on 3 of 6 medication carts. The findings included: Review of the facility's Policy and Procedure Manual revealed no list of Reportable Conditions or communicable diseases to be reported in accordance with State Laws and Regulations. During an interview on [DATE] at approximately 11:30 AM, the Infection Control Nurse stated she didn't know where the list might be. She stated she hadn't seen one and did not know what conditions or communicable diseases were reportable. Review of the infection surveillance logs indicated the facility had 4 ESBL (Extended-Spectrum Beta-Lactamase) infections in the month of January, 2012. The Infection Preventionist was not able to state whether that would constitute an outbreak of a communicable disease and stated she would have to research it. On [DATE] during initial tour, Resident #11 was noted to be on transmission-based precautions. Licensed Practical Nurse (LPN) #3 stated the resident was on contact isolation. Record Review on [DATE] at approximately 10:30 AM revealed the resident had a Culture and Sensitivity on [DATE] which was positive for [DIAGNOSES REDACTED] Pneumoniae ESBL and antibiotic therapy and isolation precautions were ordered on [DATE] when the results were received. At 6:15 PM on [DATE], Certified Nursing Assistant (CNA) #2 was observed delivering the evening meal in the resident's room without donning any PPE (Personal Protective Equipment) prior to entering. Observation of the isolation supplies hanging outside the resident's room at that time revealed an unopened package of isolation gowns containing 5 gowns. On [DATE] at 9:30 AM, observation of the isolation supplies outside the resident's room again revealed an unopened package of isolation gowns. At 10:28 AM, CNA #2 was observed entering the room of Resident #11 without donning any PPE. At 12:38 PM on [DATE], Licensed Practical Nurse #3 was observed sitting in Resident #11's room during a nebulizer treatment without a gown. LPN #3 was observed to be wearing gloves. At 12:52 PM, this surveyor opened the package of isolation gowns and donned a gown to conduct an individual interview with the resident. During the Resident Interview, when asked if the staff wore gowns when they came in to provide care, Resident #11 said Some do. At approximately 9:30 AM on [DATE], a package containing 4 isolation gowns was observed outside the resident's room. At 3:40 PM, the same package was observed outside the resident's room and it still contained 4 gowns. Review of the facility's Transmission-Based Precautions - Categories Policy Statement in the section titled Contact Precautions stated a. Examples of infections requiring Contact Precautions include, but are not limited to: (1) . urinary . infections or colonization with multi-drug resistant organisms (e.g.(for example), .ESBL). In the subsection titled c. Gloves and Handwashing, the policy stated (1) .wear gloves (clean, non-sterile) when entering the room. The subsection titled d. Gown stated (1) . wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with an actively infected resident, with environmental surfaces, items in the resident's room . At approximately 11:52 AM on [DATE], during an interview, the Director of Nursing (DON) stated that the facility provided education and in-services on transmission based precautions. She also stated that the facility monitored staff by identifying new cases of an infection in any given staff members case-load but no monitoring of staff practices was done to ensure that staff observe transmission based precautions to prevent infections from occurring. In addition, the DON stated there was no defending observations of staff not observing precautions. On [DATE] at approximately 10:30 AM, inspection of the Piedmont (A Wing) medication room revealed the following: -One unopened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62% (percent), Lot 01, expiration ,[DATE] was found atop a white, plastic storage unit. On [DATE] at approximately 11:30 AM inspection of the Piedmont (A wing) medication carts revealed the following: -Cart 1: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01. expiration ,[DATE]. -Cart 2: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. These findings (medication room and medication carts) were verified by LPN (Licensed Practical Nurse) # 1 on [DATE] at approximately 11:35 AM. LPN # 1 stated that Instant Hand Sanitizer was used to sanitize hands during patient care. On [DATE] at approximately 10:45 AM, inspection of the Riverside (D Wing) medication room revealed the following: -Two unopened 8 ounce bottles of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. -One unopened 8 ounce bottle of Clinishield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE] These three bottles were stored on the 2nd shelf, right side of a gray metal storage unit. On [DATE] at approximately 10:55 AM inspection of the Riverside (D Wing) medication carts revealed the following: Cart 1: One opened 8 ounce bottle of CliniShield Instant Hand Sanitizer ([MEDICATION NAME] 62%), Lot 01, expiration ,[DATE]. These findings (medication room and medication cart) were verified by LPN # 2 on [DATE] at approximately 11:45 AM. LPN # 2 stated that Instant Hand Sanitizer was used to sanitize hands during patient care. | 2016-06-01 |
| 8248 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 502 | D | 0 | 1 | 5WM211 | **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 follow a procedure to ensure that expired laboratory products were not stored in 1 of 3 medication rooms. The findings include: On [DATE] at approximately 10:30 AM, inspection of the Piedmont (A Wing) medication room revealed the following: -Fourteen packages of BBL Culture Swab Collection and Transport System, Lot 029H43 L.YPT233, expiration ,[DATE] were found in a plastic biohazard bag located in the 2nd drawer from the right side of a storage cabinet. This finding was verified by LPN (Licensed Practical Nurse) #1 on [DATE] at approximately 11:35 AM. | 2016-06-01 |
| 8249 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 520 | F | 0 | 1 | 5WM211 | On the days of the survey, based on an interview with the Administrator and Infection Control Preventionist, the facility's Quality Assurance Committee failed to monitor the effect of implemented changes and making needed revisions to the action plans. The findings included: Interview on 2/29/12 at approximately 10:00am with the Administrator and Infection Control Preventionist concerning the facility Quality Assurance Program revealed that the committee was actively addressing concerns in the area of Falls, Weight Loss, Infections, Skin Tears, Medications among others. However, the committee was reviewing the concerns on a case by case basis. The committee had not developed a formal system wide plan of action addressing monitoring of the interventions put into place and the effectiveness of those interventions in relation to the operation of the facility and how it could benefit all who reside within the facility. The Infection Control Preventionist stated We don't connect the dots. | 2016-06-01 |
| 8394 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2012-02-29 | 425 | D | 0 | 1 | T32311 | On the days of the survey, based on observation, record and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications. There were expired medications observed in the 2nd floor medication refrigerator and in the 3rd floor medication cart for rooms 362-373. The findings included: During the observation of the 2nd floor medication refrigerator, there were (two) 1 milliliter (ml) vials of Purified Protein Derivative (PPD) 5TU/0.1ml, provided by pharmacy for floor stock with a fill date of 1/24/12, which were open but did not have a puncture date marked on either of the bottles. An interview with Registered Nurse (RN) #1 on 2/27/12 at 4:12 PM revealed that both of the PPD bottles should have been dated when they were opened, but the bottles were not dated. RN # 1 stated the nurses were supposed to check the medications nightly. RN #1 did not know how often the medications were being checked. During the observation of the 3rd floor medication cart for rooms 362-373, there were 3 unopened packages of Albuterol Sulfate Inhalation Solution 0.083% 2.5mg/3ml with an expiration date of 12/11 and 4 single use ampules of Albuterol Sulfate Inhalation Solution 2.5mg/3ml by DEY with an expiration date of 12/11. Interviews were conducted with Licensed Practical Nurses (LPN) #1, #2, and #3 on 2/27/12 at 3:15 PM. Interview with LPN #1 revealed that the pharmacy checks the medication carts every month and it is usually the 1st week of the month. The facility has recently changed pharmacy services, which began at the beginning of the year. Interview with LPN #2 revealed that the nurses were to check the medication carts for expired medications, but there was not a set schedule. Interview with LPN #3 revealed the consulting pharmacy was at the facility in January 2012 and was also at the facility on February 6, 2012. | 2016-04-01 |
| 9223 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 157 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility failure to notify the Physician and the Responsible Party (RP) of changes in condition. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to ensure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Resident #1 and #7). The findings included: The facility admitted Resident #2 on with [DIAGNOSES REDACTED]. Review of the Social Services notes dated 02/15/2012 revealed: "DON (Director of Nurses) and SSD (Social Services Director) reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (certified nursing assistant) (CNA #1). Attempted family contact with daughter/RP (Responsible Party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM (voice mail) box set up, no response." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Further review of the Investigative File revealed the facility also did not contact the attending physician and the Medical Director until 02/15/2012. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/6/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented; 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, there was no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/1/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/3/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/6/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 2/17/12 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1 AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurses Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/2/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 02/08/2012 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9224 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 223 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged allegations of sexual abuse against Certified Nursing Assistant (CNA) #1. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation to her daughter on the evening of 02/14/2012, an incident of alleged sexual abuse. Her daughter came to the facility and reported the incident to Registered Nurse #1(RN). In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of Resident #1's Care Plan reviewed on 02/02/2012 revealed a problem area of "agitated behavior"; approaches included to observe the resident and to notify the physician as needed. Another problem area was related to anxiety and depression, again the approaches were to observe the resident and notify the physician. No care plan was developed related to behaviors or related to the resident's interactions with staff and other residents. Review of the Physician's Progress Notes dated 01/9/2012 and 01/12/2012 revealed no documentation or assessment related to the resident for behaviors. The most current progress note was dated 01/12/2012. Review of the Nurse's Notes from December 2011 to February 17, 2012 revealed no documentation related to behaviors or sexual abuse. Review of the Social Service notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another note dated 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded as occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Nurse's Notes revealed no indication of sexual abuse. Review of the Social Service notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP (responsible party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility "Summary of Investigation on allegation of sexual abuse" dated 02/20/12 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was 'he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something.' DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Today we asked (Registered Nurse #1), the nurse involved in the original incident to go back to (Resident #2) and ask her the questions again, and take the original statement with her. A copy of the second statement is attached as written by (RN #1) during the interview today. (CNA #1) was suspended immediately and asked to leave the building ... Looking at the 24 hour report sent to DHEC (Department of Health and Environmental Control), (Resident #2's) name does not appear on this, we apologize for the oversight and the RN preparing the document has been educated that every resident's name should appear on the allegation. Administration will also look more closely in the future. Returning to the office the following day the DON looked through all of the assignment sheets from January 1st 2012 through February 14, 2012. ... it was discovered that on 2 occasions only in that 6 week period, February 11 and 12, (CNA #1) had (Resident #1 and Resident #2) respectively. (CNA #1) personnel file has been reviewed with no compromising documentation found. There have been no disciplinary actions against him, his background check was good as is the status of his license. Examination of the residents was not done because there were no allegations of anything other that 'putting his penis in my hand.' The Union County Sheriff's Department as well as (SLED) met at the nursing home on Friday 2/17/12 at 10:45 AM to speak with the Administrator, DON and SSD... " Review of a facility obtained statement taken by RN #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party (RP) and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated, I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Review of a facility obtained statement from CNA #1 dated 02/15/2012 at 8:15 AM revealed, "On [DATE] I was working second shift on Unit 2 when (Nurse) asked to speak to me privately. She informed me that (Resident #1) had told her that I had asked her to touch me. (Nurse) also informed me that I had to be sent home until investigation is complete. I immediately left as asked and said that they can call me if any questions are needed from me. I have never asked any resident to touch me in any way. I have always enjoyed working for (facility) and I sincerely hope to continue to stay employed her for years to come. I am willing to speak to whoever at anytime to answer questions to make the investigation complete as possible." Review of the Assignment Sheets revealed CNA #1 was assigned to Unit 1 on February 3, 2012 from 7 P-7 A. He was assigned to Resident #1 on 02/11/2012 from 7 P-7 A and to Resident #2 on 02/12/2012 from 3 P-11 P. Further review of the Investigative File revealed staff statements taken on 02/14/2012 and 02/15/2012 from the night shift assigned to Resident #1 on 02/14/2012. A thorough investigation was not conducted to include Resident #2 and staff statements for the alleged time frames were not obtained. Prior to the 02/22/2012 inservice conducted by SLED, no staff education had been completed on Abuse/Neglect, reporting or sexual abuse related to the incident. In addition, the facility failed to contact the local police department with the allegations. (Resident #1's family member called the police on the evening of 02/14/2012 there was no evidence that Resident #2 was reported to the police). The attending physician and the Medical Director were contacted by the facility 02/15/2012. Residents #1 and #2 were not immediately assessed, physically, emotionally or psychosocially. Interviews and assessments of other residents at the facility that might have been potentially abused were not conducted. Review of CNA #1's employee file revealed no disciplinary action was located in his file. CNA #1 was alleged as a perpetrator in a prior sexual abuse allegation in August 2011. The allegation was unsubstantiated. However, no evidence of the allegation was located in the employee's personnel file. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed CNA #1 was involved in a prior sexual abuse allegation. She stated, that since the allegation was unsubstantiated, she shredded all evidence that would have been normally kept in the employee's file. She stated that this was routine practice for any employee at the facility that had an unsubstantiated allegation. She confirmed again that she shredded the documents and did not keep any evidence in the employee file. During a follow up interview at 2 PM, the DON also confirmed that the local police department was contacted by Resident #1's RP and not the facility. She stated that as of 02/21/2012, the facility had not made a report to local law enforcement regarding the sexual abuse allegation for Residents #1 and #2. The DON confirmed that Residents #1 and #2 had not been assessed. She also confirmed that there had not been an inservice on Abuse and Neglect related to this incident and that SLED was providing education on 02/22/2012. The DON confirmed that CNA #1 was assigned to Resident #1 on 02/11/2012 and that this was approximately "2-3 days" prior to the resident reporting the incident. The DON confirmed that the Physician was not contacted until 02/15/2012. During an interview on 02/21/2012 at 3:15 PM, the SSD and DON confirmed that the facility attempted to contact the Responsible Party (RP) for each resident in the facility. The Administrative staff was asked to notify the RP of each resident in the facility and ensure them the residents were safe. The DON confirmed that there was no documentation that the RP was contacted, who contacted them and when they were contacted. The SSD and DON both confirmed that as of 02/21/2012, Resident #2's responsible party had not been contacted regarding the sexual abuse allegation. Both stated that the facility was unable to reach the RP via telephone. When asked if other methods of communication had been attempted, both stated no other method had been attempted to contact the resident's RP. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/2011 and she was very upset and crying... she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her... SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/12 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30/2011, "she did go to her psychiatrist after her last delusions and changes were made to her [MEDICATION NAME] and [MEDICATION NAME] sprinkles..." On 02/22/2012 additional information was provided regarding staff statements. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9225 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 226 | K | 1 | 0 | PX0Y11 | On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to identify, investigate and report allegations of sexual abuse. The facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse. The findings included: Cross Refer to F-223 as it relates to the facility failure to identify, investigate and report allegations of sexual abuse. Review of the facility policy on Alleged Violations of Mistreatment, Neglect and Abuse revealed the following: "Residents will be free from verbal, sexual and physical or mental abuse... Residents will not be subjected to abuse by anyone including but not limited to ...staff ..." "The facility will investigate all grievances/complaints, accidents/incidents, allegations of abuse..." "Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault." "D. Prevention. The Administrator will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur... The Director of Nursing or designee reviews all aspects of accidents/incidents, medical interventions and documentation. Data is trended, analyzed and incorporated into the facility's quality assurance program." "E. Identification. The facility Administrator or designee will identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. Methods may include but are not limited to tracking, trending and analysis of facility reports and grievances for occurrences, patterns and trends." "F. Investigation. The individual assigned to conduct the investigation will conduct a thorough investigation of the allegation. Areas/items that may be included as appropriate in the investigation include: ...b. Review the resident's medical record to determine events leading up to the incident...e. Interviews with the resident's attending physician as needed to determine the residents current level of cognitive function and medical condition. f. Interviews with staff members. h. Interview other residents to whom the accused employee provides care and services. i. Review events leading up to the alleged incident." "G. Protection. ...The Nurse in Charge on each shift is responsible for monitoring residents involved in an accident/incident until that resident is considered medically stable. This includes appropriateness of care, family/responsible party notification, physician notification and documentation. Unit staff will assure the safety of the involved resident and/or other residents during an investigation." "H. Reporting. d. Local police departments and professional boards will be notified as deemed appropriate by Administration..." On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9226 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 250 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. No Social Service interventions were put in place related to the allegations. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of the Social Services notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another noted date 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded a occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Social Services notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (CNA #1). Attempted family contact with daughter/RP at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM box set up, no response." Another note on 02/15/2012 revealed: "DON and SSD went to interview resident regarding an alleged incident that occurred with her and CNA. Time frame uncertain. Resident stated that she knew the CNA and stated that he was always very kind to her. SSD asked her if CNA in question had ever been sexually inappropriate with her. She responded no, he's always been very nice to me. Upon further questioning, resident had no recall of any sexual/inappropriate behavior by this male CNA." Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since. ...it was very embarrassing, I can't even face him." Review of the SSD statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated , I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Further review of the Investigative File revealed the facility failed to assess, physically, emotionally or psychosocially, Residents #1 and #2. The facility also did not identify, interview or assess other residents at the facility at risk for potential abuse. During an interview on 02/21/12 at 2 PM, the Director of Nurses confirmed that the residents had not been assessed. During an interview on 2/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about other accusations related to CNA #1, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/11 and she was very upset and crying...she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her...SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/2012 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was not seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me. ...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Review of the Social Service Notes dated 12/19/2011 revealed Resident #6 hallucinating last week when the television is on the news. ...she stated she had CNA #1's baby. On 12/30, "she did go to her psychiatrist after her last delusions and changes were made to her Abilify and Depakote sprinkles..." On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9227 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 281 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Surveys, Immediate Jeopardy was identified related to the facility staffs failure to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Resident #1, #2 and #6). Facility staff also failed to identify and assess other residents for potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). The findings included: Review of the "Summary of Investigation on allegation of sexual abuse" dated 02/20/2012 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was "he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something." DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Today we asked (Registered Nurse #1), the nurse involved in the original incident to go back to (Resident #2) and ask her the questions again, and take the original statement with her. A copy of the second statement is attached as written by (RN #1) during the interview today. (CNA #1) was suspended immediately and asked to leave the building. The following day he came to the facility in the morning and wrote his statement which is attached herewith. Looking at the 24 hour report sent to DHEC, (Resident #2's) name does not appear on this, we apologize for the oversight and the RN preparing the document has been educated that every resident's name should appear on the allegation. Administration will also look more closely in the future. Returning to the office the following day the DON looked through all of the assignment sheets from January 1st 2012 through February 14, 2012. Copies of these are enclosed, it was discovered that on 2 occasions only in that 6 week period, February 11 and 12, (CNA #1) had (Resident #1 and Resident #2) respectively. (CNA #1) personnel file has been reviewed with no compromising documentation found. There have been no disciplinary actions against him, his background check was good as is the status of his license. Examination of the residents was not done because there were no allegations of anything other that "putting his penis in my hand." The Union County Sheriff's Department as well as (SLED) met at the nursing home on Friday 2/17/12 at 10:45 AM to speak with the Administrator, DON and SSD... On Wednesday 2/22/12 (SLED) is coming back to (facility) with posters on the new Elder Justice Act ratified at the end of 2010. He will do an education piece to all the manager who will in turn in service the staff. The posters will be put up in the Service Hall where all staff will be able to see them." Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 on 2/14/12 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since...it was very embarrassing, I can't even face him." Review of the second statement obtained by RN #1 on 2/20/12 revealed Resident #2 stated that she did not see CNA #1's penis and that he had never been inappropriate with her. Review of the SSD (social service director) statement dated on 02/15/2012 revealed: "SSD met with (Resident #1's Responsible Party (RP) and Resident #1) to discuss what had happened to her last night. (Resident #1) stated that (CNA #1) had come behind the curtain in her room and placed his penis in her hand. SSD asked her if he had done anything else with his hands or penis during this time. She stated no. (RP) informed (Resident #1) that this is a serious allegation and that she could send this man that she is accusing to jail for a long time, (Resident #1) said I know, he did this to me. SSD asked her when this happened, she stated a weeks ago, I don't remember which shift my mind is as short as my pinky finger. SSD asked (Resident #1) why she did not report this as soon as this happened. She stated , I was scared. SSD: what were you scared of? (Resident #1): I was scared he would come back in here and do other things to me. I saw him after this happened to me in the dining room. He spoke to me when he saw me in the dining room, but he was always nice and would say hello or how are you doing. SSD asked (Resident #1) about her feelings about moving from the facility, as she is apparently not safe in this facility. She stated she would go, (RP) said I know she will miss some of her friends..." Further review of the Investigative File revealed the facility failed to assess, physically, emotionally or psychosocially, Residents #1 and #2. The facility also did not identify, interview or assess other residents at the facility that might have been effected by potential abuse. During an interview on 02/21/2012 at 12 PM, the Director of Nurses confirmed no assessments had been completed for Residents #1 and #2 and confirmed no other resident were assessed for potential sexual abuse. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency. During an interview on 02/22/2012 at 3 PM, the SSD provided documentation to the surveyor related to Resident #6's allegation. Review of the documentation revealed: "SSD went into (Resident #6's) room on 12/12/2011 and she was very upset and crying...she was very upset and then stated she had had his (CNA #1's) baby and put the baby in the dumpster and the cops were looking for her...SSD ensured (sic) that (Resident #6) had an appointment with her psychiatrist that day, SSD included a letter to (the psychiatrist) regarding the behaviors she is having and requesting an evaluation." The statement was signed and dated on 12/14/2012 with a statement of "SSD has seen no signs of further problems as medications were adjusted by (Psychiatrist). A typed letter that had a handwritten date of 12/12/2012 (the year 12 was lined through with a number one) that revealed: "I am writing this letter on behalf of (Resident #6). She had hallucinations last week..." Record review revealed, Resident #6 was not seen by the psychiatrist until 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. On 02/22/2012 additional information was provided regarding staff statements. Review of the facility obtained statement dated 02/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA (quality assurance) meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Resident #1's Physician order [REDACTED]. The original order was written on 10/13/2011. Further review revealed the resident was to have finger stick blood sugars twice daily at 6 AM and 8 PM. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction - Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located. 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/06/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented. 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/01/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/03/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/06/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 02/17/2012 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurse's Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. Review of the Physician's Progress Notes revealed on 01/09/2012 the provider documented: "The patient's last A1C was 5.7 and it is in excellent control..." The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar (FSBS) Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/02/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 2/8 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the low blood sugars for both Resident #1 and #7. She confirmed there were no documented rechecks for some of the low blood sugars and confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. The DON agreed that if an intervention was provided to a resident, then a follow up should be completed with the appropriate documentation. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9228 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 309 | E | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the surveys based on record review and interview, facility staff failed to provide the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Resident #1's Physician order [REDACTED]. The original order was written on 10/13/2011. Further review revealed the resident was to have finger stick blood sugars twice daily at 6 AM and 8 PM. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/6/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented; 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, there was no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/1/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/3/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/6/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. Review of the Nurse's Notes revealed on 01/19/2012 at 6:30 AM, "FSBS @ 0600 56, (after) 15 grams (Orange Juice) and graham cracker, FSBS (increased) to 81..." On 2/17/12 at 2 AM, "...resident sitting in w/c (wheelchair) c chin on chest, clammy and wet with perspiration. Checked FSBS @ 12:30 AM was 26, [MEDICATION NAME] 15 given given PO (by mouth) followed by 3- 8 ounce cups of MedPass 2.0. FSBS rechecked @ 12:45 AM-30, another tube of [MEDICATION NAME] given per symptomatic protocol, rechecked @ 1 AM -39. MD called, (Nurse Practitioner) responded. Ordered to give another tube of [MEDICATION NAME] and call 9-1-1. EMS arrived @ 1:10 AM INT started, D50 given, rechecked 228. Resident responding but very sluggish, still not acting like herself. Transferred to (local hospital) for further evaluation and treatment. Resident's daughter contacted c message left on voicemail. Transported @ 1:50 AM." Besides the above two entries, no other documentation was located in the Nurses Notes or Finger stick log regarding physician notification, interventions and re-checks of low blood sugars. Review of the physician progress notes [REDACTED]. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/02/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 02/08/2012 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Review of the Nurse's Notes revealed on 02/24/2012 at 6 AM, "FSBS 58, Fig newtons and (two) cranberry juices given, no insulin required." Further review of the Nurses Notes from January 2012 and February 2012 revealed no other documentation related to low blood sugars, rechecks or physician notification. During an interview on 02/24/2012 at 3:45 PM, the Attending Physician stated he was not made aware of Resident #1's low blood sugars. He stated that he does review the Fingerstick Records, however not on every visit and there are times when the logs were not available. He stated that he relied on the nursing staff to inform him of problems or concerns. He confirmed the Symptomatic Protocol including the order to contact the physician with blood sugars less than 55. The Attending Physician also confirmed that a recheck of the low blood sugar was part of the protocol and should have been done. The Attending Physician stated that he reviewed the blood sugars for Resident #1 after she was sent to the hospital on [DATE]. He confirmed at that point he was aware the protocol was not being followed, interventions and rechecks were not documented and that the physician had not been notified per the protocol. The Physician stated that the facility informed him Resident #1 was an isolated case and that there were no other residents where the protocol had not been followed. Resident #7's low blood sugars with no rechecks and no physician notification was shared with the physician. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the low blood sugars for both Resident #1 and #7. She confirmed there were no documented rechecks for some of the low blood sugars and confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. The DON agreed that if an intervention was provided to a resident, then a follow up should be completed with the appropriate documentation. Cross Refers to the following citations 483.10(b)(11) Notification, F-157. The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to notified the attending physician of low blood sugars for 2 of 3 residents reviewed for blood sugar management (Residents #1 and #7). 483.20(k)(3) Services Provided Meet Professional Standards, F-281. The facility staff failed to recognize, follow up on and contact the physician regarding consistently low blood sugars for two of three residents reviewed receiving Insulin (Residents #1 and #7). | 2015-06-01 |
| 9229 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 428 | E | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the survey based on observations, record review and interview, the Consultant Pharmacist failed to report irregularities for 2 of 3 residents reviewed for blood sugar management. Resident #1 and #7's blood sugars were repeatedly low without interventions, documented rechecks and physician notification. No recommendations were made by the Consultant Pharmacist regarding the low blood sugars. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer Glucagon 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat Glucagon once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up was documented; 01/6/2012 at 6 AM, FSBS=55, "juice and cookie" given, no intervention and no follow up was documented; 01/18/2012 at 6 AM, FSBS=56, "cookies and juice" given, no follow up was documented; 01/19/2012 at 6 AM, FSBS=56, "juice and 1 graham cracker" given, no follow up was documented on log; 01/20/2012 at 6 AM, FSBS= 34, juice and cookies were given, there was no documented recheck and no physician notification; 01/30/2012 at 6 AM, FSBS=57, "juice/cookies" were given, no recheck was documented; 02/1/2012 at 6 AM, FSBS=56, juice and cookies were given, no documented recheck was recorded; 02/3/2012 at 6 AM, FSBS=46, juice was given and a recheck of 7? was recorded, however, no physician notification was located; 02/6/2012 at 6 AM, FSBS=49, juice was given, a recheck of 58 was documented, however, no physician notification was located; 02/14/2012 at 6 AM, FSBS was 55, no interventions, no rechecks and no physician notification was located; 02/16/2012 at 6 AM, FSBS was 46, juice was given and a recheck of 86 was recorded, however no physician notification was located. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Fingerstick Blood Sugar Record from January and February 2012 revealed on 01/01/2012 the 6 AM blood sugar was 55, juice was given. There was no documented recheck and no physician notification. On 01/29/2012 at 6 AM, the FSBS was 59, juice was given, however there was not a documented recheck. On 02/02/2012 at 6 AM, the FSBS was 47, juice and cookies were given, there was no recheck documented and no physician notification was located. On 02/08/2012 at 6 AM, the FSBS was 55, juice and cookies were given, no recheck was documented. On 02/24/2012 at 6 AM, the FSBS was 58, juice and cookies were given, no recheck was documented. Observation of the Medication Carts revealed the Lantus vials were stored in the medication carts. Review of the Physician order [REDACTED].**Refrigerate - Expires 28 days after opening**." During an interview on 02/24/2012 at 4:20 PM, the Consultant Pharmacist stated that he reviewed resident blood sugars monthly during his review. He stated that he checks for trends in the blood sugars and would make recommendations if needed. He also stated that his focus was primarily on sliding scale insulin residents and not routine blood sugar checks. The Consultant Pharmacist stated that he was not aware of any concerns related to low blood sugars. During a telephone interview on 02/24/2012 at 5 PM, the Pharmacy Manager confirmed the Lantus order for refrigeration. He stated that Lantus did not have to be stored in the refrigerator but confirmed that the physician signed orders would take precedent. The Pharmacy Manager stated that the orders were "bad orders" and needed to be addressed with the physician. The Pharmacy Manager also confirmed that the Consultant Pharmacist did not catch the discrepancy in the order and how the vials were stored. During an interview on 02/24/2012 at 5 PM, the Director of Nurses confirmed the low blood sugars for both Resident #1 and #7. She confirmed there were no documented rechecks for some of the low blood sugars and confirmed the physician had not been notified per the protocol. The DON also confirmed that during the monthly medication reviews, the Pharmacist also did not inform the physician of the low blood sugars. The DON agreed that if an intervention was provided to a resident, then a follow up should be completed with the appropriate documentation. | 2015-06-01 |
| 9230 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 490 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record reviews and interviews, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to utilize its resources effectively and efficiently to attain or maintain the highest practicable well being of each resident. The facility's Administration failed to identify, report and thoroughly investigate allegations of sexual abuse. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation, an incident of alleged sexual abuse to her daughter, on the evening of 02/14/2012. Her daughter came to the facility and reported the incident to Registered Nurse (RN) #1. In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." On 02/22/2012 the Administrator contacted the State Agency with additional information related to the investigation regarding Residents #1 and #2. A faxed report indicated, "Staff Assistant reported to nursing that she had reported to her supervisor and Social Services about a month ago that Resident #1 reported to her that CNA #1 had sexually abused Resident #2." During a telephone conversation on 02/22/2012 the Administrator stated this was the first he had heard of this allegations. Review of the facility obtained statement dated 2/22/2012 from Staff Assistant #1 revealed: "To whom it may concern, (HR) call me at 4:15 PM on 2/22/12 to ask me questions about something I told (Administrator and Staff Development) this morning about (Resident #2) had told (Resident #1) about (CNA #1). (Resident #1) told me she love me and could trust me. Then she told me what (Resident #2) said that (CNA #1) came into her room, was playing with his penis, he pull it out, (Resident #2) said it was real red then he started to play with her breast that's what (Resident #1) told me. Then (Resident #1) said (Resident #2) was scared of him. (Resident #1) also said what if he bothered (roommate), she couldn't tell anybody about it. (Resident #1) said he should try to bother her should would knock the hell out of him. I told her she should tell someone, that's when she said (Resident #2) was scared of him. (Resident #1) told me about the sexual abuse in Jan second week 2012. I was putting ice on the halls on Unit I. Then I went to (Risk Manager) my supervisor. I ask what I should do, she told me to go to Social Services, I did. I talk with (SSD and SSA) and told her what (Resident #1) had told me. She said (CNA #1) had already been sent 3 times before. (????suspension???) She said she could talk with (Resident #2) and (Resident #1) without them knowing I told her about a report of maybe sexual abuse. (SSD) said she would take care of it. I went to Social Services before 11 AM second week in [DATE]." Additional comments were added by the Staff Assistant: "(SSD) also told me that she didn't want to see (CNA #1) to lose his job. I was also told the names of 2 of the residents who had allegations against (CNA #1). (SSD) told me the names!." Review of the facility obtained statement from the Risk Manager dated 02/22/2012 at 6:30 PM revealed, "(Staff Assistant) stopped me in hall and stated (Resident #2 mentioned to her that she had been touched on the breast, should she tell someone or just keep to herself. I told her to tell Social Services. Later (Staff Assistant) told (SSD). That is the last time it was mentioned." Review of the facility obtained statement from the SSD on 02/22/2012 revealed: "I had no knowledge of sexual abuse on (Resident #2) until I read it in (RN #1's) statement on 2/15/12...." During an interview on 02/24/2012 at 1:15 PM, the ADON (assistant director of nurses) confirmed the written statements and stated that the Staff Assistant reported the incident to her supervisor appropriately. The ADON stated that her supervisor was Risk Management and that she attended all the morning stand up meetings and QA (quality assurance) meetings. The ADON stated that she did not report the incident to anyone. The ADON stated that the SSD, SSA and the Risk Manager had all been suspended. The ADON confirmed that the Risk Manager was considered part of the facility's Administration and was responsible for relaying the information to the rest of the Administration. Cross Refers to the following citations: 483.10(b)(11) Notification, F-157 was identified at a scope and severity of "K". The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to assure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Residents #1 and #7). 483.13(c) Staff treatment of [REDACTED]." The facility failed to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies, F-226 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". Residents #1, #2, and #3 alleged sexual abuse against Certified Nursing Assistant #1 the facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse related to the allegations. 483.15(g)(1) Medically Related Social Services, F-250 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". The facility failed to provide medically related social services to three of three residents involved in allegations of sexual abuse. Resident #1, #2 and #6 alleged sexual abuse by Certified Nurses Assistant #1. No Social Service interventions were put in place related to the allegations. 483.20(k)(3) Services Provided Meet Professional Standards, F-281 was identified at Immediate Jeopardy at a scope and severity level of "K". The facility staff failed to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Residents #1, #2 and #6). Facility staff also failed to identify and assess other residents that may have been affected by potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). . 483.75(i) Medical Director, F-501 was identified at Immediate Jeopardy at a scope and severity of "K". The Medical Director failed to ensure that the facility policies and procedures were implemented for residents with allegations of sexual abuse. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9231 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 501 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Surveys based on record review and interview, Immediate Jeopardy was identified as existing in the facility as of 02/14/2012. Allegations of sexual abuse were made involving three residents and Certified Nursing Assistant (CNA)#1; the facility's Medical Director failed to implement policies related to identification, reporting and investigating allegations of sexual abuse, and failed to ensure each resident was assessed and protected from further potential abuse. The findings included: Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 from Resident #2 on 02/14/2012 at 9:45 PM revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since....it was very embarrassing, I can't even face him." Further review of the Investigative File revealed staff statements were taken on 02/14/2012 and 02/15/2012, the statements referenced the night shift of 02/14/2012 only for Resident #1. A thorough investigation had not been conducted to include Resident #2 or to include staff statements for the alleged time frames. No staff education was completed on Abuse/Neglect, reporting or sexual abuse related to the incident. In addition, the facility failed to contact the local police department with the allegations. (Resident #1's family member called the police on the evening of 02/14/2012, there was no evidence that Resident #2 was mentioned in the report). The facility did not contact the attending physician and the Medical Director until 02/15/2012. Residents #1 and #2 were not assessed, physically, emotionally or psychosocially. Other residents were not identify, interview or assessed that might have been effected by potential abuse. During an interview on 02/21/2012 at 4:30 PM, the Medical Director stated that he was notified of the sexual abuse allegation on 02/15/2012. He stated that he did not assess the residents since there was no reported penetration. He stated that since it was emotional upsetness there was no reason for an assessment. The Medical Director stated that Resident #2 was interviewed several times regarding the allegation, he stated that when pressed for information, the resident would "clam up." The Medical Director stated that CNA #1 had 2 prior accusations before Residents #1 and #2. During another interview on 02/22/2012 at 12:10 PM, the DON (director of nurses) was asked about the 2 prior accusations, she stated that Resident #6 had stated she was having CNA #1's baby. The DON stated that no investigation had been completed related to the incident. The other accusation was reported to the State Agency in September 2011. Review of the Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS of "3" and no behaviors, hallucinations or delusions were coded as occurring in the assessment period. Record review revealed, Resident #6 was seen by the psychiatrist 12/19/2011 when the psychiatrist noted increased delusions and hallucinations. The residents medications were increased. Review of the Nurse's Notes revealed on 12/12/2011 the only documentation was "body audit-skin warm and dry, intact. On 12/19/2011 at 12 PM, (Resident #6) upset because "a girl pushed me out here and shouldn't have, waiting on (CNA #1). (CNA #1) will come and get me and take care of me...you don't know, he'll be here to get me... Attempted to reassure the resident." Further review of the Nurse's Notes from November and December 2011 revealed no other documentation of behaviors, hallucinations or delusions. Cross Refers to the following citations: 483.10(b)(11) Notification, F-157 was identified at a scope and severity of "K". The facility staff failed to notify the Physician and the Responsible Party of changes in condition or accident. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to assure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Residents #1 and #7). 483.13(c) Staff treatment of [REDACTED]." The facility failed to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. 483.13(c) Develop/Implement Abuse/Neglect, Etc. Policies, F-226 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". Residents #1, #2, and #3 alleged sexual abuse against Certified Nursing Assistant #1 the facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse related to the allegations. 483.15(g)(1) Medically Related Social Services, F-250 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of "K". The facility failed to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nurses Assistant #1. No Social Service interventions were put in place related to the allegations. 483.20(k)(3) Services Provided Meet Professional Standards, F-281 was identified at Immediate Jeopardy at a scope and severity level of "K". The facility staff failed to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Residents #1, #2 and #6). Facility staff also failed to identify and assess other residents that may have been affected by potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). . 483.75 Effective Administration, F-490 was identified at Immediate Jeopardy at a scope and severity of "K". The facility Administration failed to follow accepted procedures for the investigation of incidents involving alleged sexual abuse and failed to educate all facility staff regarding the allegations and any interventions necessary to protect all residents at risk of becoming victims. On 02/24/2012 at 5:00 PM the facility Administrator and Director of Nurses was informed that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-281, F-490 and F-501 related to the facility failure to identify, investigate and report allegations of sexual abuse. The facility also failed to identify and protect other residents in the facility from potential abuse. The Substandard Quality of Care and/or Immediate Jeopardy (IJ) identified at F-157, F-223, F-226, F-250, F-281, F-490, and F-501 at a scope and severity of "K" remained ongoing at the time the surveyors exited the facility on 02/24/2012. The survey remained open until all identified staff with knowledge of the IJ concerns could be located and interviewed. These interviews were critical to the accuracy and thoroughness of the State Agency investigation and were completed on 02/29/2012 at which time the survey ended. | 2015-06-01 |
| 9234 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 250 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the failure of the facility to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility Social Services Department failed to ensure that resident, staff and Responsible Party concerns of potential neglect/abuse/misappropriation were thoroughly investigate and/or reported to the appropriate State Agency. The facility Social Services Department failed to following up on and document the resolutions of concerns found in the facility Grievance Log. The Social Services Department failed to ensure that Resident #19 had necessary clothing; Resident #16 social services notes were not documented at least quarterly (last notes 8/2011); Resident #17 failed to have eye or dental appointment scheduled. The findings included: During the Complaint Survey, related to allegations of grievances not thoroughly investigated and resolved, the facility's grievances were reviewed. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations had a staff member identified. The facility provided "teachable moments" to two of the five identified staff members and failed to provide any education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The Social Services Department was responsible for the grievance process and was responsible for assuring the investigations were completed as well as responsible for following up on each grievance. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 1/15/12 the resident's family member made the following complaint: "(CNA) in charge from 3 to not sure shift. 6:45 PM, Oxygen tank needed refill had to get someone to get her a tank. Sat there a few minutes my daughter asked her Nanny what was wrong. My mother said she was soaking wet. Took her to bathroom (diaper soaked and had come through pants and soaked her cushions, wheelchair). Commode full of crap..." Further review of the facility's investigation revealed staff statements regarding the residents oxygen tank and toilet. No staff member had been identified and a thorough investigation had not been completed. The facility also failed to identify and report the allegation as potential neglect to the appropriate state agency. No resolution or follow up had been completed. The facility admitted Resident #26 on 2/14/12 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 2/20/12 the resident and the therapy department lodged the following grievance: "Pt (patient) stated he had been trying to get somebody to clean his brief with diarrhea in it since 6:30 AM. Pt states the CNA/nurse med(ium) size, African American with a wide mouth told him to lay there and suffer and if you die they will take care of you." The findings of the facility were as follows: "Pt (light) was on, I ask how I could help him, pt stated he needed to be changed. Pt stated it was burning. I didn't see anyone at the moment so I changed him. Pt bed and bottom a mess. I cleaned pt and changed bed. As I was cleaning (Resident #26 up), pt started all the above. Two therapists came in and helped." Resident #26 signed the grievance, however the staff member who provided care for the resident was not identified. Further review of the Grievance revealed no other investigation had been completed. There was no evidence of resolution, recommendations of actions taken. The facility admitted Resident #27 on 5/26/2004 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/27/2011 the resident's family member lodged the following complaint: "Resident's clothing is saturated with urine when they come to pick them up. Has socks missing." No staff member was identified. The allegation was not reported as potential neglect to the State Survey and Certification Agency. The allegation also was not thoroughly investigated. The facility conducted an inservice related to staff changing residents in a timely manner, only 18 staff members attended. The resident's family member was "notified by unit manager, accepted resolution." There was no documentation of the resolution. The facility admitted Resident #28 on 1/31/03 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/22/11 the resident family member lodged the following complaint: "Last two Sundays, resident is in chair saturated from urine. W/C (wheelchair) is also soaked. Resident sister reports that this happens often. Resident complain of pain on backside. Resident sister reports there was odor from the urine. Resident has not had a cushion for last 3-4 weeks from urine incontinence. Staff has also told sister we are short staffed, and that resident requires a great deal of care and pt is on lasix." The resolution was "teachable moment for the CNA of frequency of checks for toileting." The family member was notified by the Director of Nurses (DON) and "was satisfied." Further review revealed a Teachable Moment dated 7/25/11 revealed "It was brought to our attention that residents are being left wet and clothes are saturated. Residents are to be checked every 2 hours. If you know they are heavy wetters check more frequently. It is unacceptable for our residents to remain in wet/soiled clothing." The Teachable Moment was signed by the Interim DON and the staff member. One staff statement by a Registered Nurse was taken on 7/25/11 that indicated the resident was "checked on Saturday and Sunday at 2:15 PM" and the resident "was dry." A thorough investigation had not been conducted. The facility failed to identify and report the allegation as potential neglect to the appropriate state agency. Another grievance was made by the Resident #28's RP on an unknown date and time that revealed: "(RP) reports that she came in to visit on Saturday August 27, to find her sister soaked sitting in w/c. She has reported this before. CNAs got her up upon request and changed her but reported they were unable to get her back up because they Hoyer sling was wet and there were no more in the facility..." No investigation had been completed and the facility failed to identify and report the allegation as potential neglect to the appropriate state agency. No resolution/recommendations/actions had been taken related to the grievance. The facility admitted Resident #30 on 11/17/10 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/17/11 the resident lodged the following complaint: "Pt reports she was lying in a soaked brief for 3 hours on 7/18/11 before anyone came in to answer her call light. Resident reports this happens often." Review of the Investigation and Findings revealed: "In to speak with res regarding complaint. Res could not say exactly which shift it was. Res then began to have conversation with this nurse about various things. Res happy with new catheter at this time." Review of the Resolution revealed: "Staff re-educated about proper way to position catheter while in bed and importance of emptying cath bag every shift. Res enjoys talking with staff and others as they go into room. Res is lonely for interaction." Review of the Follow up revealed: "Res is satisfied with resolution of above is very appreciative of staff and care is happy with new cath. Has not reported any leaking." Review of the Inservice conducted on 7/20/11 revealed the topic was "Understanding importance of positioning res's with catheters while in bed and chair and emptying cath bag in a timely manner. Ten staff members attended. Further review revealed no staff member was identified, a thorough investigation had not been completed and the facility failed to identify and report the allegation as neglect to the appropriate State Agency. Another Grievance was lodged by the resident on 12/1/11 that revealed: "C/O (Complaints of) resident staying wet two hours at a time, C/O resident light stays on two hours at a time, no one answers but Nsg will turn light off at desk, C/O resident refusing showers related to leaving resident in hallway wet and wet hair and resident gets cold." Further review revealed no investigation had been conducted. The facility failed to identify, report an allegation of potential neglect to the appropriate State Agency. No follow up and resolution had been documented. The facility admitted Resident #32 on 4/14/10 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member lodged the following complaint on 7/15/11: "resident had a visitor on 7/8/11. Visitor reported to (RP) that (Resident #32) was sitting in the hall and her brief was soaked to the point that it was running out in her chair. This incident occurred at 3:15 PM. Visitor reported to CNA and she changed her. Monday July 11, 2011, (family member) came to visit resident and resident was going into another res room to use the restroom. (Family member) re directed her to her room and attempted to assist her to bathroom. (Resident #32) reported she was burning. (Family Member) reported that feces had dried on her body where she was not properly cleaned. (Family) reported to a nurse or CNA, not sure which. It was reported to her that I am just coming in so it had to happen on 1st shift. As soon as I get report I will come in and take of. This was between 3-3:30 PM. Does not know if they every checked. (Family) cleaned..." Further review revealed the facility did not identify the incidents as potential neglect, thoroughly investigate the incidents and the facility failed to report the incidents to the appropriate state agency. The resolution was the resident was placed on a every two hour toileting program, the RP was "in agreement" with the resolution. A teachable moment was provided to one staff member on 7/20/11 related to proper peri care. The facility admitted Resident #33 on 12/4/08 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 9/22/11 the resident's family member made the following complaint: "Our mother was in the dining room waiting on dinner tray. The odor coming from her was unbearable. We took her to her bathroom and she was soiled through her diaper, clothes and socks. We only saw two CNA's for 2 halls, 1 med tech from agency and 1 employee at nurses station. How can you legally operate understaffed, residents filthy, resident not being fed (that can't feed themselves) with an employee sitting behind the nurses desk on the phone throughout dinner? My Mom's dinner was a small spoon of chicken salad in a clump in the middle of her bread less than half a cup of soup and applesauce. Someone in our family is here everyday. We are glad to fed (sic) her and help other residents that can't help themselves. We have no problem taken our mother to the bathroom and clean her, but it is unexceptable for Mom (or any resident soiled and having to wait for a CNA to take them to be cleaned up. How comfortable would you feel soaked with urine and feces eating a meal or sitting in front of food you can't fed yourself. By the time a CNA gets to those that can't fed themselves the food is cold or the residents trying to feed themselves have spilled their water or tea in their plates. The food is ruined and another tray isn't offered. This is not exceptable (sic). It's now 8:00 PM and we still haven't seen a CNA for our mother nor has anyone asked if our mother needed anything. You don't even have out the grievance or complaint sheets at the box. We gladly praise the CNAs and med tech and nurses that do their jobs. My biggest regret was not having someone from DHEC here tonight." The "Investigation and findings" were as follows: "DON called (residents family member) on 9/23/11 at approx(imately) 1:36 PM, daughter shared concerns for all residents (at facility) per incident /those w (with) no family available, (RP) very pleasant/stated have never received a call from Adm before. (RP) very gracious to staff that do their jobs well also (?) out lack of staff. Adm assured (RP) (the facility) is taking applications interviewing and hiring. Shared with (RP) that DON/ADON will (follow up) w this issue and will be back in touch." Further review revealed no investigation had been completed, the allegation had not been sent to the State Survey and Certification Agency and no staff members had been identified. The facility also had not provided a resolution to the resident's RP. Another Grievance dated 1/27/12 was lodged by the residents RP that revealed: "Mother was sitting in a urine soaked diaper. I changed it. At 12:10 PM I took my mother again to the bathroom. No CNA came in that time to take my mother to the bathroom." The findings were as follows: "(RP) stated she came in at 10 AM. Res was wet then stated brief was in trash can in room. I checked brief in trash can. Brief was dry. CNA stated she had made rounds at 10 AM and took res to bathroom at that time." Further review revealed a CNA documented a statement on 1/27/12 that the resident was changed twice prior to 10 AM. No other investigation was found. The facility did not identify and report the allegation as potential neglect to the appropriate State Agency. Another grievance dated 11/18/11 made by a staff member revealed the following: "Was walking into Magnolia Unit and stopped to speak with (Resident #33) as I walked by her. She asked that I take her out of (facility). When I asked why she would want to leave, she stated she was in pain. I asked where and she pointed to her stomach and legs. I asked her if she needed a nurse- she said yes and she wanted to speak with them. Walked to nurses station, and told (nurse) that (Resident #33) needed a nurse. (Nurse) was very rude and acted as if I was interrupting her. When I told (the nurse) about (Resident #33) being in pain her comment was, "what do you want me to do about it?" I then said if she wasn't the one to help her who would I need to get. Then (the nurse) stated that if (Resident #33) would take her medicine and not spit it out then she wouldn't be in pain. Then I asked her if she was going to tell (Resident #33) that- (The nurse) then turned around, I went to speak with (Administrator) directly afterwards." A thorough investigation had not been completed. The recommendations/actions taken were "res meds were re-offered. Nurse received sensitivity training." The facility admitted Resident #34 on 12/22/08 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the residents RP lodged the following complaint on 11/10/11: "...RP stated res's diapers are not being changed as often as they should be." The Investigation revealed: "Resident is being laid down for a nap after lunch and is getting back up before supper. Staff re-educated on frequent checks of residents and pericare." No recommendations or actions had been taken. The RP had not been contacted related to the allegation. A thorough investigation had not been conducted. The facility failed to identify and report the allegation as potential neglect to the appropriate state agency. The facility admitted Resident #35 on 1/10/10 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 11/22/11 the resident made the following complaint: "Res stated he woke up at 5:30 AM, turned on his light because his brief needed to be changed. Res stated people kept walking by stating they would get someone else to help him. Res stated no one every came and his sheets and bedding were soiled/soaked and had to be changed." Review of the Investigation revealed: "BSW (Social Worker) met with res again in the afternoon. Res then stated he never had on a brief and was just lying in the bed waiting for a CNA to put a brief on him. Res stated he toileted during the day but needed a brief at night." The Recommendations/Actions were "BSW assessed there was inconsistency with res's statements. Res does have a history of making inaccurate statements." There was no evidence of resolution to the grievance. Further review revealed a thorough investigation had not been completed. The facility failed to identify and report the allegation as potential neglect to the appropriate state agency. The facility admitted Resident #36 on 7/8/11 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed Resident #36's RP made the following complaint on an unknown date and time: "Mother has not had a bath or shower. CNA told daughter that she had a shower on Wednesday. She took Mother's socks off feet were dirty (sic). Dirty and clean clothes are being mixed together. Mother is not getting pain medication. Bottom is red, staying in wet diapers." Further review revealed no investigation had been conducted and no resolution was documented. The facility failed to identify and report the allegation as potential neglect to the appropriate state agency. The facility admitted Resident #37 on 2/25/2008 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/15/12: "CNA-Very lazy- this is not the first time I have came (sic) to visit my mother and she needed to be dried. Another CNA did it for me, ask (CNA) to help but she disappeared- she also has a BO (body odor) problem. I would appreciate if she would not be my mother's CNA..." There was no investigation related to the incident. The allegation was not identified or reported as potential neglect to the appropriate state agency. The CNA identified had no disciplinary action or education documented. No resolution/recommendation or action taken related to the grievance. Another Grievance dated 1/5/12 was made by Resident #37's family member that revealed: "My sister was visiting and noticed a smell and saw after checking my mother that she had feces on both feet, hands and bottom. The CNA who had changed her prior to visit did not clean her properly and dressed her with the feces on her. My sister reported this to the 1st shift nurse on duty as well as to the 1st shift CNA. Said it must have been 3rd shift as my mother was already up and shift start. No investigation had been completed. The facility did not identify or report the incident to the state agency. No resolution or follow up had been documented. The facility admitted Resident #38 on 11/14/08 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 11/21/11 the resident reported to the Social Worker the following: "(Resident #38) reports she is missing a gold necklace. She realized it was missing on Sunday 11/20/11 in AM. The last time she recall seeing the necklace was Thursday or Friday last week. 11/25/11-BSW spoke with CNA who stated she searched the room and was unable to locate necklace." Review of the investigation revealed: "11/21/11 BSW spoke with Administrator who stated incident was not reportable because there was no evidence to support theft. 11/30/11-BSW spoke with res who stated she believed a CNA took her necklace, but she did not know her name. Res stated CNA put silver necklace in bag but not gold one. Res stated she last saw necklace on Friday 11/18/11." The recommendations were, "Facility replaced necklace and was unable to interview alleged CNA due to lack of knowledge of alleged perpetrator." Further review revealed no evidence of an investigation and no attempts to identify the alleged perpetrator. The facility also failed to report the incident to the appropriate state agency. The facility admitted Resident #39 on 1/25/11 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed during the Weekly Resident Interviews on 11/21/11 the resident reported the following: "5. Does staff assist you to the bathroom? " The resident responded, "sometimes, they will get real made at us." Further review revealed no investigation had been conducted. The facility failed to identify the allegation as potential abuse/neglect and failed to report the incident to the appropriate state agency. The facility admitted Resident #40 on 8/26/10 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "Not being changed on 3rd shift- wet up back of shirt every AM..." Further review revealed no investigation had been conducted. The facility failed to identify the incident as potential neglect and failed to report the allegation to the appropriate state agency. No resolution/recommendations or actions were documented. The facility admitted Resident #41 on 9/4/08 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "concerned about cushion in wheelchair and how often it is cleaned or changed out. Resident's nephew stated he took resident out one Sunday and residents cushion was soaked." There was no evidence of an investigation. The facility failed to identify and report the allegation as potential neglect. No resolution, recommendations or actions were documented related to the allegation. The facility admitted Resident #42 on 12/10/03 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/12/12: "Weekend CNA. When I got to (Resident #42's) room he had a BM (bowel movement) from his back to his knees. I turned light on, no one came. I started to clean him up because he was so bad. (Staff member) came in and helped me finish. CNA didn't come into room until 5 PM. If I had not been there, (Resident) would have layed (sic) in a mess for 2 hours. I am sorry but I feel like this is not right." Further review revealed a thorough investigation had not been completed. The facility also failed to identify and report the allegation as potential neglect. No resolution/recommendations or actions had been documented. Another grievance was made by Resident #42's family member on 1/1/12 that revealed: "(Resident #42) was not layed down after breakfast. He was soaking wet. CNA lied to me about laying him down. He was in dining room upset and crying." The staff member was identified, however, a thorough investigation was not completed and the allegation was not identified or reported as potential neglect. No resolution, recommendations or actions had been documented. The facility admitted Resident #45 on 1/24/10 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 10/21/11 the resident's RP made the following complaint: "concerned that resident is not being taken care of and concerned that (facility) can not keep any staff." Further review revealed no investigation had been conducted. There was no evident of follow up, resolution, recommendations or actions documented. The facility admitted Resident #46 on 5/3/10 with [DIAGNOSES REDACTED]. During an interview on 2/28/12 at 4 PM, Resident #46 stated that staff did not check on the resident during the night. She stated that she stayed up in her wheelchair until the early morning hours and staff still did not check on her. Resident #46 stated that staff did not assist her to the bathroom and that once she was in the bed she did not get out of the bed until the next day. Resident #46 also stated that she "dreads going to bed." Review of the Grievance Log revealed 1/14/12 the resident's family member made the following complaint: "My mother informed me that she did not get her 9 PM Lantus Injection. According to the MAR she is correct. There is no signature on the 13th of Jan to indicate she received insulin. She said there were other nights she did not get her insulin. There are other blanks on the MAR, [DATE]..." Further review of the investigation revealed the facility investigated the blank on 1/13/12 but not the blank on 1/7/12. The facility resolved the grievance with the resident and the resident's responsible party regarding the administration of the insulin on 1/13/12. However, the facility had not resolved the grievance related to the insulin administration on 1/7/12. The facility failed to provide evidence of a thorough investigation related to the allegation. During an interview on 2/27/12 at 1:45 PM, the Social Worker (SW) stated that she was responsible for grievances. She stated that when a grievance was received she made the initial report. Then the concern goes to the Administrator for review to determine if it is a reportable incident. If not reportable the grievance goes to the appropriate department for investigation. After the completion of the investigation, the Social Worker stated that she gets the grievance and the investigation back and then she was responsible for following up and documenting the resolutions. The SW confirmed that there were several different grievance forms in use; that the grievances were not thoroughly investigated; that follow up and resolution had not been documented for all grievances. The Social Worker stated that any concerns brought up during the resident council meeting should be placed on a grievance form for investigation and resolution. The SW confirmed that the concerns documented in the resident council minutes had not been placed on a grievance form and that there was no evidence of an investigation or follow up on the concerns. During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator confirmed the Resident Council Meeting Minutes and confirmed that there concerns should have been placed on a grievance log for investigation. The Administrator confirmed no grievances were located related to the resident council minute concerns. The facility admitted Resident #19 on 1/26/12 with [DIAGNOSES REDACTED]. Record review on 2/28/12 at approximately 4:55 PM revealed a "Social Progress Notes" dated 1/27/12 that indicated was observed in her room by the facility social services staff wearing "a hospital gown and a pink bath robe." The social note further indicated the social services contacted Resident #19 Department of Social Services caseworker in reference to the resident needing clothing. An observation and interview on 2/29/12 at approximately 9:45 AM with CNA #5 in reference to the resident closet and dresser revealed the resident had 2 pairs of pants and 1 top. CNA #5 confirmed the observation that there was no clothing of any kind in the resident dresser draws. CNA #5 stated the resident may have clothing in the laundry area. An interview on 2/29/12 at approximately 10:12 AM with the SSA (Social Services Assistant) revealed there was no follow up with the Department of Social Services caseworker to ensure the resident had additional clothing. The SSA provided surveyor a "Personal Inventory Possessions" list which indicated the resident had a pink bathroom, pink slippers, a Memorex Radio on admission. An observation and interview in the laundry area on 2/29/12 at approximately 10:20 AM with laundry worker #1 revealed there was no clothing in the laundry area for Resident #19. The facility admitted Resident #16 on 5/21/07 with [DIAGNOSES REDACTED]. Record review on 2/29/12 at approximately 8:50 AM revealed a "Social Progress Notes" dated 8/09/11 that indicated resident was a [AGE] year old Laotian. Family does visit on occasion and social worker will continue to monitor and assist as needed. Further record revealed there was no further documentation in the "Social Process Notes" to indicate that the social worker continued to monitor as assist as needed. There was Annual MDS (Minimum Data Set) signed 1/20/12 and a Quarterly signed 10/26/11. An interview on 2/29/12 at approximately 9:30 AM with SSA (Social Services Assistant) confirmed the findings related to last social services progress note was dated 8/09/11. An interview on 2/29/12 at approximately 10:15 AM with the SSD (Social Services Director) revealed social progress notes should be documented at least quarterly based on the MDS ( Minimum Data Set). The SSD further stated the SSD was checking to see if additional "Social Progress Notes" were available for Resident #16. An interview on 2/29/12 at approximately 10:30 AM with the Administrator confirmed that "Social Progress Notes" should be documented quarterly. The Administrator further stated the social notes should be documented more often based on resident behavioral concerns. The facility admitted Resident #17 on 5/06/11 with [DIAGNOSES REDACTED]. Record review on 2/29/12 at approximately 11:40 AM revealed a "Social Progress Notes" dated 2/02/12 that indicated the resident requested medical appointments with a dentist and eye doctor and that nursing was informed. The social note further indicated "Res (resident) stated seeing double vision." "Res stated to see both eye doctor and dentist to address needs." An interview on 2/29/12 at approximately 1:15 PM with LPN (Licensed Practical Nurse)#1 revealed social services had the responsibility of scheduling appointment for eye doctor and dentist. LPN #1 stated no effort had been made to schedule eye examine or dental appointments for the Resident #17. An interview on 2/29/12 at approximately 1:25 PM with the (SSD) Social Services Director confirmed the finding that no effort had been made to schedule an eye or dental appointment for the resident. The SSD stated she informed a nurse of the resident request. The SSD further stated she did not do any additional follow-up with the resident's requ | 2015-06-01 |
| 9235 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 441 | E | 1 | 1 | F0R711 | **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 maintain an Infection Control Program to help prevent the development and transmission of disease and infection. The facility had incomplete/missing data relative to their surveillance and/or tracking and trending of infections in the facility. The facility failed to implement Contact Precautions for Resident #3, one of two sampled residents with MRSA (Methicillin Resistant Staph Aureus). Two of two sampled residents reviewed for pre-admission [DIAGNOSES REDACTED] screening (Residents #12 and #13) did not have their 1st step PPDs done prior to admission. Three CNAs were observed handling resident's food with their bare hands. The findings included: The facility has 3 units, Peach (100's), Dogwood (200's), and Magnolia (300's). During an interview on 2/28/12 at 4:25 PM, the Director of Nursing (DON) and 2 nurse consultants verified they were unable to locate documentation relative to surveillance and/or tracking and trending of infections relative to individual residents on the following units for the following months: August 2011- Peach, Dogwood, and Magnolia. September 2011- Dogwood. October 2011- Dogwood and Magnolia. November 2011- Dogwood. During an interview on 2/29/12 at 10:42 AM, the DON and the Regional Nurse Consultant were present. The DON stated she had been the Infection Control Coordinator in November, December, and January prior to taking the DON position. She stated she was responsible to ensure staff are inserviced on infection control issues. She stated that each month in their QA (Quality Assurance) meeting any trends are brought to the committee and discussed. She stated each unit manager maintains a running log of any residents with a potential and/or true infection. She stated they would log any residents with symptoms, tests pending to confirm or rule out an infection, or any resident on an antibiotic. She stated the Unit Managers give the Infection Control Nurse (ICN) this information, and the (ICN) goes back and after determining the true infections, maps this information and identifies/documents any trends. According to the Nurse Consultant, this tracking and trending is also done by the Unit Managers as they collect the data on their logs and communicate this to additional staff in the morning meetings. According to the Nurse Consultant, the facility had identified Infection Control issues and realize some of their data is missing. The facility was unable to provide any summaries related to the missing months listed above. The facility admitted Resident #3 on 10/26/11 with [DIAGNOSES REDACTED]. The resident was known by the facility to have MRSA (Methicillin Resistant Staph Aureus) in a wound that was receiving treatment. Facility staff failed to implement Contact Precautions for Resident #3 with an infected wound and documented history of the Wound Vac dressing coming loose. They also failed to inform staff and visitors on the requirements and need for Contact Precautions and could provide no documentation relative to the Tracking/Trending of the resident's MRSA wound infection. Review of labs on 2/27/12 at 3:22 PM revealed a Wound Culture report dated 2/21/12 (faxed to Wound Center 2/24/12) which documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = Methicillin Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation Recommended...Escherichia Coli (E. Coli)". A second Wound Culture report dated 12/27/11 (faxed to Wound Center 12/30/11) documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = Methicillin Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation [MEDICATION NAME] Faecalis- (Group D). Review of Physician Telephone Orders dated 1/13/12 and 2/24/12 revealed physician orders [REDACTED]. Review of Physician order [REDACTED]. On 12/20/12 the resident returned from the Wound Center with orders for "...Dressing changes Tue(sdays)-Wound Center, Thurs(days)-Sat(urdays) (at the facility". Review of Interdisciplinary Progress Notes from 12/1/11- 2/18/12 revealed the following entries related to the Wound Vac Dressing coming loose. -12/23/11 at 2:20 PM "...This nurse applied adhesive drsg (dressing) to current wound drsg b/c (because) wound vac had lost suctioning. Res(ident) noted in therapy this AM...". -12/27/11 at 10:35 AM "...Wound Center wrote FYI that if wound vac comes off, it is to be replaced w/in (within) 2 hours...". -12/30/11 at 2:00 PM "..Res(ident's) wound vac has been alarming throughout. Family reported res(ident) had been grabbing @ wound vac tubing. Upon turning res(ident) wound vac dressing was noted coming off. Replaced dressing by this nurse...". -1/16/12 at 2:00 PM "Resident (with) appt @ Dr. --this afternoon. Wound vac came unsecure and wet to dry dsg applied (with) NS (Normal Saline) r/t (related to) MD (Physician) appt. Wound Center notified and wound vac will be replace (after) MD appt". -1/31/12 at 8:50 AM "Transport here to get res(ident) by stretcher for appt @ wound center...Wound vac dressing came off @ 7:30 AM while incont(inent) care was being provided. This nurse called wound center .... who stated to put a wet to dry drsg in place b/c wound vac drsg would be replaced @ appt". -2/3/12 at 2:00 PM "...Wound vac (changed) @ noon r/t res(ident) pulling on cord...Family reports res(ident) keeps pulling @ brief, feeding tube, + wound vac tubing". -2/8/12 at 11:45 AM "...Wound vac replaced by this nurse after coming unintact during incont(inent) care...". -2/13/12 at 3:00 PM "...Wound vac drsg (changed) this AM by wound nurse r/t res(ident) pulling @ tubing causing drsg to come off...". Review of Weekly Wound Documentation revealed an entry dated 2/8/12 revealed "Resident with healing stage 4 pressure to sacral area...large amount of serosanguinous drainage...". Another Weekly Wound Documentation report dated 2/22/12 stated "...Wound vac having to be changed more frequently related to losing suction. Order from wound center to replace wound vac within 2 hours if comes off...". Review of Interdisciplinary Progress Notes, 24 Hour Reports, physician's orders [REDACTED]. Observations of the resident's room on 2/27/12 through 2/29/12 revealed no indication the resident was on any transmission based precautions. After this surveyor brought the concern to the facility's attention on 2/29/12, a sign was placed on the resident's door for staff and visitors to see the nurse prior to entering the room. During an interview on 2/29/12 at approximately 9:30 AM and again at 10:10 AM, Licensed Practical Nurse (LPN) #1 stated he was called on Friday 2/24/12 by the Wound Center and informed the resident had MRSA in her wound. He stated when he found out, he informed the CNAs (Certified Nursing Assistants) that were working, along with therapy and told them they needed to use contact precautions with the resident. He stated he talked to both LPN #2 and #5 along with the RN supervisor and asked what needed to be done. He stated he was told to use Universal Precautions. He stated he put red bags in the room for the staff to use for linen and told them to double bad and wash their hands. He also told the oncoming nurse. He provided a 24 hour report dated 2/24/12 which indicated the resident was on antibiotics relative to MRSA in her wound. During an interview on 2/28/12 at 12:45 PM, the resident's sitter stated she has worked with the resident for the last 5 years. She stated she stayed with the resident while she was at home and now sits with the resident at the facility 6 days a week from 8:00 AM to 1:30 PM. The sitter stated that she found out yesterday (2/28/12) when she accompanied the resident to the Wound Center and was told by the Wound Center staff about the MRSA in the resident's wound. She stated when she found out, she went to see the resident's son to tell him, but he was aware of the infection. She stated the facility still had not informed her that the resident had MRSA. She stated she had performed care on the resident; had changed her brief and helped the staff to wash her up without knowing that the resident had an infection. During an interview on 2/29/12 at 9:45 AM, LPN #8 stated she had been told either late Monday or yesterday (2/28/12) that the resident had MRSA. During an interview on 2/29/12 at 10:02 AM, CNA #7 stated she found out on Monday that the resident had MRSA and had no knowledge prior to this. She verified there was no indication that the resident was on any type of precautions, no sign on the door or cart in or near the room that contained gowns or protective equipment. She stated she had not been using a gown, only gloves. When asked if she knew of a time when the wound vac dressing had come loose, she stated approximately one week ago the wound vac dressing had come loose and she had to help clean the resident up. She stated at the time she did not use a gown since she was not aware of an infection. When asked where the gowns were located, she pointed to the supply room which was down the hall from the resident's room. During an interview on 2/29/12 at 10:10 AM, CNA #8 stated she was working today and had worked yesterday (2/28/12) down the hall where the resident was located. She stated there was no sign on the door or a cart near or in the room that contained any protective equipment. She had worked the past weekend and didn't think there was a sign or cart at that time either (couldn't be sure). She stated she had just been told a few minutes prior to my interview about the resident having MRSA. She stated it was probably a month or more since she was assigned the resident, and she had used only gloves at the time. During an interview on 2/29/12 at 10:20 AM, LPN #8 was asked if she had told any of the staff that the resident had MRSA in her wound. She stated she told CNA #7 today. She stated she had reported this information to the nurse taking over for her but she already knew. When asked if she was aware the resident had a wound culture report positive for MRSA in December, she stated she knew the resident was on [MEDICATION NAME], but couldn't remember if it was for MRSA or not. When asked how CNA's are informed about residents with infections or any precautions needed, she stated it should be on the resident's Kardex and/or they would receive a verbal report. Review of the Kardex for Resident #3 revealed no information related to MRSA or any potential/needed precautions. During an interview on 2/29/12 at 10:32 AM, the Wound Care Nurse stated she was aware of a couple times recently when the wound vac dressing had come loose. She stated with a history of MRSA they would just use standard precautions. She stated she was aware of the active [DIAGNOSES REDACTED]. During an interview on 2/29/12 at 11:00 AM the Regional Nurse Consultant was present along with the Director of Nursing (DON). When asked for infection control documentation relative to Resident #3's MRSA wound infection, they provided a log for November 2011 which included an entry dated 11/28/11 for a "pot(ential)" wound infection. A December 2011 log indicated the resident had a "pot(ential)" wound infection on 12/14/11. There was nothing to indicate the MRSA wound infection had been identified or tracked. When asked if they were aware of which residents had histories of and/or active infections with multi-drug resistant organisms and how that was tracked, the DON stated the Infection Control Nurse takes this information from the log that the unit managers provide monthly of residents with infections. She stated the Infection Control Nurse then maps this on a facility room map. Those residents with MDRO's (Multidrug Resistant Organisms) are not taken off. They could not provide any documentation relative to Resident #3 having been mapped for her MRSA infection. The DON and nurse consultant were told of the concern about the resident's Wound Vac dressing coming loose- resulting in infectious wound drainage not being contained with no transmission based precautions put into place. According to the Nurse Consultant, if the drainage was not contained, the resident should have been put on contact precautions. If there were any chance of contact with secretions, staff should wear a gown, glove, and mask along with linen being bagged. When asked when the contact precautions should stop, she stated when the wound was no longer draining. When asked how visitors and staff are informed that precautions are put into place, she stated that a sign would be placed on the door to "see the nurse before entering". She stated this information should also be relayed to the nursing assistants. She thought the reason Contact Precautions were not implemented was that staff were confused over the need for the precautions because of the wound vac. She stated if the wound drainage had been contained, Contact Precautions would not have been needed. Review on 2/29/12 of the policy provided by the facility entitled "Transmission Precautions: Contact" dated 11/15/2002 revealed that "Contact precautions will be initiated when a resident is believed to have an infection requiring such precautions...In addition to Standard Precautions, Contact Precautions may be indicated for residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment". The policy states to "Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Wear a gown if the resident is incontinent, has diarrhea, an ileostomy, or has wound drainage not contained by a dressing...". Review of the policy provided by the facility entitled "Initiating Isolation" dated 3/2004 revealed "Isolation precautions will be initiated when there is reason to believe that a resident has an infectious or communicable disease..Isolation precautions are required for certain infected residents to prevent the spread of disease to other residents, staff, and visitors". According to the policy, when isolation precautions are initiated, the facility is to "...Maintain an adequate supply of isolation supplies (gloves, gowns, masks, etc., as needed) in or near the isolation room so that appropriate personal protective equipment can be easily used. Post an isolation notice sign...on the room entrance door instructing staff and visitors to report to the nursing station before entering the room...". The facility admitted Resident #12 on 12/22/11. The resident's [DIAGNOSES REDACTED]. Record review on 2/28/12 at 1:00 PM revealed no documentation in the chart relative to a pre-admission screening test for [DIAGNOSES REDACTED]. Review of the discharge information from the hospital and the facility Immunization sheet did not include documentation of a PPD. During an interview on 2/28/12 at 1:23 PM, LPN #6 verified she could find no documentation of a PPD (Purified Protein Derivative) having been placed. She stated she would try to find more information. During an interview on 2/29/12 at 1:10 PM, LPN #6 stated she had called the hospital and they did not have documentation relative to a PPD being placed prior to discharge. She stated she had called Hospice since they had started care for the resident when he was at home. She said Hospice said he had refused his PPD. When asked who was responsible for ensuring residents had their PPDs prior to coming to the facility she directed me to the Admissions Coordinator. During an interview on 2/29/12, the Admissions Coordinator stated he was under the impression the Hospice Nurse had placed a PPD, either that or the resident may have had a Chest X-Ray in the hospital. He stated he was trying to get information, but did not provide any documentation prior to exit. During an interview on 2/29/12 at approximately 11:30 AM, the Regional Nurse Consultant stated residents are supposed to have a PPD prior to admission. She provided a policy which included information related to "Resident [DIAGNOSES REDACTED] Screening". The policy stated "For Low Risk and Medium Risk: 1. Admission/Baseline two-step TST or a single BAMT: All residents within one (1) month prior to admission unless there is a documented TST or a BAMT result during the previous twelve (12) months. If a newly-admitted resident had had a documented negative TST or a BAMT result within the previous twelve (12) months, a single TST (or the single BAMT) can be administered within one (1) month prior to admission to the facility to serve as the baseline...". The facility admitted Resident #13 on 2/9/2012 with [DIAGNOSES REDACTED]. Review of Resident #13's chart revealed that he had a Physician's Telephone Order dated 2/16/12 which stated "1st step PPD 0.1 ml (milliter) to be given on 2/16/12 and read on 2/18/12" Resident #13 was admitted on [DATE] prior to receiving his 1st step PPD. Observation on 2/18/12 at 12:48 PM revealed CNA #1 serving Resident #12 his lunch tray in his room. She picked up his roll, unwrapped the plastic wrapping, and placed it back on his tray with her bare hands. On 2/28/12 at 8:10 AM, Certified Nursing Assistant (CNA) #3 was observed during the breakfast meal holding a resident's bread with her bare hands. She buttered the bread, folded it and placed it on the resident's plate. On 2/29/12 during the lunch meal, CNA #4 was observed unwrapping bread for 2 residents, removing the bread from the wrapping with her bare hands and placing it on resident's plates. On 2/29/12 at 2:10 PM, during an interview with CNA #4, she did not dispute the surveyors observations of her placing bread on resident's plates with her bare hands. She stated that she did not remember because she probably does it all the time. When asked by the surveyor if the staff were to touch the resident's food with bare hands, she stated "no." On 2/29/12 at 2:30 PM, during an interview with CNA #3, she stated that she did remember putting butter on a resident's bread and onto the resident's plate with her bare hands. When asked by the surveyor if they (facility staff) should touch the resident's food with bare hands she stated "no." | 2015-06-01 |
| 9236 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 166 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey based on observations, record review, interview and review of the facility Grievance Policy, the facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. Several different grievance forms were used. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 1/15/12 the resident's family member made the following complaint: "(CNA) in charge from 3 to not sure shift. 6:45 PM, Oxygen tank needed refill had to get someone to get her a tank. Sat there a few minutes my daughter asked her... what was wrong. My mother said she was soaking wet. Took her to bathroom (diaper soaked and had come through pants and soaked her cushions, wheelchair). Commode full of crap..." Further review of the facility's investigation revealed staff statements regarding the resident's oxygen tank and toilet. No staff member was identified. The facility also failed to identify and report the allegation as potential neglect to the appropriate State Agency. No resolution or follow up was completed. The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 2/20/12 the resident and the therapy department lodged the following grievance: "Pt (patient) stated he had been trying to get somebody to clean his brief with diarrhea in it since 6:30 AM. Pt states the CNA/nurse med(ium) size, African American with a wide mouth told him to lay there and suffer and if you die they will take care of you." The findings of the facility were as follows: "Pt (light) was on, I ask how I could help him, pt stated he needed to be changed. Pt stated it was burning. I didn't see anyone at the moment so I changed him. Pt bed and bottom a mess. I cleaned pt and changed bed. As I was cleaning (Resident #26 up), pt started all the above. Two therapists came in and helped." Resident #26 signed the grievance, however the staff member who provided care for the resident was not identified. Further review of the Grievance revealed no other investigation had been completed. There was no evidence of resolution, recommendations of actions taken. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/27/2011 the resident's family member lodged the following complaint: "Resident's clothing is saturated with urine when they come to pick them up. Has socks missing." No staff member was identified. The allegation was not reported as potential neglect to the State Survey and Certification Agency. The facility conducted an inservice related to staff changing residents in a timely manner, only 18 staff members attended. The resident's family member was "notified by unit manager, accepted resolution." There was no documentation of the resolution. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/22/11 the resident family member lodged the following complaint: "Last two Sundays, resident is in chair saturated from urine. W/C (wheelchair) is also soaked. Resident sister reports that this happens often. Resident complain of pain on backside. Resident sister reports there was odor from the urine. Resident has not had a cushion for last 3-4 weeks from urine incontinence. Staff has also told sister we are short staffed, and that resident requires a great deal of care and pt is on [MEDICATION NAME]." The resolution was "teachable moment for the CNA of frequency of checks for toileting." The family member was notified by the Director of Nurses (DON) and "was satisfied." Further review revealed a Teachable Moment dated 7/25/11 revealed, "It was brought to our attention that residents are being left wet and clothes are saturated. Residents are to be checked every 2 hours. If you know they are heavy wetters check more frequently. It is unacceptable for our residents to remain in wet/soiled clothing." The INTERIM DON and the staff member signed the Teachable Moment. One staff statement by a Registered Nurse was taken on 7/25/11 that indicated the resident was "checked on Saturday and Sunday at 2:15 PM" and the resident "was dry." The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. Another grievance made by Resident #28's RP on an unknown date and time revealed: "(RP) reports that she came in to visit on Saturday August 27, to find her sister soaked sitting in w/c. She has reported this before. CNAs got her up upon request and changed her but reported they were unable to get her back up because the Hoyer sling was wet and there were no more in the facility..." No investigation was completed and the facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. No resolution/recommendations/actions was taken related to the grievance. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 7/17/11 the resident lodged the following complaint: "Pt reports she was lying in a soaked brief for 3 hours on 7/18/11 before anyone came in to answer her call light. Resident reports this happens often." Review of the Investigation and Findings revealed: "In to speak with res regarding complaint. Res could not say exactly which shift it was. Res then began to have conversation with this nurse about various things. Res happy with new catheter at this time." Review of the Resolution revealed: "Staff re-educated about proper way to position catheter while in bed and importance of emptying cath bag every shift. Res enjoys talking with staff and others as they go into room. Res is lonely for interaction." Review of the Follow up revealed: "Res is satisfied with resolution of above is very appreciative of staff and care is happy with new cath. Has not reported any leaking." Review of the Inservice conducted on 7/20/11 revealed the topic was "Understanding importance of positioning res's with catheters while in bed and chair and emptying cath bag in a timely manner. Ten staff members attended. Further review revealed no staff member was identified, a thorough investigation was not completed and the facility failed to identify and report the allegation as neglect to the appropriate State Agency. Another Grievance lodged by the resident on 12/1/11 revealed: "C/O (Complaints of) resident staying wet two hours at a time, C/O resident light stays on two hours at a time, no one answers but Nsg (nursing) will turn light off at desk, C/O resident refusing showers related to leaving resident in hallway wet and wet hair and resident gets cold." Further review revealed no investigation was conducted. The facility failed to identify, report an allegation of potential neglect to the appropriate State Agency. No follow up and resolution was documented. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member lodged the following complaint on 7/15/11: "resident had a visitor on 7/8/11. Visitor reported to (RP) that (Resident #32) was sitting in the hall and her brief was soaked to the point that it was running out in her chair. This incident occurred at 3:15 PM. Visitor reported to CNA and she changed her. Monday July 11, 2011, (family member) came to visit resident and resident was going into another res room to use the restroom. (Family member) re directed her to her room and attempted to assist her to bathroom. (Resident #32) reported she was burning. (Family Member) reported that feces had dried on her body where she was not properly cleaned. (Family) reported to a nurse or CNA, not sure which. It was reported to her that I am just coming in so it had to happen on 1st shift. As soon as I get report I will come in and take of. This was between 3-3:30 PM. Does not know if they every checked. (Family) cleaned..." Further review revealed the facility failed to identify the incidents as potential neglect, failed to thoroughly investigate the incidents and failed to report the incidents to the appropriate State Agency. The resolution was the resident was placed on an every two hour toileting program, the RP was "in agreement" with the resolution. A teachable moment was provided to one staff member on 7/20/11 related to proper peri care. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 9/22/11 the resident's family member made the following complaint: "Our mother was in the dining room waiting on dinner tray. The odor coming from her was unbearable. We took her to her bathroom and she was soiled through her diaper, clothes and socks. We only saw two CNA's for 2 halls, 1 med tech from agency and 1 employee at nurse's station. How can you legally operate understaffed, residents filthy, resident not being fed (that can't feed themselves) with an employee sitting behind the nurse's desk on the phone throughout dinner? My Mom's dinner was a small spoon of chicken salad in a clump in the middle of her bread less than half a cup of soup and applesauce. Someone in our family is here everyday. We are glad to fed (sic) her and help other residents that can't help themselves. We have no problem taken our mother to the bathroom and clean her, but it is unexceptable for Mom (or any resident soiled and having to wait for a CNA to take them to be cleaned up. How comfortable would you feel soaked with urine and feces eating a meal or sitting in front of food you can't fed yourself. By the time a CNA gets to those that can't fed themselves the food is cold or the residents trying to feed themselves have spilled their water or tea in their plates. The food is ruined and another tray isn't offered. This is not exceptable (sic). It's now 8:00 PM and we still haven't seen a CNA for our mother nor has anyone asked if our mother needed anything. You don't even have out the grievance or complaint sheets at the box. We gladly praise the CNAs and med tech and nurses that do their jobs. My biggest regret was not having someone from DHEC here tonight." The "Investigation and findings" were as follows: "DON called (residents family member) on 9/23/11 at approx(imately) 1:36 PM, daughter shared concerns for all residents (at facility) per incident /those w (with) no family available, (RP) very pleasant/stated have never received a call from Adm before. (RP) very gracious to staff that do their jobs well also (?) out lack of staff. Adm assured (RP) (the facility) is taking applications interviewing and hiring. Shared with (RP) that DON/ADON will (follow up) w this issue and will be back in touch." Further review revealed no investigation was completed, the allegation not sent to the State Survey and Certification Agency and no staff member was identified. The facility failed to provide a resolution to the resident's RP. Another Grievance dated 1/27/12 was lodged by the residents RP that revealed: "Mother was sitting in a urine soaked diaper. I changed it. At 12:10 PM I took my mother again to the bathroom. No CNA came in that time to take my mother to the bathroom." The findings were as follows: "(RP) stated she came in at 10 AM. Res was wet then stated brief was in trash can in room. I checked brief in trash can. Brief was dry. CNA stated she had made rounds at 10 AM and took res to bathroom at that time." Further review revealed a CNA documented a statement on 1/27/12 that the resident was changed twice prior to 10 AM. No other investigation was found. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. Another grievance dated 11/18/11 made by a staff member revealed the following: "Was walking into Magnolia Unit and stopped to speak with (Resident #33) as I walked by her. She asked that I take her out of (facility). When I asked why she would want to leave, she stated she was in pain. I asked where and she pointed to her stomach and legs. I asked her if she needed a nurse- she said yes and she wanted to speak with them. Walked to nurses station, and told (nurse) that (Resident #33) needed a nurse. (Nurse) was very rude and acted as if I was interrupting her. When I told (the nurse) about (Resident #33) being in pain her comment was, "what do you want me to do about it?" I then said if she wasn't the one to help her who would I need to get. Then (the nurse) stated that if (Resident #33) would take her medicine and not spit it out then she wouldn't be in pain. Then I asked her if she was going to tell (Resident #33) that- (The nurse) then turned around, I went to speak with (Administrator) directly afterwards." A thorough investigation was not completed. The recommendations/actions taken were "res meds were re-offered. Nurse received sensitivity training." The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the residents RP lodged the following complaint on 11/10/11: "...RP stated res's diapers are not being changed as often as they should be." The Investigation revealed: "Resident is being laid down for a nap after lunch and is getting back up before supper. Staff re-educated on frequent checks of residents and pericare." No recommendations or actions were taken. The RP was not contacted related to the allegation. There was no evidence of a thorough investigation. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 11/22/11 the resident made the following complaint: "Res stated he woke up at 5:30 AM, turned on his light because his brief needed to be changed. Res stated people kept walking by stating they would get someone else to help him. Res stated no one every came and his sheets and bedding were soiled/soaked and had to be changed." Review of the Investigation revealed: "BSW (Social Worker) met with res again in the afternoon. Res then stated he never had on a brief and was just lying in the bed waiting for a CNA to put a brief on him. Res stated he toileted during the day but needed a brief at night." The Recommendations/Actions were "BSW assessed there was inconsistency with res's statements. Res does have a history of making inaccurate statements." There was no evidence of resolution to the grievance or a thorough investigation. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed Resident #36's RP made the following complaint on an unknown date and time: "Mother has not had a bath or shower. CNA told daughter that she had a shower on Wednesday. She took Mother's socks off feet were dirty (sic). Dirty and clean clothes are being mixed together. Mother is not getting pain medication. Bottom is red, staying in wet diapers." Further review revealed no investigation and no resolution was documented. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/15/12: "CNA-Very lazy- this is not the first time I have came (sic) to visit my mother and she needed to be dried. Another CNA did it for me, ask (CNA) to help but she disappeared- she also has a BO (body odor) problem. I would appreciate if she would not be my mother's CNA..." There was no investigation related to the incident. The allegation was not identified or reported as potential neglect to the appropriate State Agency. The CNA identified had no disciplinary action or education documented. There was no resolution/recommendation or action taken related to the grievance. Another Grievance dated 1/5/12 was made by Resident #37's family member that revealed: "My sister was visiting and noticed a smell and saw after checking my mother that she had feces on both feet, hands and bottom. The CNA who had changed her prior to visit did not clean her properly and dressed her with the feces on her. My sister reported this to the 1st shift nurse on duty as well as to the 1st shift CNA. Said it must have been 3rd shift as my mother was already up and shift start. No investigation was completed. The facility failed to identify or report the incident to the State Agency. The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 11/21/11 the resident reported to the Social Worker the following: "(Resident #38) reports she is missing a gold necklace. She realized it was missing on Sunday 11/20/11 in AM. The last time she recall seeing the necklace was Thursday or Friday last week. 11/25/11-BSW spoke with CNA who stated she searched the room and was unable to locate necklace." Review of the investigation revealed: "11/21/11 BSW spoke with Administrator who stated incident was not reportable because there was no evidence to support theft. 11/30/11-BSW spoke with res who stated she believed a CNA took her necklace, but she did not know her name. Res stated CNA put silver necklace in bag but not gold one. Res stated she last saw necklace on Friday 11/18/11." The recommendations were, "Facility replaced necklace and was unable to interview alleged CNA due to lack of knowledge of alleged perpetrator." Further review revealed no evidence of an investigation and no attempts to identify the alleged perpetrator. The facility also failed to report the incident to the appropriate State Agency. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed during the Weekly Resident Interviews on 11/21/11 the resident reported the following: "5. Does staff assist you to the bathroom? " The resident responded, "sometimes, they will get real made at us." Further review revealed no investigation was conducted. The facility failed to identify the allegation as potential abuse/neglect and failed to report the incident to the appropriate State Agency. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "Not being changed on 3rd shift- wet up back of shirt every AM..." Further review revealed no investigation was conducted. The facility failed to identify the incident as potential neglect and failed to report the allegation to the appropriate State Agency. No resolution/recommendations or actions were documented. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "concerned about cushion in wheelchair and how often it is cleaned or changed out. Resident's nephew stated he took resident out one Sunday and residents cushion was soaked." There was no evidence of an investigation. The facility failed to identify and report the allegation as potential neglect. No resolution, recommendations or actions were documented related to the allegation. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/12/12: "Weekend CNA. When I got to (Resident #42's) room he had a BM (bowel movement) from his back to his knees. I turned light on, no one came. I started to clean him up because he was so bad. (Staff member) came in and helped me finish. CNA didn't come into room until 5 PM. If I had not been there, (Resident) would have layed (sic) in a mess for 2 hours. I am sorry but I feel like this is not right." Further review revealed a thorough investigation was not completed. The facility also failed to identify and report the allegation as potential neglect. No resolution/recommendations or actions was documented. On 1/12/12 Resident #42's family member made another grievance that indicated: "(Resident #42) was not layed down after breakfast. He was soaking wet. CNA lied to me about laying him down. He was in dining room upset and crying." The staff member was identified, however, a thorough investigation was not completed and the allegation was not identified or reported as potential neglect. No resolution, recommendations or actions was documented. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of the Grievance Log revealed on 10/21/11 the resident's RP made the following complaint: "concerned that resident is not being taken care of and concerned that (facility) can not keep any staff." Further review revealed no investigation was conducted. There was no evident of follow up, resolution, recommendations or actions documented. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. During an interview on 2/28/12 at 4:00 PM Resident #46 stated that she stayed up in her wheelchair until the early morning hours and staff still did not check on her. Resident #46 stated that staff did not assist her to the bathroom and that once she was in the bed she did not get out of the bed until the next day. Resident #46 also stated that she "dreads going to bed." Review of the Grievance Log revealed 1/14/12 the resident's family member made the following complaint: "My mother informed me that she did not get her 9 PM [MEDICATION NAME] Injection. According to the MAR indicated [REDACTED]. She said there were other nights she did not get her insulin. There are other blanks on the MAR, [DATE]..." Further review of the investigation revealed the facility investigated the blank MAR indicated [REDACTED]. However, the facility had not resolved the grievance related to the insulin administration on 1/7/12. The facility failed to provide evidence of a thorough investigation related to the allegation. During an interview on 2/27/12 at 1:45 PM, the Social Worker (SW) stated that she was responsible for grievances. She stated that when a grievance was received she made the initial report. Then concern goes to the Administrator for review to determine if it is a reportable incident. If not reportable the grievance goes to the appropriate department for investigation. After the completion of the investigation, the Social Worker stated that she gets the grievance and the investigation back and then she was responsible for following up and documenting the resolutions. The SW confirmed that there were several different grievance forms in use; that the grievances were not thoroughly investigated; that follow up and resolution had not been documented for all grievances. The Social Worker stated that any concerns brought up during the resident council meeting should be placed on a grievance form for investigation and resolution. The SW confirmed that the concerns documented in the resident council minutes had not been placed on a grievance form and that there was no evidence of an investigation or follow up on the concerns. During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator confirmed the Resident Council Meeting Minutes and confirmed that the concerns should have been placed on a grievance log for investigation. The Administrator confirmed no grievances were located related to the concerns stated in the resident council minute. Review of the facility's Grievance Policy revealed: "It is the policy of the facility to support each Resident's right to voice grievances and to ensure that after a grievance has been received, the facility will actively resolve the issue and communicate the resolution's progress to the resident and/or responsible party in a timely manner. The Administrator is ultimately responsible for the resolution of all grievances and/or complaints...All grievances and complaints are investigated, resolved and documented." "3. A copy of the written grievance is to be forwarded to the Facility's Administrator within 24 hours of receipt. 4. Upon receipt of a written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation...5. The Administrator will review the finding with the person investigating the complaint to determine what corrective actions and resolutions need to be made. 6. The Administrator will document receipt of all grievances on the Grievance QA & A Log. The report will be used for tracking and trending as part of the facility's Quality Assessment and Assurance Program. 7. The resident or person filing the complaint on behalf of the resident will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee will complete this report within 3-5 working days of the receipt of the grievance or complaint within the facility. 9. The Resident Council and or Family Council are additional forums for voicing complaints and grievances. Complaints and grievances received from these councils will be acted upon in accordance with this policy..." | 2015-06-01 |
| 9237 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 224 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the failure of the facility to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide any education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS (brief interview of mental status) of 7. The resident coded as incontinent of bowel and bladder requiring extensive one person assist with toilet use, hygiene and transfers. Review of the Grievance Log revealed on 1/15/12 the resident's family member made the following complaint: "(CNA) in charge from 3 to not sure shift. 6:45 PM, Oxygen tank needed refill had to get someone to get her a tank. Sat there a few minutes my daughter asked her Nanny what was wrong. My mother said she was soaking wet. Took her to bathroom (diaper soaked and had come through pants and soaked her cushions, wheelchair). Commode full of crap..." Further review of the facility's investigation revealed staff statements regarding the resident's oxygen tank and toilet. No staff member had been identified and a thorough investigation had not been completed. The facility also failed to identify and report the allegation as potential neglect to the appropriate state agency. No resolution or follow up had been completed. The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS (brief interview of mental status) of 10 indicating moderate impairment. The resident coded as frequently incontinent of bowel and bladder requiring extensive one person assist with toilet use, hygiene and transfers. The resident was noted to communicate via a dry erase board. Review of the Grievance Log revealed on 2/20/12 the resident and the therapy department lodged the following grievance: "Pt (patient) stated he had been trying to get somebody to clean his brief with diarrhea in it since 6:30 AM. Pt states the CNA/nurse med(ium) size, African American with a wide mouth told him to lay there and suffer and if you die they will take care of you." The findings of the facility were as follows: "Pt (light) was on, I ask how I could help him, pt stated he needed to be changed. Pt stated it was burning. I didn't see anyone at the moment so I changed him. Pt bed and bottom a mess. I cleaned pt and changed bed. As I was cleaning (Resident #26 up), pt started all the above. Two therapists came in and helped." Resident #26 signed the grievance, however the staff member who provided care for the resident was not identified. Further review of the Grievance revealed no other investigation. There was no evidence that the allegation was identified and reported as potential neglect/abuse to the appropriate State Agency. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident's BIMS as 3, indicating severe impairment. The resident was noted as always incontinent of bowel and bladder requiring extensive one person assist with toilet use and hygiene. Review of the Grievance Log revealed on 7/27/2011 the resident's family member lodged the following complaint: "Resident's clothing is saturated with urine when they come to pick them up. Has socks missing." No staff member was identified. The allegation was not reported as potential neglect to the State Survey and Certification Agency. The allegation was not thoroughly investigated. The facility conducted an inservice related to staff changing residents in a timely manner, only 18 staff members attended. The resident's family member was "notified by unit manager, accepted resolution." There was no documentation of the resolution. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident's BIMS as 11, indicating moderate impairment. The resident was coded as always incontinent of bowel and bladder requiring two person total dependence for transfers and one person extensive assist with toilet use and hygiene. Review of the Grievance Log revealed on 7/22/11 the resident family member lodged the following complaint: "Last two Sundays, resident is in chair saturated from urine. W/C (wheelchair) is also soaked. Resident sister reports that this happens often. Resident complain of pain on backside. Resident sister reports there was odor from the urine. Resident has not had a cushion for last 3-4 weeks from urine incontinence. Staff has also told sister we are short staffed, and that resident requires a great deal of care and pt is on [MEDICATION NAME]." The resolution was "teachable moment for the CNA of frequency of checks for toileting." The family member was notified by the Director of Nurses (DON) and "was satisfied." Further review revealed a Teachable Moment dated 7/25/11 revealed "It was brought to our attention that residents are being left wet and clothes are saturated. Residents are to be checked every 2 hours. If you know they are heavy wetters check more frequently. It is unacceptable for our residents to remain in wet/soiled clothing." The INTERIM DON and the staff member signed the Teachable Moment. One staff statement by a Registered Nurse was taken on 7/25/11 that indicated the resident was "checked on Saturday and Sunday at 2:15 PM" and the resident "was dry." A thorough investigation was not conducted. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. Another grievance was made by the Resident #28's RP on an unknown date and time that revealed: "(RP) reports that she came in to visit on Saturday August 27, to find her sister soaked sitting in w/c. She has reported this before. CNAs got her up upon request and changed her but reported they were unable to get her back up because they Hoyer sling was wet and there were no more in the facility..." No investigation was completed and the facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. No resolution/recommendations/actions was taken related to the grievance. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident's BIMS score as 10 indicating moderate impairment. The resident was coded as always incontinent of bowel and bladder, requiring total dependence with transfers and extensive one person assist with toilet use and hygiene. Review of the Grievance Log revealed on 7/17/11 the resident lodged the following complaint: "Pt reports she was lying in a soaked brief for 3 hours on 7/18/11 before anyone came in to answer her call light. Resident reports this happens often." Review of the Investigation and Findings revealed: "In to speak with res regarding complaint. Res could not say exactly which shift it was. Res then began to have conversation with this nurse about various things. Res happy with new catheter at this time." Review of the Resolution revealed: "Staff re-educated about proper way to position catheter while in bed and importance of emptying cath bag every shift. Res enjoys talking with staff and others as they go into room. Res is lonely for interaction." Review of the Follow up revealed: "Res is satisfied with resolution of above is very appreciative of staff and care is happy with new cath. Has not reported any leaking." Review of the Inservice conducted on 7/20/11 revealed the topic was "Understanding importance of positioning res's with catheters while in bed and chair and emptying cath bag in a timely manner. Ten staff members attended. Further review revealed no staff member was identified, a thorough investigation was not completed and the facility failed to identify and report the allegation as neglect to the appropriate State Agency. Another Grievance was lodged by the resident on 12/1/11 that revealed: "C/O (Complaints of) resident staying wet two hours at a time, C/O resident light stays on two hours at a time, no one answers but Nsg will turn light off at desk, C/O resident refusing showers related to leaving resident in hallway wet and wet hair and resident gets cold." Further review revealed no investigation had been conducted. The facility failed to identify, report an allegation of potential neglect to the appropriate State Agency. No follow up or resolution was documented. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident had short-term memory problems and was moderately impaired with decision-making abilities. The resident was coded as frequently incontinent of bowel and bladder requiring one person extensive assist with transfers, toilet use and hygiene. Observation of Resident #32 on 2/28/12 revealed the resident was up in her wheelchair with an alarming seat belt in place. The resident stated that she was trying to get to the bathroom but no one would come to help. The resident told the surveyor that she was going to go anyway. The resident unhooked her seatbelt and was going to stand up. The surveyor asked the resident to stay seated in her wheelchair. The Unit Manager heard the alarm and responded to the resident's room quickly and assisted the resident to the restroom. Review of the Grievance Log revealed the resident's family member lodged the following complaint on 7/15/11: "resident had a visitor on 7/8/11. Visitor reported to (RP) that (Resident #32) was sitting in the hall and her brief was soaked to the point that it was running out in her chair. This incident occurred at 3:15 PM. Visitor reported to CNA and she changed her. Monday July 11, 2011, (family member) came to visit resident and resident was going into another res room to use the restroom. (Family member) re directed her to her room and attempted to assist her to bathroom. (Resident #32) reported she was burning. (Family Member) reported that feces had dried on her body where she was not properly cleaned. (Family) reported to a nurse or CNA, not sure which. It was reported to her that I am just coming in so it had to happen on 1st shift. As soon as I get report I will come in and take of. This was between 3-3:30 PM. Does not know if they every checked. (Family) cleaned..." Further review revealed the facility failed to identify the incidents as potential neglect, thoroughly investigate the incidents and the facility failed to report the incidents to the appropriate State Agency. The resolution was to place the resident on an every two hour toileting program, the RP was "in agreement" with the resolution. A teachable moment was provided to one staff member on 7/20/11 related to proper peri care. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident's BIMS as 2 indicating severe impairment. The resident was coded as always incontinent of bowel and bladder requiring one person extensive assist with toilet use, hygiene and transfers. Review of the Grievance Log revealed on 9/22/11 the resident's family member made the following complaint: "Our mother was in the dining room waiting on dinner tray. The odor coming from her was unbearable. We took her to her bathroom and she was soiled through her diaper, clothes and socks. We only saw two CNA's for 2 halls, 1 med tech from agency and 1 employee at nurse's station. How can you legally operate understaffed, residents filthy, resident not being fed (that can't feed themselves) with an employee sitting behind the nurse's desk on the phone throughout dinner? My Mom's dinner was a small spoon of chicken salad in a clump in the middle of her bread less than half a cup of soup and applesauce. Someone in our family is here everyday. We are glad to fed (sic) her and help other residents that can't help themselves. We have no problem taken our mother to the bathroom and clean her, but it is unexceptable (sic) for Mom (or any resident soiled and having to wait for a CNA to take them to be cleaned up. How comfortable would you feel soaked with urine and feces eating a meal or sitting in front of food you can't fed yourself. By the time a CNA gets to those that can't fed themselves the food is cold or the residents trying to feed themselves have spilled their water or tea in their plates. The food is ruined and another tray isn't offered. This is not exceptable (sic). It's now 8:00 PM and we still haven't seen a CNA for our mother nor has anyone asked if our mother needed anything. You don't even have out the grievance or complaint sheets at the box. We gladly praise the CNAs and med tech and nurses that do their jobs. My biggest regret was not having someone from DHEC here tonight." The "Investigation and findings" were as follows: "DON called (residents family member) on 9/23/11 at approx(imately) 1:36 PM, daughter shared concerns for all residents (at facility) per incident /those w (with) no family available, (RP) very pleasant/stated have never received a call from Adm before. (RP) very gracious to staff that do their jobs well also (?) out lack of staff. Adm assured (RP) (the facility) is taking applications interviewing and hiring. Shared with (RP) that DON/ADON will (follow up) w this issue and will be back in touch." Further review revealed no investigation was completed, the allegation was not sent to the State Survey and Certification Agency and no staff members was identified. The facility failed to provide a resolution to the resident's RP. Another Grievance dated 1/27/12 was lodged by the residents RP that revealed: "Mother was sitting in a urine soaked diaper. I changed it. At 12:10 PM I took my mother again to the bathroom. No CNA came in that time to take my mother to the bathroom." The findings were as follows: "(RP) stated she came in at 10 AM. Res was wet then stated brief was in trash can in room. I checked brief in trash can. Brief was dry. CNA stated she had made rounds at 10 AM and took res to bathroom at that time." Further review revealed a CNA documented a statement on 1/27/12 that the resident was changed twice prior to 10 AM. No other investigation was found. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. Another grievance dated 11/18/11 made by a staff member revealed the following: "Was walking into Magnolia Unit and stopped to speak with (Resident #33) as I walked by her. She asked that I take her out of (facility). When I asked why she would want to leave, she stated she was in pain. I asked where and she pointed to her stomach and legs. I asked her if she needed a nurse- she said yes and she wanted to speak with them. Walked to nurse's station, and told (nurse) that (Resident #33) needed a nurse. (Nurse) was very rude and acted as if I was interrupting her. When I told (the nurse) about (Resident #33) being in pain her comment was, "what do you want me to do about it?" I then said if she wasn't the one to help her who would I need to get. Then (the nurse) stated that if (Resident #33) would take her medicine and not spit it out then she wouldn't be in pain. Then I asked her if she was going to tell (Resident #33) that- (The nurse) then turned around, I went to speak with (Administrator) directly afterwards." A thorough investigation was not completed. The recommendations/actions taken were "res meds were re-offered. Nurse received sensitivity training." The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident had short-term and long-term memory problems with moderately impaired decision-making abilities. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with transfers, toilet use and hygiene. Review of the Grievance Log revealed the residents RP lodged the following complaint on 11/10/11: "...RP stated res's diapers are not being changed as often as they should be." The Investigation revealed: "Resident is being laid down for a nap after lunch and is getting back up before supper. Staff re-educated on frequent checks of residents and pericare." No recommendations or actions was taken. The RP was not contacted related to the allegation. A thorough investigation was not conducted. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident had no cognitive impairments and coded as frequently incontinent of bladder and always continent of bowel. The resident was coded as requiring extensive one person assist with hygiene and toilet use. Review of the Grievance Log revealed on 11/22/11 the resident made the following complaint: "Res stated he woke up at 5:30 AM, turned on his light because his brief needed to be changed. Res stated people kept walking by stating they would get someone else to help him. Res stated no one every came and his sheets and bedding were soiled/soaked and had to be changed." Review of the Investigation revealed: "BSW (Social Worker) met with res again in the afternoon. Res then stated he never had on a brief and was just lying in the bed waiting for a CNA to put a brief on him. Res stated he toileted during the day but needed a brief at night." The Recommendations/Actions were "BSW assessed there was inconsistency with res's statements. Res does have a history of making inaccurate statements." There was no evidence of a resolution to the grievance. Further review revealed a thorough investigation was not completed. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident had short-term and long-term memory problems and was moderately impaired with daily decision-making abilities. The resident coded as occasionally incontinent of bladder and frequently incontinent of bowel requiring one person extensive assist with hygiene and toilet use. Review of the Grievance Log revealed Resident #36's RP made the following complaint on an unknown date and time: "Mother has not had a bath or shower. CNA told daughter that she had a shower on Wednesday. She took Mother's socks off feet were dirty (sic). Dirty and clean clothes are being mixed together. Mother is not getting pain medication. Bottom is red, staying in wet diapers." Further review revealed no investigation was conducted with any documented resolution. The facility failed to identify and report the allegation as potential neglect to the appropriate State Agency. The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident's BIMS as 0 indicating severe impairment. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with toilet use and hygiene. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/15/12: "CNA (certified nurse aide) - Very lazy- this is not the first time I have came (sic) to visit my mother and she needed to be dried. Another CNA did it for me, ask (CNA) to help but she disappeared- she also has a BO (body odor) problem. I would appreciate if she would not be my mother's CNA..." There was no investigation related to the incident. The allegation was not identified or reported as potential neglect to the appropriate State Agency. There was no disciplinary action or education documented for the identified CNA. No resolution/recommendation or action taken related to the grievance. Another Grievance dated 1/5/12 was made by Resident #37's family member that revealed: "My sister was visiting and noticed a smell and saw after checking my mother that she had feces on both feet, hands and bottom. The CNA who had changed her prior to visit did not clean her properly and dressed her with the feces on her. My sister reported this to the 1st shift nurse on duty as well as to the 1st shift CNA. Said it must have been 3rd shift as my mother was already up and shift start. No investigation had been completed. The facility failed to identify or report the incident to the State Agency. No resolution or follow was documented. The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS revealed the resident's BIMS as 12 indicating moderate impairment. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with hygiene and toilet use. Review of the Grievance Log revealed on 11/21/11 the resident reported to the Social Worker the following: "(Resident #38) reports she is missing a gold necklace. She realized it was missing on Sunday 11/20/11 in AM. The last time she recall seeing the necklace was Thursday or Friday last week. 11/25/11-BSW spoke with CNA who stated she searched the room and was unable to locate necklace." Review of the investigation revealed: "11/21/11 BSW spoke with Administrator who stated incident was not reportable because there was no evidence to support theft. 11/30/11-BSW spoke with res who stated she believed a CNA took her necklace, but she did not know her name. Res stated CNA put silver necklace in bag but not gold one. Res stated she last saw necklace on Friday 11/18/11." The recommendations were, "Facility replaced necklace and was unable to interview alleged CNA due to lack of knowledge of alleged perpetrator." Further review revealed no evidence of an investigation and no attempts to identify the alleged perpetrator. The facility failed to report the incident to the appropriate State Agency. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. Review of the Annual MDS revealed the resident's BIMS as 10 indicating moderate impairment. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with toilet use and hygiene. Review of the Grievance Log revealed during the Weekly Resident Interviews on 11/21/11 the resident reported the following: "5. Does staff assist you to the bathroom? " The resident responded, "sometimes, they will get real made at us." Further review revealed no investigation had been conducted. The facility failed to identify the allegation as potential abuse/neglect and failed to report the incident to the appropriate State Agency. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident's BIMS as 8. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with hygiene and toilet use. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "Not being changed on 3rd shift - wet up back of shirt every AM..." Further review revealed no investigation was conducted. The facility failed to identify the incident as potential neglect and failed to report the allegation to the appropriate State Agency. No resolution/recommendations or actions were documented. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident's BIMS as 9. The resident coded as always incontinent of bowel and bladder requiring extensive one person assist with toilet use and hygiene. Review of the Grievance Log revealed the resident's family member made the following complaint on 10/21/11: "concerned about cushion in wheelchair and how often it is cleaned or changed out. Resident's nephew stated he took resident out one Sunday and residents cushion was soaked." There was no evidence of an investigation. The facility failed to identify and report the allegation as potential neglect. No resolution, recommendations or actions were documented related to the allegation. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident was coded as having short-term memory problems with severely impaired decision-making abilities. The resident coded as always incontinent of bowel and bladder requiring total dependence with toilet use and hygiene. Review of the Grievance Log revealed the resident's family member made the following complaint on 1/12/12: "Weekend CNA. When I got to (Resident #42's) room he had a BM (bowel movement) from his back to his knees. I turned light on, no one came. I started to clean him up because he was so bad. (Staff member) came in and helped me finish. CNA didn't come into room until 5 PM. If I had not been there, (Resident) would have layed (sic) in a mess for 2 hours. I am sorry but I feel like this is not right." Further review revealed a thorough investigation was not completed. The facility failed to identify and report the allegation as potential neglect. No resolution/recommendations or actions were documented. Resident #42's family member made another grievance on 1/1/12 that indicated: "(Resident #42) was not layed down after breakfast. He was soaking wet. CNA lied to me about laying him down. He was in dining room upset and crying." The staff member was identified, however, a thorough investigation was not completed and the allegation was not identified or reported as potential neglect. No resolution, recommendations or actions were documented. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had short-term memory problems with moderately impaired with decision-making abilities. The resident coded as requiring two person total dependence for transfers and bathing; one person assist with dressing, eating, hygiene and toilet use was required. The resident coded as always incontinent of bowel and bladder. Review of the Grievance Log revealed on 10/21/11 the resident's RP made the following complaint: "concerned that resident is not being taken care of and concerned that (facility) can not keep any staff." Further review revealed no investigation was conducted. There was no documented follow up, resolution or recommendation. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident had no cognitive impairment. The resident coded as one person limited assist with toilet use and hygiene. The resident was identified by the facility as interviewable. During an interview on 2/28/12 at 4 PM, Resident #46 stated that staff did not check on her during the night. She stated that she stayed up in her wheelchair until the early morning hours and staff still did not check on her. Resident #46 stated that staff did not assist her to the bathroom and that once she was in the bed she did not get out of the bed until the next day. Resident #46 also stated that she "dreads going to bed." During an interview on 2/27/12 at 1:45 PM, the Social Worker (SW) stated that she was responsible for grievances. She stated that when a grievance was received she made the initial report. Then concern goes to the Administrator for review to determine if it is a reportable incident. If not reportable the grievance goes to the appropriate department for investigation. After the completion of the investigation, the Social Worker stated that she gets the grievance and the investigation back and then she was responsible for following up and documenting the resolutions. The SW confirmed that there were several different grievance forms in use; that the grievances were not thoroughly investigated; that follow up and resolution had not been documented for all grievances. The Social Worker stated that any concerns brought up during the resident council meeting should be placed on a grievance form for investigation and resolution. The SW confirmed that the concerns documented in the resident council minutes had not been placed on a grievance form and that there was no evidence of an investigation or follow up on the concerns. During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator confirmed the Resident Council Meeting Minutes and confirmed that the concerns should have been placed on a grievance log for investigation. The Administrator confirmed no grievances were located related to the concerns stated in the resident council minute. | 2015-06-01 |
| 9238 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 226 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the facility failure to follow their Abuse and Neglect Prohibition Policy related to the identification of potential neglect, to thoroughly investigate allegations of potential neglect, to report potential neglect and to protect residents from potential neglect. The findings included: Cross Refers to F-224 as it related to the failure of the facility to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The facility's Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The Social Services Department was responsible for the grievance process and was responsible for assuring the investigations were completed as well as responsible for following up on each grievance. Review of the facility Policy on Abuse and Neglect Prohibition revealed the following: "Prevention 1. Resident's, families and staff will be able to report concern, incidents and grievances without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring... Identification 1. The facility QA &A Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investigation/intervention through analysis of systems, audits and reports.... Investigation 1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulations. 3. The facility will report all investigation findings to the state as per state regulations. 4. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of resident property, identified through analysis conducted by the QA&A committee, with intervention, reporting or policy/procedure modification as appropriate..." During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator confirmed the Resident Council Meeting Minutes and confirmed that there concerns should have been placed on a grievance log for investigation. The Administrator confirmed no grievances were located related to the resident council minute concerns. | 2015-06-01 |
| 9239 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 490 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified and the Administration was informed on 2/28/2012 at 9:50 AM related to the facility's Administration to effectively utilize it's resources to maintain the highest practicable well being of each resident. The facility Administrator failed to address reported grievances to ensure prompt resolution and to ensure actual/potential neglect/abuse/misappropriation of property had not occurred. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Several different grievance forms were used. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. During an interview on 2/27/12 at 1:45 PM, the Social Worker (SW) stated that she was responsible for grievances. She stated that when a grievance was received she made the initial report. Then the concern goes to the Administrator for review to determine if it is a reportable incident. If not reportable the grievance goes to the appropriate department for investigation. After the completion of the investigation, the Social Worker stated that she gets the grievance and the investigation back and then she was responsible for following up and documenting the resolutions. The SW confirmed that there were several different grievance forms in use; that the grievances were not thoroughly investigated; that follow up and resolution had not been documented for all grievances. The Social Worker stated that any concerns brought up during the resident council meeting should be placed on a grievance form for investigation and resolution. The SW confirmed that the concerns documented in the resident council minutes had not been placed on a grievance form and that there was no evidence of an investigation or follow up on the concerns. During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility's failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator reviewed the Resident Council Meeting Minutes and confirmed that there were concerns that should have been placed on a grievance log for investigation. The Administrator confirmed no grievances were located related to the resident council minute concerns. Review of the facility's Grievance Policy revealed: "It is the policy of the facility to support each Resident's right to voice grievances and to ensure that after a grievance has been received, the facility will actively resolve the issue and communicate the resolution's progress to the resident and/or responsible party in a timely manner. The Administrator is ultimately responsible for the resolution of all grievances and/or complaints...All grievances and complaints are investigated, resolved and documented." "3. A copy of the written grievance is to be forwarded to the Facility's Administrator within 24 hours of receipt. 4. Upon receipt of a written grievance and/or complaint, the Administrator will refer it to the appropriate department head for investigation...5. The Administrator will review the finding with the person investigating the complaint to determine what corrective actions and resolutions need to be made. 6. The Administrator will document receipt of all grievances on the Grievance QA & A Log. The report will be used for tracking and trending as part of the facility's Quality Assessment and Assurance Program. 7. The resident or person filing the complaint on behalf of the resident will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. This report will be completed by the Administrator, or his or her designee within 3-5 working days of the receipt of the grievance or complaint within the facility. 9. The Resident Council and or Family Council are additional forums for voicing complaints and grievances. Complaints and grievances received from these councils will be acted upon in accordance with this policy..." | 2015-06-01 |
| 9240 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 520 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey, Substandard Quality of Care was identified and the Administration was informed on 2/28/2012 at 9:50 AM related to the facility's failure to provide medically related social services related the facility's grievance process. The facility failed to identify potential neglect, thoroughly investigate allegations of potential neglect, report potential neglect and protect residents from potential neglect. Resident #4, 26, 27, 29, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 had grievances logged related to lack of incontinent care "resident's were left saturated in urine and or feces" and abuse/neglect. The facility social services department failed to thoroughly investigate each incident and failed to report potential abuse/neglect/misappropriation of property to the appropriate State Agency. The systematic failure was not identified as a concern by the facility Quality Assurance program. The findings included: During the Complaint Survey, related to allegations of grievances not thoroughly investigated and resolved, the facility's grievances were reviewed. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations had a staff member identified. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The Social Services Department was responsible for the grievance process and was responsible for assuring the investigations were completed as well as responsible for following up on each grievance. During an interview on 2/28/12 at 10:05 AM, the Administrator was informed that Substandard Quality of Care existed in the facility related to the facility's failure to identify, investigate and report allegations of potential neglect. The above grievances were reviewed with the Administrator. The Administrator stated that all grievances were brought to the morning standup meeting and were reviewed. He confirmed that he attended the morning meetings and was aware of the grievances. During a follow up interview at 1:30 AM, the Administrator verified Resident Council Meeting Minutes reflected similar concerns and confirmed that the concerns should have been placed on a grievance log for further investigation. No grievances were located related to the documented resident council minute concerns. During an interview on 2/28/12 at 10:20 AM, the Administrator and DON were present. The Administrator stated that grievances are discussed in the morning meetings. The staff involved in the meetings included himself, the ADON, (Assistant Director of Nursing) DON (Director of Nursing) , MDS (Minimum Data Set) Coordinators, and all department heads. When asked whether a grievance was submitted February 20th for sampled Resident #26, he stated that they did discuss the grievance, but since the resident was a poor historian and unreliable, no further action had been taken. He could provide no documentation related to any investigation having been done related to this grievance. When questioned about other grievances involving possible abuse or neglect, facility documentation failed to show an attempt to identify the staff involved and failed to conduct staff interviews. One resident had run out of Oxygen and was found sitting in a wet wheelchair saturated down to his socks. According to the facility documentation, this was noted to be a teachable moment on checking Oxygen. However, the possible lack of incontinence care was not addressed. The DON stated that she saw that this was a problem could see where a breakdown exists. . When asked how Resident Council Meeting concerns were addressed, the DON stated depending on the concern, the department involved would handle it. For example if the concern in Resident Council was related to staffing on 3rd shift, Nursing would be responsible for investigating the concern and this should be documented on a grievance form so it can be resolved. When asked if the Resident Council Meeting Minutes were discussed in the morning meetings, the DON did not believe any of the councils concerns had been documented in their morning meeting. The following concerns were noted to be concerns addressed by the resident council: e January- Call light removed?, cream?, staff not coming around every shift. December- Didn't feel CNAs/Nurses treated residents fairly, Call light turned off at the desk. November- Staff short handed on night shift, Staff not answering call lights timely. When asked where grievances could be found relative to the above resident council concerns, the DON stated that Social Services should have them. The Administrator stated "There's a problem with the system". On 2/29/12 at approximately 2:50PM, during an interview with facility Administration related to the facility Quality Assurance (QA) Program, it was stated that "somethings" were QA'd including accident/incidents, infection control and safety issues. However, the facility could not provide any documentation - including action plans or proposed time lines for correction. | 2015-06-01 |
| 9989 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 315 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record review, and review of the facility provided policy for Catheter Care, the facility failed to provide appropriate catheter care for 2 of 3 residents observed for catheter care. Facility Certified Nursing Assistants failed to practice acceptable infection control standards during catheter care for Residents #7 and #15. The findings included: The facility admitted Resident #15 on 5/18/11 with [DIAGNOSES REDACTED]. Catheter care was provided on 2/28/12 at approximately 2:15 PM by CNA (Certified Nursing Assistant) # 6 and CNA #5. Both CNA's knocked, entered the room, identified self and explained the procedure, provided privacy by closing the door and pulling the privacy curtain. They washed hands and gloved. CNA #6 used a disposable wipe to clean the right side of the tip of the penis downward toward the shaft and discarded the wipe. She then used a clean disposable wipe and cleaned the left side of the tip of the penis downward toward the shaft and discarded the wipe. CNA #6 then used a third disposable wipe and cleaned the catheter tubing avoiding the meatus, thus not cleaning the site of tube insertion into the urethra. CNA #6 bagged up the trash, removed the soiled gloves, washed hands and with assistance from CNA #5, the resident was repositioned and covered. CNA #6 then placed the trash in the soiled linen room and washed hands in another resident's room. On 2/29/12 at approximately 4:00 PM, during an interview with the Director of Nursing (DON) regarding expected practice of catheter care related to infection control standards, she confirmed the importance of cleaning the meatus and the catheter tubing at this site. The facility admitted Resident #7 on 3/19/10 with [DIAGNOSES REDACTED]. Record review on 2/28/12 revealed lab results from December 2011 through February 2012 documenting several UTI's (Urinary Tract Infections) for Resident #7. Observation of catheter care on 2/29/12 at 11:45 AM revealed Certified Nursing Assistant (CNA) #7 performing catheter care while Licensed Practical Nurse (LPN) #8 assisted. Observation when the covers were removed revealed the catheter was not secured to the resident's thigh to prevent tension on the tubing. While holding the resident's penis with her left hand, CNA #7 took a wipe from the overbed table and wiped once around the right side. She took another wipe and wiped once around the left side. She did not start at or clean around the meatus. She then anchored the tubing with her left hand and wiped down the tubing with an additional wipe. She then removed her gloves, picked up the trash bag, and left the room without washing her hands. During an interview immediately after the procedure, CNA #7 did not dispute the surveyor's observations. Review on 2/29/12 of the policy provided by the facility entitled "Indwelling Catheter Care", "Routine catheter care helps prevent infections and other complications...". According to the policy, the procedure for catheter care included "...12. Use a saturated, sterile gauze pad, sterile cotton tipped applicator, and/or skin wipes to clean outside of catheter and tissue around meatus...21. Remove gloves and dispose, 22. Wash hands". | 2014-08-01 |
| 9990 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 279 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record reviews and interviews, the facility failed to develop a comprehensive care plan for Resident #13, (1 of 1 with a Intr[DIAGNOSES REDACTED]c Defibrillator), that included measurable objectives and timetables to meet a resident's needs that were identified in the comprehensive assessment. The findings included: The facility admitted Resident #13 on 2/9/2012 with [DIAGNOSES REDACTED]. On 2/28/12 at 11:45 AM, record review for Resident #13 revealed that the resident had had an ICD placed prior to admission to the facility. Review of the Nursing Admission/Quarterly Evaluation Form dated 2/9/12 indicated that the resident was assessed as having "scars" on the upper right and left areas of his chest. The Nursing notes for 2/9/12 contained no documentation related to the areas. Review of the resident's care plan revealed the resident had no care plan for the ICD. During an interview on 2/29/12 at 8:55 AM, Licensed Practical Nurse (LPN) #5 verified that the resident did not have a care plan for the ICD. | 2014-08-01 |
| 9991 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 280 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification and complaint survey, based on record review and interview, the facility failed to update a plan of care for 1 of 2 sampled residents reviewed [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus). The care plan for Resident #3 was not updated related to the resident'[MEDICAL CONDITION] wound infection. The findings included: The facility admitted Resident #3 on 10/26/11 with Left Lower Lobe Pneumonia, History of Hypotensive Septic Shock, Urosepsis and Metabolic Acidosis. . Review of the resident's labs on 2/27/12 at 3:22 PM revealed a Wound Culture report dated 2/21/12 (faxed to Wound Center 2/24/12) which documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation Recommended...Escherichia Coli (E. Coli)". A second Wound Culture report dated 12/27/11 (faxed to Wound Center 12/30/11) documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation [MEDICATION NAME] Faecalis- (Group D). Review of Physician Telephone Orders dated 2/24/12 revealed an entry for "1. [MEDICATION NAME] 500 mg (1) per tube QID (Four times daily) X 10 days, 2. Keflex 500 mg (milligrams) (1) via tube QID X 10 days". According to the Wound Culture report dated 2/21/12, [MEDICATION NAME] was listed as being sensitive to Staph Aureus while Keflex was listed as being sensitive to the E. Coli. Review of Physician order [REDACTED]. If wound vac off replace in 2 hours, [MEDICATION NAME] 300 mg Q (every) 8 hrs (hours) X 6 weeks...Cont(inue) [DEVICE]". Review of facility Physician Telephone Orders revealed an entry dated 1/3/12 to "D/C Bactrim, Start [MEDICATION NAME] (1) via tube TID (Three Times Daily) X 6 weeks, ...". According to the Wound Culture report dated 12/27/11, [MEDICATION NAME] was listed as being sensitive to Staph Aureus. Review of the Care Plan on 12/29/12 revealed an entry dated 12/6/11 which stated "Resident had the following skin problems...Sacral US...". The goal was that the "Resident will show improvement in each area and no s/s (signs/symptoms) of infections through 1/31/12" and had been updated to go through 4/20/12. The Approaches included updates relative to the Antibiotics prescribed on 1/3/12 and 2/24/12, but did not include information that the resident [MEDICAL CONDITION] (drug resistant infection) in her wound. During an interview on 2/29/12 at 9:53 AM, LPN #5 verified the resident's Care Plan did not included information relative to the resident'[MEDICAL CONDITION] wound infection. She stated she was not aware the resident had [MEDICAL CONDITION]. She stated she updated the Care Plan as she received the Physician orders [REDACTED]. | 2014-08-01 |
| 9992 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 281 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record reviews and interviews, the facility failed to provide services that met professional standards of quality for 3 of 14 sampled residents reviewed for medication administration. Resident #8 received no follow up related to a medication that was placed on hold on 11/29/11. Nursing staff inaccurately notified the Physician of a positive [MEDICAL CONDITION] lab result for Resident #3, resulting in an unnecessary treatment with [MEDICATION NAME]. Resident #7 was not provided Sliding Scale Insulin as ordered by the Physician. The findings included: The facility admitted Resident #8 on 2/18/10 with [DIAGNOSES REDACTED]. On 2/27/12, review of the Physician's Telephone Orders and Nurse's Notes dated 11/29/11 stated to "hold [MEDICATION NAME] until further notice". Communication from the [MEDICAL TREATMENT] Clinic stated "Phosphorus is low at 2.3-Hold [MEDICATION NAME]." The Resident's current Medication Administration Record [REDACTED]"Hold until further notice r/t (related to) phosphorus level 11-29-11 labs at DCI ([MEDICAL TREATMENT] Clinic)." The resident's lab results revealed that the facility had not obtained results since November 2011. In an interview on 2/27/12 with Licensed Practical Nurse (LPN) #6, she stated that she would have expected the order to hold the medication to be evaluated when the next lab results were received . She verified labs are drawn at the [MEDICAL TREATMENT] Clinic. LPN #6 and LPN #7 verified that the facility had not received lab results since November 2011 and agreed that they should have followed up on the order sooner. The facility admitted Resident #3 on 10/26/11 with [DIAGNOSES REDACTED]. Record review on 2/28/12 at approximately 11:00 AM revealed a lab result dated 2/1/12 for [MEDICAL CONDITION] which was reported as "negative". Review of Interdisciplinary Progress Notes on 2/29/12 revealed the following notes:-2/2/12 at 7:30 PM "Res(ident's) stool culture received. Indicated positive for [MEDICAL CONDITION]. This nurse called res(idents) doctor...+ family. (Doctor) gave telephone order for [MEDICATION NAME] 500 mg (1) via tube TID (Three times daily) X 7 days...". Further review of the Interdisciplinary Progress Notes revealed Resident #3 had been treated with [MEDICATION NAME] (Antibiotic) for [MEDICAL CONDITION] through 2/9/12 . Review of "Weekly Wound Documentation" for Resident #3 revealed a note dated 2/8/12 which stated "...Resident's appt (appointment) for wound center was rescheduled this week in relation to resident had [MEDICAL CONDITION] last week. Resident has continual diarrhea as a side effect from tube feeding...". During an interview on 2/29/12, Licensed Practical Nurse (LPN) #1 was asked about any precautions used for the resident's [MEDICAL CONDITION] infection. He stated that contact precautions were put into place at the time. He provided a copy of a 24 Hour Report/Change of Condition Report dated 2/3/12 which stated "*(Resident #3)- [MEDICAL CONDITION] +, Contact Precautions*FYI (For Your Information)". Prior to exit on 2/29/12 at approximately 5:10 PM, the Nurse Consultant stated she could not find a [MEDICAL CONDITION] positive lab result after reviewing the lab results. The facility admitted Resident #7 on 3/19/10 with [DIAGNOSES REDACTED]. Accucheck/ Insulin Flow Records for November 2011, December 2011, and January 2012, documented 2 units of Regular Insulin should have been given for FSBSs of 151-200. Record review on 2/28/12 at 2:32 PM revealed the following entries for Finger Stick Blood Sugars (FSBS) that required 2 units of Regular SSI (Sliding Scale Insulin) that were not administered: 1/1/12 at 4:00 PM, Blood sugar 152. 1/3/12 at 6:00 AM Blood sugar 154. 12/9/11 at 6:00 AM Blood sugar 162. 11/25/11 at 4:00 PM Blood sugar 165. During an interview on 2/28/12 at 2:32, LPN #1 verified the above blood sugar documentation. He stated the resident should have received 2 units of insulin coverage per the physician's orders [REDACTED]. | 2014-08-01 |
| 9993 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 285 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, the facility failed to obtain a Preadmission Screening for Resident #13 prior to admission. (1 of 24 sampled residents reviewed for PASARR completion.) The PASARR for Resident # 13 was not completed until after the resident resided in the facility for six days. The findings included: The facility admitted Resident #13 on 2/9/2012 with [DIAGNOSES REDACTED]. On 2/28/12 at 10:40 AM, record review for Resident #13 revealed that he was admitted to the facility on [DATE] and that his PASARR was not completed until 2/14/12 at the facility. At the time of record review, Licensed Practical Nurse (LPN) #6 verified that the PASARR was dated 2/14/12 and should have been completed prior to the resident being admitted to the facility. | 2014-08-01 |
| 9994 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 371 | E | 0 | 1 | F0R711 | On the days of the survey, based on observations and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Dietary staff members were observed improperly wearing harinets. Food items stored in the freezer were unlabeled or stored in torn bags. Resident meal trays were cracked with metal exposed on the rims. The findings included: On 2/27/12 at 10:30 AM, two dietary staff members and the Dietary Manager (DM) were observed improperly wearing hair restraints. Hair was exposed and not restrained by the hair nets while the staff was observed in the food service area. The concern was not disputed by the DM. Observation of the facility's freezer revealed a bag of Chicken Cordon Bleu stored out of its original box with no label/date, and the bag was torn. There was also 1 large bag of meatballs and 1 large bag of diced ham which was not dated nor labeled. On 2/28/12 at 11:00 AM, an additional 2.5 large bags of tatter tots were observed in the freezer with no date/label and not in the original box (all unlabeled items were identified/verified by the DM). Meal trays which were being used to serve resident meals were observed with chipped sides, exposed metal on the edges. | 2014-08-01 |
| 9995 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 425 | D | 0 | 1 | F0R711 | On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medication (insulin) was not stored with other medications available for use in 2 of 6 medication carts. The findings included: On 2/29/12, review of the facility's medication carts revealed that the Peach (short hall cart) contained a 100 unit/milliliter (ml) vial of Lantus Insulin with an opened date of 1/22 and an expiration date of 2/19 and one 100 unit/ml vial of Regular Insulin with an expiration date of 2/15/12. Both of the insulins were available for staff use despite being past their expiration date. The (long hall) cart on the Peach Unit contained a 100 unit/ml vial of Lantus Insulin with an open date of 1/21/12 and an expiration date of 2/17/12 that should not have been available for resident use. Registered Nurse #1 verified the expiration dated of the Insulins on the short hall cart and Licensed Practical Nurse #4 verified the expiration date of the Insulin on the long hall cart. | 2014-08-01 |