rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
10266,CHERAW HEALTHCARE,425005,400 MOFFAT ROAD,CHERAW,SC,29520,2010-04-14,281,D,,,THIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of acceptable standards of practice for licensed staff , the facility failed to assure for 1 of 2 residents reviewed for accurate documentation related to a [MEDICAL TREATMENT] site that the documentation was thorough and accurate as entered. Resident #4 had documentation of thrill and bruit checks after the shunt site was changed and the physician discontinued the order. The findings included: The facility admitted Resident #4 on 6/26/09 with the following Diagnoses: [REDACTED]. The record review on 4/12/10 revealed a physician's orders [REDACTED]. Further review revealed another order written on 11/5/09 for removal of infected [MEDICAL TREATMENT] catheter and replacement of [MEDICAL TREATMENT] catheter- a tummeled catheter due to permanent placement access. During an interview with Registered Nurse (RN) #1 on 4/12/10 he/she stated "" a thrill and bruit is not checked because the resident has a catheter in her right chest, the other site was removed."" The nurse's notes revealed that Licensed Practical Nurse (LPN) # 2 documented in the notes ""thrill felt and bruit heard"" on the following dates 3/11/10, 3/13/10, 3/27/10 and 4/10/10. LPN #1 documented in the nurse's notes on 3/13/10 ""bruit and thrill felt"". LPN #3 documented in the nurse notes on 3/30/10 ""thrill felt and bruit heard"". During an interview with LPN #1 on 4/12/10 at 4 PM, when asked how he/she checked for a thrill and bruit, he/she stated ""I just put the stethoscope above the catheter and hear a ""LUB-DUB"". During an interview with LPN #2 on 4/12/10 at 4:15 PM when asked how he/she checked for a thrill and bruit, he/she stated "" you have to check that in the arm, but hers is in the chest"". When ask why he/she documented that the thrill and bruit was checked, the LPN stated ""I don't know"".",2014-01-01
10267,CHERAW HEALTHCARE,425005,400 MOFFAT ROAD,CHERAW,SC,29520,2010-04-14,315,D,,,THIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy and procedure, the facility failed to provide appropriate catheter care for one of one catheter treatments observed. The Registered Nurse (RN) failed to properly anchor the catheter tubing during Resident # 3's catheter care. The findings included: The facility admitted Resident #3 on 7/27/09 with the following Diagnoses: [REDACTED]. During the catheter care observation on 4/13/10 at 9:15 AM RN #2 failed to secure the tubing to prevent pressure from tugging of the suprapubic catheter while cleaning, then drying the tube. At 9:20 AM on 4/13/10 during an interview with RN #2 he/she stated when ask about anchoring the tube ""I didn't anchor it because its in the stomach."" The facility policy titled Catheter Care, Suprapubic, stated under Procedure #11 ""Gently grasp the catheter with non-dominant hand and use clean wash cloth to work down the tubing approximately 6 inches""",2014-01-01
10268,CHERAW HEALTHCARE,425005,400 MOFFAT ROAD,CHERAW,SC,29520,2010-04-14,323,E,,,THIH11,"On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Three bathrooms in the common area observed to be used by residents had no call light system in place. The findings included: A random observation on 4/12/10 revealed a female resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. Another random observation on 4/13/10 revealed a male resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. An inspection of the bathrooms 1. located on the back hall next to the main dining room, 2. the bathroom directly across from the main dining room and 3. the bathroom located between the beauty shop and the activity room, all revealed no call light system in place. During an interview with the Director of Nursing (DON) on 4/13/10 at 11:40 AM, he/she confirmed that ""these bathrooms are used by everyone, staff, visitors and residents"". The DON stated that ""the residents are assisted"". When he/she was informed of the observations of residents using the bathroom alone, he/she stated ""well we do have some that can go by themselves.""",2014-01-01
10269,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2010-09-14,279,D,,,916711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observations and interviews, the facility failed to develop and implement care plans with interventions to prevent aspiration for Residents #1, #2, #3 and #4 prescribed mechanically altered diets with nectar thick liquids and assessed as at risk for aspiration. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. ""The cup must have been left by the weekend staff."" Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area ""Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. Has severe dysphagia with high aspiration risk, family declines feeding tube."" Interventions listed ""will provided diet/snacks as ordered, will report hypo/hyper glycemia, will honor food preferences, will provide OHA's (oral hypoglycemic agents) as ordered"". The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area ""History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..."" Interventions included ""will provide honey thick liquids as ordered"". The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a telephone order dated 08/26/2010 for a pureed diet with nectar-like thick liquids. Review of Resident #3's care plan revised 08/26/2010 listed as a focus area ""Nutrition: potential for weight loss related to dementia is also a diabetic; therapeutic mech (mechanically) alt (altered) diet with nectar thicken liquids..."" Interventions included ""encourage and assist as needed to consume all foods and/or supplements and fluids offered at and between meals. 8-26-2010 now to receive nectar thick liquids..."" The facility admitted Resident #4 on 05/19/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Review of Resident #4 care plan initiated 08/12/2010 listed as a focus area ""Feeding tube use with potential for complications also received ordered liquids and PO (by mouth) diet..."" Interventions included ""elevated head 30-45 degrees at all times... monitor for and report any signs of aspiration or intolerance of feeding..."" Review of the Certified Nurse Aide (CNA) Kardex failed to list Resident #1 as at risk for aspiration; Residents #2, #3 and #4 were noted on the CNA Kardex as at risk for aspiration. The PIW (patient intervention worksheet) used by the CNAs did not include aspiration precautions for Residents #1, #2, #3 and #4. In a face-to-face interview with the surveyor on 09/14/2010 at 1:00 PM Speech Therapist #1 stated that any resident receiving nectar thick liquids should be on aspiration precautions, that she taught the CNA individually about aspiration precautions when she worked with the residents. When asked if she taught every shift she stated, ""No."" The Speech Therapist stated she was concerned about posting information at the bedside due to it being personal information about the resident. In face-to-face interviews with the surveyor on 09/14/2010 CNAs #1, #2 and #3 stated they would position the resident upright and give them small bites. The CNAs could not recall an inservice related to aspiration precautions. In reviewing the CNA Kardex monitor with the surveyor CNA #3 was not sure if the CNA Kardex addressed aspiration precautions, until she saw aspiration precautions on the monitor.",2014-01-01
10270,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2010-09-14,315,G,,,916711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review and interviews the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, ""Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..."" Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, ""Urinary tract infection. We will initiate [MEDICATION NAME]. The last two urine cultures had produced fluoroquinolone resistant species. The patient was given [MEDICATION NAME] in the ER, although these were both acceptable [MEDICATION NAME] given the patient's unspecified [MEDICATION NAME] history, we will refrain cephalosporins and initiate carbapenem therapy pending final culture. 2. Altered mental status secondary to problem 1..."" On 09/13/2010 a review of the laboratory studies revealed no results for the UA/CS ordered by the physician STAT in the AM on 08/13/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, ""wait for C and S"". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated.",2014-01-01
10271,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2010-09-14,281,G,,,916711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, ""Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..."" Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, ""Urinary tract infection..."" On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery (DCD) for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The nursing staff failed to assure that the lab picked up the urine on 08/14/2010. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, ""wait for C and S"". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the DCD for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated. The DCD stated that the urinalysis results were usually received within 24 hours of the collection date and the culture/sensitivity results was received within 48 hours of the collection date. The nursing staff failed to followup on a urinalysis done on 08/05/2010 until 08/09/2010, four days after the urine was sent to the lab. As stated in paragraph one, the facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. ""The cup must have been left by the weekend staff."" Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area ""Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. On 09/14/2010 at 8:15 AM Resident #1 was observed in the dining room independently eating a pureed breakfast and drinking thicken water. The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area ""History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..."" On 09/14/2010 at 8:20 AM Resident #2 was observed in the dining room independently drinking thicken juice at breakfast. Additional review revealed the facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a telephone order dated 08/26/2010 for a pureed diet with nectar-like thick liquids. Review of Resident #3's care plan revised 08/26/2010 listed as a focus area ""Nutrition: potential for weight loss related to dementia is also a diabetic; therapeutic mech (mechanically) alt (altered) diet with nectar thicken liquids..."" On 09/13/2010 at approximately 3:15 PM Resident #3's granddaughter stated that her grandmother was unable to drink unassisted. The facility admitted Resident #4 on 05/19/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Review of Resident #4 care plan initiated 08/12/2010 listed as a focus area ""Feeding tube use with potential for complications also received ordered liquids and PO (by mouth) diet..."" On 09/14/2010 at 10:00 AM Resident #4 stated that he needed help with drinking and eating. Aspiration precautions were not care planned as a focus area for Residents #1, #2, #3 and #4 and observations on 09/13/2010 and 09/14/2010 revealed no system to identify residents who were at risk for aspiration. Review of the Certified Nurse Aide (CNA) Kardex failed to list Resident #1 as at risk for aspiration; Residents #2, #3 and #4 were noted on the CNA Kardex as at risk for aspiration. The PIW (patient intervention worksheet) used by the CNAs did not include aspiration precautions for Residents #1, #2, #3 and #4. In a face-to-face interview with the surveyor on 09/14/2010 at 1:00 PM Speech Therapist #1 stated that any resident receiving nectar thick liquids should be on aspiration precautions, that she taught the CNA individually about aspiration precautions when she worked with the residents. When asked if she taught every shift she stated, ""No."" The Speech Therapist stated she was concerned about posting information at the bedside due to it being personal information about the resident. In face-to-face interviews with the surveyor on 09/14/2010 CNAs #1, #2 and #3 stated they would position the resident upright and give them small bites. The CNAs could not recall an inservice related to aspiration precautions. In reviewing the CNA Kardex monitor with the surveyor CNA #3 was not sure if the CNA Kardex addressed aspiration precautions, until she saw aspiration precautions on the monitor.",2014-01-01
10272,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-09-16,328,D,,,UGRJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record review the facility failed to ensure residents received timely foot care. The physician saw resident #2 and prescribed an antibiotic and cleaning to the right toenail bed until seen by the podiatrist related to redness of the toenail bed; resident #2 had a history of [REDACTED]. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to skin care. Review of the current medical record on 09/16/2010 revealed the most recent Podiatry visit as 01/20/2010. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, ""CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010 and continued the previous orders. The antibiotic was completed on 03/19/2010. Review of the nurse's notes from 03/19/2010 thru 08/18/2010 revealed no documentation related to the resident's toenails. A nurse's note dated 08/19/2010 at 2:00 PM stated, ""Brought to this nurse's attention; Resident's daughter went to nurse from station 4 to show her resident's (R) great toenail very thick and crusty in some areas. Nurse able to pull back some of crustation (sic) revealing some redness along cuticle line no puss or secretions of any kind noted. Resident denies any discomfort. Resident seen by covering NP (nurse practitioner) orders rcd (received) for Keflex 500 PO (by mouth) TID (three times a day) x 7 days and cleanse (R) great toe nail bed with NSS (normal saline solution) BID (twice a day) until seen by foot MD (medical doctor)...Resident has been added to podiatry list."" Review of the Weekly Skin Assessment's from 04/2010 thru 08/13/2010 showed no documentation related to Resident #2's toenails. An observation with the surveyor on 09/16/2010 at 2:10 PM with Licensed Practical Nurse (LPN) #1 revealed Resident #2 wearing bunny boots on both feet; the great toe nails on both feet appeared fragile, rough, thickened and yellow; there was very little nail seen on all toes. Resident #2 stated that she had no pain when asked if the toenails were painful. LPN #1 stated that the resident was on the list to be seen by the podiatrist. In an interview with the surveyor on 09/16/2010 at approximately 4:20 PM the Director of Nurses provided a list of residents who were to been see by the podiatrist at his next visit. When asked when that would be she stated that she did not know, that it was difficult to get the podiatrist to come to the facility. She stated that the RN (registered nurses) cut the toenails for the residents as needed. The DON added that the ward clerk who kept up with the podiatrist appointments was on vacation and she would return next week. The facility was unable to provide a written nail care policy. In an interview with the surveyor on 09/22/2010 at 10:50 AM the Ward Clerk responsible for making the podiatry appointments stated that the podiatrist was in the facility on 01/20/2010, 02/08/2010, 03/25/2010, 04/02/2010, 05/05/2010, 06/23/2010, 07/12/2010 and 08/09/2010. When asked when he would be there again she stated she had not called to ask him to return, that she usually waited two weeks after his visit, then called and schedule him to come to another station; the facility had 4 nursing stations. The Ward Clerk said that she collected the names of the residents who needed to be seen by the podiatrist from each station and then scheduled the residents; she confirmed that Residents #2 was on the list to be seen on the next podiatry visit. When asked if she had been told that Resident #2 had an order for [REDACTED].",2014-01-01
10273,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-09-16,157,D,,,UGRJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review the facility failed to notify the physician of changes for one of five residents reviewed for foot care. Resident #2 with prescribed antibiotics for an infection of the left great toe developed ""a purlent (sic) yellow discharge"" that was not reported timely to the physician. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to foot care. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, ""CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during foot care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010.",2014-01-01
10274,"UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC",425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2010-09-29,225,D,,,LLC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to report an injury of unknown origin within the allowed time frame, failed to promptly begin an investigation into the injury, and failed to thoroughly investigate the resident's injury for a possible explanation of how it occurred for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower. Review of the Change Of Condition Nurses Notes and Resident Incident Report showed the discoloration was to the left back. There was no inflammation or [MEDICAL CONDITION] noted to the area. The facility did not report this injury of unknown origin or begin any investigation into the injury's possible origin. The facility did report to the State survey and certification agency on 7/15/10 that the resident's weekly skin audit done on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: ""Res. was noted to have bruising on back on 7/13/10 which was noted on 7/15/10 to also have new area on arm. No pain noted w/verbalization or movement until 7/15/10. Res. had sling too small for her size on 7/13/10 (sic), which is the date the initial bruising was noted. ..."" The facility's investigation revealed interviews were done with direct caregivers and a determination was made that the resident's injury was due to staff using the wrong size mechanical lift sling during transfer. Written statements were taken from the LPN who assessed the bruises, and from Certified Nursing Assistants (CNAs) who provided care to the resident. CNA #1 worked the 3-11 shift on 7/12/10, CNA #2 worked the 7-3 shift on 7/12, 13, 14, and 15/10, and CNA #3 worked the 3-11 shift on 7/13/10. CNA #4 provided a written statement but was not listed on the daily schedule as being assigned to the resident during the same time period. The investigative materials did not show evidence of interviews or written statements from the 11-7 staff, the 7/14/10 3-11 CNA, or any of the staff that assisted the assigned caregivers during transfer of the resident from bed to chair on the days of 7/12-14/10. The investigation did not show what size sling was used for the resident on 7/13/10, which allegedly caused the injury. (The CNA statement alleging the wrong sling size was used was for 7/12/10, not 7/13/10.) Nor did the investigation show any information about which sling size was used for the resident on 7/14/10. The delay in beginning the investigation allowed for the possibility of further injury to the resident. During the survey, discrepancies were noted in the facility's investigative report, statements obtained, and information revealed in staff interviews concerning the sling used, and the location and characteristics of the bruises: CNA #1 stated on 9/28/10 at 12:25 PM that he found the resident on 7/12/10 up in the recliner chair with the wrong type of sling underneath her. He stated the resident needed a full body sling, not the divided leg sling. CNA #1 stated he and another CNA, who he could not recall, removed the sling from under the resident and then applied a full body sling under her before assisting the resident to bed. When asked how the slings were changed, the CNA stated they did it while the resident was still in the recliner by turning her from side to side. CNA #1's written statement said: ""... Resident up on (with) sling under her in Geri chair. He states he was nervous to move her (with) smaller sling so he went to get another CNA to help him. The two CNA removed the small sling & replaced (with) a larger sling and she was then transferred to the bed (without) incident."" Review of the manufacturer information on mechanical lift slings revealed divided leg slings were designed to allow for application while a resident was seated, full body slings were not. CNA #3 stated in an interview on 9/28/10 at 4:20 PM that the resident was in the recliner chair on 7/13/10 when he started his 3-11 shift. The CNA gave the resident her shower while she remained in the recliner chair, then got assistance from another staff member to transfer the resident to bed. CNA #3 could not recall what type of sling was used for the transfer. While getting the resident ready for bed, CNA #2 noticed a blackish blue area under the resident's left axilla extending under the left breast. The CNA gave an approximate size of 4 centimeters. The resident showed no signs of distress from the area. CNA #3 reported his finding to the nurse. CNA #3's statement for the facility's investigation stated the area was black in color or very dark and it was under her axilla. The information from CNA#3 did not indicate injury to the left flank or left back. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated, approximately 3 inches by 1 inch reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. On 7/15/10, the LPN witnessed a deep purple bruise on the left breast/chest area. It was approximately 4 inches in size. The back of the resident's upper left arm was also purple in color, about ""3 fingers"" large. The previously noted area on the resident's upper back was lighter in color and smaller in size. Resident #3's left clavicle appeared different and the physician was notified. LPN #1's written statement said discoloration was noted on the left back on 7/13/10 with improvement noted on 7/14/10. On 7/15/10 ""body audit noted discoloration anterior Lt. arm, Lt back same area, same discoloration Lt rib area to under Lt breast. Grimacing when Lt arm moved. Appearance of Lt clavicle area different than Rt. ..."" LPN #1 did not reference the resident's left flank in either her interview or in her statement. CNA #2's statement for the facility's investigation revealed she saw on Wednesday (7/14/10) or Thursday (7/15/10) a bruise at the resident's left breast under and toward ""(R) back"" in axilla line. She also noticed discoloration to the left arm that was a yellow-greenish color from elbow to shoulder. The resident moaned when moved, as if in pain. CNA #2 reported her findings to LPN #1 on 7/15/10. During an interview with the Administrator and DON on 9/29/10 at 12:30 PM, they stated their conclusion that the wrong size sling caused the resident's injury was based on the CNA admitting that the wrong size sling was used. However, the DON continued to say that CNA #2 reported that a too small sling was used on 7/12/10 but CNA #2 reported an appropriate sling size was used with the resident on 7/12/10. When asked why the facility failed to report and begin an investigation on 7/13/10, with the first signs of injury to the resident, the Administrator and DON stated it was because the bruising noted on 7/13/10 was not reported to them until the injuries on 7//15/10 were reported. The Administrator and DON said that prior to the resident's incident, no direction was provided to the CNA staff about which type of lift sling or what size of lift sling was to be used with each resident.",2014-01-01
10275,"UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC",425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2010-09-29,496,D,,,LLC411,"On the days of the survey, based on review of employee information provided, the facility failed to ensure that registry verification was completed before allowing an individual to serve as a Certified Nursing Assistant (CNA) for 2 of 3 employees reviewed who were hired in 2010 as CNAs. The findings included: During the complaint investigation, information concerning the staff on duty around the time of an injury of unknown origin was requested from the facility. The information provided failed to show that two of the CNAs had registry verification checks done prior to hire. The Director of Nurses (DON) was asked for this information on 9/28/10. On 9/29/10, the DON stated she knew the registry verification checks were done before hire, but Human Resources could not produce evidence of this.",2014-01-01
10276,"UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC",425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2010-09-29,514,D,,,LLC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, the facility failed to ensure that resident records were complete and accurately documented for 1 of 3 resident records reviewed (#3). Documentation in the medical record concerning Resident #3's injury of unknown origin was incomplete and inaccurate. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Change Of Condition Nurses Notes showed staff found a discoloration on the resident's left back. The area was without inflammation or [MEDICAL CONDITION]. The nurse's note by LPN #1 did not describe the discoloration's size, shape, color, or specific location on the resident's left back. Certified Nursing Assistant (CNA) #3 found the area on 7/13/10 after the resident's shower and reported it to the nurse for assessment. This CNA was interviewed on 9/28/10 at 4:20 PM and stated what he saw was an area under the resident's left axilla extending to the left breast, it was blackish blue in color, and was approximately 4 by 4 centimeters big. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated; approximately 3 inches by 1 inch, reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. Documentation in the Change of Condition Nurses Notes on 7/14/10 by LPN #1 described the ""left flank discoloration"" as not as large as yesterday. The medical record showed no information of any discolored area on the resident's flank. LPN #1 did not reference the resident's left flank in either her interview or in her statement. The information at the top of the page on the 7/15/10 Change of Condition Nurses Notes showed the resident's bruise on the left back was not as large. Purple discoloration was noted on the upper anterior left arm and left chest. Farther down the page, under the Current Care Plan Interventions and physician's orders [REDACTED]."" LPN #1 did both entries. The documentation did not show measurements or any other defining characteristics of the new bruising. Review of the skin assessment dated [DATE] showed that an area described as deep purple was outlined on the body form that included the posterior elbow to shoulder and corresponding area on the upper back on the resident's left side. A deep purple area was outlined on the body depiction at the right breast/chest area. LPN #1's statement for the facility's investigation stated that on 7/15/10 ""... body audit noted discoloration anterior Lt. arm, Lt back same area, same discoloration Lt rib area to under Lt breast. ..."" Documentation in the medical record showed no mention of the rib area or left breast involvement. During the interview with LPN #1, she said that on 7/15/10, she witnessed a deep purple bruise on the resident's left breast/chest area. It was approximately 4 inches in size. The back of the resident's upper left arm was also purple in color, about ""3 fingers"" large. The previously noted area on the upper back was lighter in color and smaller in size. CNA #2 provided care to the resident on the 7-3 shift on 7/13, 14, and 15/10. Her statement for the facility's investigation revealed she saw on Wednesday (7/14/10) or Thursday (7/15/10) a bruise at the resident's left breast under and toward ""(R) back in axilla line."" She also noticed discoloration to the left arm that was a yellow-greenish color from elbow to shoulder.",2014-01-01
10277,"UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC",425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2010-09-29,323,D,,,LLC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower in the left axilla area. On 7/15/10, the resident's weekly skin audit on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: ""Res. was noted to have bruising on back on 7/13/10 which was noted on 7/15/10 to also have new area on arm. No pain noted w/verbalization or movement until 7/15/10. Res. had sling too small for her size on 7/13/10 (sic) which is the date the initial bruising was noted. ..."" The investigation did not show what size sling was used for the resident on 7/13/10, which allegedly caused the injury. (The CNA statement alleging the wrong sling size was used was for 7/12/10, not 7/13/10.) Nor did the investigation show any information about which sling size was used for the resident on 7/14/10. CNA #1 stated on 9/28/10 at 12:25 PM that he found the resident on 7/12/10 up in the recliner chair with the wrong type of sling underneath her. He stated the resident needed a full body sling, not the divided leg sling. CNA #1 stated he and another CNA, who he could not recall, removed the sling from under the resident and then applied a full body sling under her before assisting the resident to bed. When asked how the slings were changed, the CNA stated they did it while the resident was still in the recliner by turning her from side to side. CNA #1's written statement said: ""... Resident up on (with) sling under her in Geri chair. He states he was nervous to move her (with) smaller sling so he went to get another CNA to help him. The two CNA removed the small sling & replaced (with) a larger sling and she was then transferred to the bed (without) incident."" Review of the manufacturer information on mechanical lift slings revealed divided leg slings were designed to allow for application while a resident was seated, full body slings were not. During an interview with the Administrator and DON on 9/29/10 at 12:30 PM, they stated their conclusion that the wrong size sling caused the resident's injury was based on the CNA admitting that the wrong size sling was used. However, the DON continued to say that CNA #2 reported that a too small sling was used on 7/12/10 but CNA #2 reported an appropriate sling size was used with the resident on 7/12/10. The Administrator and DON said that prior to the resident's incident, no direction was provided to the CNA staff about which type of lift sling or what size of lift sling was to be used with each resident.",2014-01-01
10278,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2010-07-28,425,E,,,1BYP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy, supplying medications to the facility, failed to assure the accurate administration of all drugs for 1 of 6 residents observed during medication pass. Resident A with a physician's orders [REDACTED]. The findings included: On 7/27/10 at 8:50 AM during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #4 was observed to measure Miralax Powder to the 15 milliliter mark in a medication cup used to measure liquid medications. The Miralax Powder was dissolved in 7 ounces of water and administered to the resident along with 8 other medications. Reconciliation of medication pass for Resident A revealed a current physician's orders [REDACTED]. DX (diagnosis) CONSTIPATION"". The identical physician's orders [REDACTED]. All of the orders were signed by the physician without clarifying the ambiguous dosage. Further review revealed that the Physician's admission orders [REDACTED]. Dx Constipation"". During an interview on 7/28/10 at 8:40 AM, the pharmacist at the pharmacy supplying the medications to the facility, stated that the pharmacy did not have the original order for the Miralax Powers (written 1/20/04) on hand. She/he stated that, on the pharmacy side, they have 17 Gms in 8 ounces of water as the standard (manufacturer's recommended) dose for Miralax and confirmed that the dosage on the monthly orders, printed by the pharmacy, was not clear. She/he further stated that, if there was an error, it was the pharmacy's fault. During an interview on 7/28/10 at 8:47 AM, LPN #4 stated that the pharmacist came to the facility yesterday (7/27/10) at about 5 PM, after the observation of medication by this surveyor the morning of the same day, and changed the dose for the Miralax on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].",2014-01-01
10279,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2010-07-28,314,D,,,1BYP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the product insert sheet for Santyl/facility policy for the application of a [MEDICATION NAME] product, the facility failed to assure that one of two sampled resident's reviewed for pressure ulcer care received appropriate treatment and services. During observation of the pressure ulcer treatment for [REDACTED]. Facility staff was unaware if the pressure relieving mattress in use was appropriately set for the resident's use. The findings included: The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/27/10 at 9:10am, an observation of the resident's pressure ulcer treatment was conducted. During the the procedure, the wound care nurse was observed to clean the outside raised edge of the pressure ulcer but not clean the wound bed itself. The wound bed was noted to contain slough and tunneling was noted. Following the treatment, the wound care nurse was questioned as to why the wound bed was not cleaned. S/he stated s/he did not want the spray the ""collect"" where the wound was undermined and did not want to injure the wound bed by having to pat it dry. S/he also stated s/he felt the use of Santyl cleaned the wound bed when the previous dressing was removed. Review of the product insert sheet from Santyl revealed the manufacturers recommendation stated to clean the wound bed prior to the application of Santyl. The instructions stated the wound bed should be cleansed prior to application.. remove as much loose debris as possible, gently cleanse the wound bed with saline or wound cleanser followed by saline each time the dressing is changed. Additionally, the facility policy also stated the wound bed should be cleansed prior to the application of a [MEDICATION NAME] product. Also following the completion of the treatment, the facility wound care nurse was questioned related to the use of the pressure relieving mattress which was in place on the resident's bed. The head, foot and middle areas were all set at the same maximum level - 5. When asked how s/he knew the setting was appropriate for the resident, s/he stated maintenance department set up the bed and s/he did not know. During an interview with the Maintenance Supervisor on 7/28/10, s/he stated Maintenance did set up the bed and s/he could tell by ""looking at it"" if the setting was appropriate. The Maintenance supervisor confirmed the instructions for determining the appropriate setting for resident use were not used by the maintenance department.",2014-01-01
10280,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2010-07-28,373,D,,,1BYP11,"On the days of the survey, based on observation, interview and record review, the facility failed to identify the use of a paid feeding assistant program and failed to implement the approved program consistent with State law. The findings included: On 7/26/10, upon entrance to the facility, the Administrator stated the facility did not utilize a paid feeding assistant program. On 7/27/10, at approximately 1:30pm, the Administrator and Nurse Consultant again stated the facility did not have or use a paid feeding assistant program. During random observations during the evening meal on 7/26/10, two activity staff members were observed feeding residents in the ""B"" building. One resident was being fed in a small alcove in the ""B"" building and another resident was being fed in his/her room. Both staff members stated they were not Certified Nursing Assistants. During the noon meal on 7/27/10, the activity members were again observed feeding residents either in their rooms (building ""B"") or dining room (main building). Further investigation revealed the facility did have an state approved feeding assistant program. On 7/27/10 at 2PM, during an interview with the Staff Development Coordinator (SDC) , s/he stated s/he had not taught the feeding assistant program since her return to the facility 12/09 but s/he previously had taught it at the facility. S/he stated an awareness that both activity personnel had previously completed the feeding assistant program. When asked which residents a staff member who had completed the program could feed, the SDC stated they would feed ""easier"" residents. S/he further stated one particular activity staff member would feed ""anyone she felt comfortable with...s/he would not step out of her comfort zone."" A review of personnel files revealed both staff members had completed the paid feeding assistant program at the facility (in 2005 and 2007). On 7/28/10, during an interview with the Administrator it was verified that the facility was not cognizant that using trained staff members to feed residents constituted use of a paid feeding program. Additionally, the facility had not been following the stated mandated guideline for the paid feeding program by assuring a record was maintained of all individuals used as feeding assistants; assuring coordination of the program under the general supervision of a nurse; assuring a nurse was readily available for the supervision of feeding assistants while feeding; and identifying and assessing residents who could be fed by feeding assistants based on a charge nurse's assessment.",2014-01-01
10281,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2010-07-28,441,E,,,1BYP11,"**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 maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. Following observation of catheter care for Resident # 3, handwashing concerns were identified. The findings included: On 7/27/10 at 11AM, an observation of the facility laundry department was conducted. Laundry worker # 1 was observed placing soiled laundry into a washing machine. After the soiled laundry was placed, s/he was observed to remove the protective gown by pulling it over his/her head when unable to untie the strings. The same laundry worker was asked to explain the process on how to handle laundry from an infected resident. Both Laundry worker # 1 and # 2 stated they would wear two pair of gloves and put on two gowns for protection. When asked how the two gowns would be applied, they stated one frontward and one backward. A box containing 3 pillows (1 cloth and 2 vinyl covered) was observed in the soiled area. When asked how the pillows would be cleaned, Laundry worker # 1 stated one pillow would be discarded because it was torn. The other two pillows would would be cleaned the same by spraying and wiping off with a disinfectant cleaner and then dried with a towel. Review of the label of the product indicated would be used stated it was to be used for non-porous surfaces. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. The facility water temperature for personal laundry was identified as cold/warm. Appropriate chemical sanitization was used for bedding and other linens when washed. On 7/27/10 at 11:25AM, an interview was conducted with the Maintenance Supervisor, identified as in charge of the laundry. S/he also stated that s/he would ""guarantee"" that s/he would wear two gowns and two pairs of gloves if handling known infectious laundry. During an interview with the Staff Development Coordinator who also was in charge of the facility infection control program, s/he stated laundry staff was in-serviced on hire related to infection control. Thereafter, (annually) staff completed a self study program. Laundry staff was not asked to demonstrate knowledge on how to apply/remove personal protective equipment. The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/28/10 , an observation of the resident' s catheter care was conducted. After cleaning the residents catheter, the nurse removed his/her gloves, applied the resident's brief, covered the resident, discarded the overbed covering, bagged soiled supplies, raised the resident's head of bed, lowered the bed height, returned an unused brief to the resident's closet, opened the bedside curtain, walked down the hallway and opened the room door prior to discarding used supplies and then sanitized his/her hands. The Facility policy for hand hygiene stated that hands should be washed ""after removing gloves.""",2014-01-01
10282,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2010-07-28,156,D,,,1BYP11,"**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 ensure a Resident's responsible party's stated interest in a Do Not Resuscitate order was acted upon timely. Resident # 11's responsible party expressed interest in formulating an Advanced Directive. After the Resident was determined to lack capacity for healthcare decisions, the facility took no further action. (1 of 13 sampled resident's reviewed for Advanced Directives) The findings included: The facility last admitted Resident # 11 on 7/7/10. The resident's [DIAGNOSES REDACTED]. On 7/26/10 a review of the current medical record revealed a Social progress note dated 7/8/10 which stated: ""Res (resident) has POA (Power of Attorney) copy placed on chart and no living will. RP (Responsible party) is interested in DNR (Do not Resuscitate)."" On 7/14/10 two physicians documented the resident lacked capacity to make healthcare decisions. Additional Social progress notes were documented on 7/16 and 7/19/10 noting resident behaviors and family visits/contacts. However, there was no further documentation related to the resident's advanced directive status. On 7/26/10 at 4:10pm, during an interview with the nurse consultant, s/he stated the resident was a ""full code."" On 7/27/10 at 11am, during an interview with social services employee # 1, s/he stated once a resident's capacity has been determined, appropriate action related to the residents/responsible party stated wishes for advanced directives should ""happen quickly"". S/he verified no action had been taken by the facility after the resident's capacity has been determined. S/he further stated the RP had been contacted and would be coming to the facility ""today"" to sign the paperwork for the resident's Do Not Resuscitate status.",2014-01-01
10283,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2010-09-22,281,D,,,OR4T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to clarify and follow a Physicians order related to discontinuing [MEDICATION NAME] for Resident # 12, 1 of 1 resident reviewed on anticoagulant therapy. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed a physician's orders [REDACTED].= 2.0"". Further record review revealed an INR drawn on 9/13/10 was 4.05 and on 9/14/10 the INR was 3.03. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The INR results dated 9/9/10 had an order written [REDACTED].> 2). On 9/21/10 at 1:00 PM Licensed Practical Nurse (LPN) # 2 stated during an interview that ""the order should have been clarified, because the orders are not the same. Someone should have called the doctor and asked about it, I think it should be stopped after it is greater than 2.0."" The Unit Manager for the 100 hall stated during an interview on 9/21/10 at 2:00 PM "" It (the [MEDICATION NAME]) should have been stopped when they got a INR of 2.0 or greater."" During a telephone interview with LPN # 3 on 9/22/10 at 10:40 AM she confirmed that she took the order and stated "" they were to stop the [MEDICATION NAME] when the INR is 2.0 or greater, I don't know why I would have written equal, that is just a slip of the pen or something, but it should be stopped when the INR is 2.0 or greater."". LPN # 2 called the Physician and received a clear order on 9/21/10 at 1:00 PM which reads ""D/C [MEDICATION NAME] when INR greater than or equal to 2.0"".",2014-01-01
10284,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2010-09-22,329,E,,,OR4T11,"**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 decrease [MEDICATION NAME] as ordered for Resident # 12. The resident received 30 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Licensed Practical Nurse (LPN) # 2 stated during a interview on 9/21/10 that ""the nurse who checked the MAR indicated [REDACTED]."" The Unit Manager for Hall 100 stated during an interview on 9/21/10 "" I checked those MAR's and I missed that, it is a problem."" Both nurses stated "" we will need to do a medication error report on this.""",2014-01-01
10285,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2010-09-22,502,D,,,OR4T11,"**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 ensure that laboratory services were provided in a timely manner for 1 of 13 residents (Resident #4) reviewed for laboratory services. The findings included: The facility admitted Resident # 4 on 6/18/10 with the following Diagnoses: [REDACTED]. The record review on 9/20/10 revealed an order for [REDACTED]. On the bottom of this report a note/recommendation was made that stated "" Mixed culture: 3 or more organisms isolated suggest repeat culture to rule out contamination."" No other reports were found on the medical record. During an interview with Licensed Practical Nurse # 2 she stated "" we should get another urine sample"". This resident does have a Foley catheter and a history of Urinary Tract Infections with the last one documented and treated in July 2010.",2014-01-01
10286,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2010-12-08,441,E,,,R42P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of facility policies, the facility failed to develop and maintain an infection control program which prevented the spread of infection. During three of four pressure ulcer treatment observations, concerns were identified related to glove use or handwashing. (Resident's # 1, #2, and #5) During observation of three of three gastric tube flushes, the nursing staff failed to clean the stethoscope either before or following the treatment. (Resident's #2, #3, and #8) In two of three medication rooms, supplies were found stored beyond the manufacturer's expiration date. (One hundred and three hundred units) The findings included: The facility last admitted Resident # 1 with [DIAGNOSES REDACTED]. On [DATE] at 10:45AM, Licensed Practical Nurse (LPN) # 5 was observed performing wound care for the resident. LPN # 5 was observed to remove the soiled dressing from the residents left hip area, and without changing gloves proceeded to clean the wound using clean supplies. The facility last admitted Resident # 5 with [DIAGNOSES REDACTED]. On [DATE] at approximately 11AM, Licensed Practical Nurse # 5 was observed performing pressure ulcer care. LPN # 5 removed the soiled dressing from the residents sacrum and without changing gloves proceeded to clean the Stage IV pressure area with clean supplies. After cleaning the area with normal saline and drying the area, LPN #5 removed her gloves, washed her hands and donned clean gloves. The nurse then skin prepped the perimeter of the wound, fanned the area dry, applied Santyl to the areas containing slough, wet a dressing with saline, unfolded it, folded it into a smaller size and placed it directly onto the wound. A cover dressing was applied. LPN #5, continuing to wear the same gloves, reached into her uniform pocket, removed a pen and tape which were used to initial and date the dressing. After moving the bedside table away from the bed, the nurse removed her gloves, placed the tape and pen back into her uniform pocket and then washed her hands. A facility provided QA (Quality Assurance) Worksheet (for) Aseptic Treatment/Dressing Changes stated: ""Wear gloves when removing soiled dressings, then discard gloves and dressing."" The facility admitted Resident # 2 on [DATE] with [DIAGNOSES REDACTED]. During observation of wound care on [DATE] at approximately 1:30 PM, the Licensed Practical Nurse (LPN # 1) entered the room, pulled the privacy curtain between the beds to the foot of the bed. After cleaning the wound, LPN # 1 discarded the wipes, removed gloves, washed hands, and pulled a pair of gloves from the box on the wall. As LPN # 1 returned to the bedside, his keys fell out of his pocket. He reached over and picked them up with his bare right hand, returned them to his pocket and then put the gloves on without washing his hands again. LPN # 1 then continued to put the clean bandage over the open wound. During an interview with LPN # 1 on [DATE] at approximately 4:00 PM, he confirmed that he had not washed his hands after picking up his keys off the floor during the treatment. The facility admitted Resident # 8 with Anoxic Brain Injury and status Gastrostomy. On [DATE] at 9:55AM, Licensed Practical Nurse # 5 was observed flushing the resident's gastric tube. The nurse walked to the resident's room wearing a stethoscope around her neck. The stethoscope bell was placed directly onto the resident's skin to check placement. The nurse then wrapped the stethoscope around her neck. The bell of the stethoscope was observed to touch the nurses uniform front and also her upper sleeve as the tube flush was administered. The stethoscope remained around the nurses neck. At the completion of the observation, the nurse was asked if she was finished and if she needed to do anything additional. The nurse stated she was ""finished."" The facility admitted Resident # 2 on [DATE] with [DIAGNOSES REDACTED]. During observation of tube flush on [DATE] at approximately 9:30 AM, Licensed Practical Nurse ( LPN # 1) entered room, explained treatment to Resident # 2, and returned to the hall to get supplies. LPN # 1 picked up a stethoscope from the medication cart and placed it around his neck, then set up the supplies on the over the bed table and proceeded to use the stethoscope to check for placement. At no time did this surveyor observe LPN # 1 cleaning the stethoscope. During an interview with LPN # 1 on [DATE] at approximately 4:00 PM, he stated that he had cleaned the stethoscope after the surveyor left the area, but not before the procedure. The facility admitted Resident # 3 on [DATE] with [DIAGNOSES REDACTED]. During observation of tube flush on [DATE] at approximately 11:30 AM, Licensed Practical Nurse (LPN # 2), entered the room, provided privacy, and set up the supplies on the over the bed table, washed her hands and gloved. She then took the stethoscope from the tube pole and proceeded to check for placement. After using the stethoscope, she returned it to the tube pole and proceeded with the tube flush. She did not clean the stethoscope during or after the procedure. On [DATE] at 3:50 PM, observation of the 300 Hall Medication Room revealed one container of 70 Premoistened Clorox Germicidal Wipes, 6.75 inches by 9 inches, marked ""For equipment only"", with an expiration date of [DATE]. During an interview on [DATE] at 4:12 PM, Registered Nurse (RN) #1 revealed that the medication nurses were responsible for checking the medication room for expired products. Pharmacy comes once a month and does a total check of the medication rooms. RN #1 stated that the wipes could have been used to clean equipment. On [DATE] at 10:43 AM, observation of the 100 Hall Medication Room revealed a container marked ""Disaster Emergency Box"", which contained supplies that included two [MEDICATION NAME] Transparent Adhesive Dressings, 6 centimeters by 7 centimeters with an expiration date of ,[DATE]. During an interview on [DATE] at 10:53 AM, Licensed Practical Nurse (LPN) #4 revealed that she (LPN #4) was responsible for checking the medication room for expired products. The medication nurses check the medication room periodically. LPN #3 orders stock medications and monitors stock medication expiration dates.",2014-01-01
10287,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2010-12-08,520,E,,,R42P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to fully identify quality concerns related to restraints. Resident # 2 with a known restraint, had no quarterly assessment to determine if the restraint was the least restrictive device and whether or not the restraint continued to be necessary. The facility conducted weekly restraint quality assurance reviews and failed to fully identify missing documentation related to the restraint. The findings included: The facility admitted Resident # 20 with a primary [DIAGNOSES REDACTED]. During the initial tour of the facility on 12/6/10 the resident was identified as wearing a hand mitt restraint, ""at the families request."" The resident was observed with an oven mitt with a splint applied over the mitt on the right hand. On 12/8/10, record review revealed an order was written on 2/2/10 for: ""Oven mitt to right hand(with) left hand Spica. Remove for ADL's (Activities of Daily Living) + (and) check skin integrity Q (every) shift d/t (due to) restlessness, Dementia, playing in feces and self scratching."" Further review revealed a Quarterly Restraint Review dated 1/8/10 (before the restraint order) which stated: ' Continue current restraint order. ...Look for alternative to mitt that is less restrictive."" The quarterly physical restraint review was completed thirteen times, each time recommending the continued use of the restraint. On 12/8/10 from 10AM to approximately 11:15AM, interviews were conducted with the Director of Rehabilitation who stated she was responsible for restraint documentation and the Physical therapist. It was questioned what follow up was done to obtain an alternative which was less restrictive and or whether the resident still required the use the use of the restraint. In reviewing the nurses notes, there was no documentation of the resident scratching or attempting to play in feces when the restraint was released for ADL's. The last note documenting the behavior was 2/2/10 which was stated by the daughter on the day the order was written. The restorative notes did not document any behaviors when the restraint was released for range of motion. There was no documentation that an attempt was made to allow the resident to be either restraint free or attempt made to use a lesser device. The Director of Rehabilitation stated an additional form was used to assess if a resident was a candidate for restraint reduction but verified there was no form in the resident's chart. A search for additional information was also conducted in the thinned record and in the therapy department. On 5/16/10, nursing documented a 2 cm (centimeter) round light purple bruise to the residents right wrist ""where glove applied."" Safety committee notes for 5/16/10 noted the bruise and stated ""glove to be placed loosely""- therapy screening. On 5/17/10 occupational therapy documented a follow up from 5/17/10 concern of a ""pressure area ""over the right anterior wrist.. The screen stated the therapist had reviewed with the daughter/caregiver to leave strap through loop but not to pull through D ring and tighten over wrist with Velcro. On 7/2/10 the therapist documented reviewed with pts. (patients) splint on, straps correctly placed through d- ring only. no redness, swelling noted. (previous pressure area over wrist). Neither documentation addressed the need for the restraint, whether it was the least restrictive device, resident behaviors or whether the resident had been tried restraint free. At approximately 11AM, the concerns were shared with the Administrator. At 11:15AM, the Director of Rehabilitation provided a form titled report of quality improvement action team. The form was dated 12/6/10 and identified three residents who had not been ""tried at a lower rest. (restraint) level for at least 1 year."" The possible solution was for trial lower restraint levels this month to see if downgrades are possible with a goal date of 1/1/11. When the Director was asked how she had identified the concern, she stated she had been looking at the chart. When asked if she had also discovered there had been no quarterly assessments documented per policy, she stated ""no."" At approximately 11:30AM, during an interview with the Administrator, she stated a quality assurance review for restraints was completed every week on Monday. The Administrator verified the weekly quality assurance had not fully identified concerns related to the restraint.",2014-01-01
10288,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2010-12-08,164,D,,,R42P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to ensure 1 of 3 residents received privacy during wound care. (Resident # 2) The findings included: The facility admitted Resident # 2 on 12-30-08 with [DIAGNOSES REDACTED]. During observation of wound care on 12-7-10 at approximately 1:30 PM, the Licensed Practical Nurse (LPN # 1) entered the room, pulled the privacy curtain between the beds to the foot of the bed, and asked the room mate if she wanted to leave the room while care was being given to Resident # 2. The room mate declined to leave the room, and was moving around her side of the room in her wheelchair. The privacy curtain which could have surrounded Resident # 2's bed was left at the head of her bed and not pulled around her bed. During the treatment LPN # 1 used up all of the supplies and stated to this surveyor, that he needed to leave the room to obtain more supplies to complete the treatment. At that time, Resident # 2 was lying on her side facing the door, with her brief unfastened and her entire backside exposed to view. When LPN # 1 left the room, the door was left ajar and unidentified persons were noted to be walking in the hall past the door.",2014-01-01
10289,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2010-12-08,315,D,,,R42P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the South Carolina Nurse Aide Candidate Handbook, and review of the facility policy on catheter care, the facility failed to provide appropriate treatment for 1 of 1 resident observed for catheter care. During observation of catheter care for Resident # 7, the Certified Nursing Assistant failed to secure the catheter close to the meatus to prevent tension or pressure on the bladder wall when cleaning the catheter tubing. The findings included: The facility admitted Resident # 7 on 6-7-10 with [DIAGNOSES REDACTED]. ,During observation of catheter care on 12-7-10 at approximately 10:00 AM, Certified Nursing Assistant (CNA # 1) knocked, entered the room, provided privacy, washed hands and gloved. CNA # 1 then set up the supplies on the over the bed table: 3 separate cups, one containing soapy water and gauze wipes, one containing clear water and gauze wipes, and the third containing dry gauze wipes. After Resident # 7 was positioned for the treatment, CNA # 1 again washed hands and gloved. CNA # 1 then positioned her left hand to separate the labia and secure the catheter. Using her right hand she used a soapy gauze wipe to clean around the left side of the labia, and discarded the gauze wipe, then repeated the procedure on the right side. CNA # 1 then used the third soapy gauze wipe to clean the catheter, beginning at the entry point of the catheter into the body, she wrapped the gauze around the catheter and pulled away from the body to where the fingers of her left hand secured the catheter (about 4 inches from the body). Tension was observed when the catheter was being cleaned. This entire process was repeated with the clear water rinse, and in drying. Review of the facility policy revealed the following: ""Female residents: Separate labia with one hand. With the soapy gauze, cleanse from front to back one stroke down one side, discard the used gauze then stroke down the other side with a clean soapy gauze and discard. Anchoring the catheter with the hand holding the labia, complete one wipe down the middle cleaning the catheter and wipe away from the resident. Repeat each step with the rinse gauze and again with the dry gauze."" Review of the South Carolina Nurse Aide Candidate Handbook revealed the following; ""Provide Catheter Care for Female"" #8 While holding catheter near meatus without tugging, cleans at least four inches of catheter nearest meatus, moving in only one direction, away from meatus...#9 While holding catheter near meatus without tugging, rinses at least four inches of catheter nearest meatus, moving only in one direction, away from meatus....#10 While holding catheter near meatus without tugging, dries four inches of catheter moving away from meatus."" When these findings were shared with the Administrator and the Assistant Director of Nursing (ADON), on 12-8-10 at approximately 12:30 PM, the ADON stated that the policy would have to be changed to reflect the correct anchoring position.",2014-01-01
10290,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2012-02-01,251,C,,,2C1L11,"On the days of the survey, based on interviews and review of the ""South Carolina Code of Laws Title 40-Professions and Occupations Chapter 63: Social Workers"", the facility, with more than 120 beds, failed to employ a Licensed Social Worker as required by state law. The facility Social Worker had a Bachelor's Degree and had not been licensed. The findings included: During an interview on 02-01-12 with the facility Social Worker, she revealed she had a Bachelor's degree and had not been licensed. During an interview on 02-01-12 with the Administrator, she revealed she did not know a Licensed Social Worker was required. She stated the facility would contract with a Licensed Social Worker as a Consultant to oversee the facility Social Worker at least 20 hours per month. Review of the ""South Carolina Code of Laws Unannotated, Current through the end of the 2011 Session, Title 40-Professions and Occupations, Chapter 63: Social Workers"" revealed in Section 40-63-30: License as prerequisite to practice or offer to practice; providing social work services through telephone or electronic means. A) No individual shall offer social work services or use the designation ""Social Worker"", ""Licensed Baccalaureate Social Worker"", ""Licensed Masters Social Worker"", ""Licensed Independent Social Worker-Clinical Practice"", ""Licensed Independent Social Worker-Advanced Practice"", or the initials ""LBSW"", ""LMSW"", or ""LISW"" or any other designation indicating licensure status or hold themselves out as practicing social work or as a Baccalaureate Social Worker, Masters Social Worker, or Independent Social Worker unless licensed in accordance with this chapter"".",2014-01-01
10291,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2012-02-01,252,E,,,2C1L11,"On the days of the survey, based on observation and interviews, the facility failed to ensure that the residents' room and care equipment were clean and sanitary for 1 out of 3 units observed for cleanliness. Resident rooms that contained feeding pumps were noted with soiled areas; stains were noted on ceiling tiles; dust was apparent under resident beds and a base board was not intact. The findings included: Observation during the initial tour on 1/30/2012 at 11:00 AM and follow up observation on 1/31/2012 at 9:30 AM on the Ventilator Unit revealed the following concerns. -12-A---tube feeding spills in bathroom; on grab bar; and shower chair. -12-B-- tube feeding noted at the base of the feeding pump. -12-D--wall at the head of the bed had dried spills. -13-C--tube feeding noted on the floor and wall behind the bed. -14-- noted stained ceiling tiles. -14-B---tube feeding noted on feeding pump. -14-D-- tube feeding noted on feeding pump. -15-C-- tube feeding noted on feeding pump and dust under the bed -15-D-- tube feeding noted on feeding pump and dust the under the bed. -16-A-- tube feeding noted on feeding pump and dust under the bed. -17-A-- dust particles noted behind the bed. -17-B-- tube feeding noted on the feeding pump. -18--wall and floor noted with spills. -19--dust noted behind the bed and portion of the base board was not intact. During an interview with the Unit Manager on 1/31/2012 at 3:15 PM, she stated that all staff were responsible for keeping the resident's care equipment and room clean. The Housekeeping and Laundry Supervisor verified all of the following listed above during a walking tour on 1/31/2012 at 4:00 PM. The Housekeeping and Laundry Supervisor stated that is was the responsibility of everyone to ensure all equipment and rooms are kept clean and sanitary.",2014-01-01
10292,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2010-09-30,441,F,,,IK8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews and interviews, the facility failed to provide Tracheostomy care for one of one resident reviewed for tracheostomy care in a manner that would prevent possible infection on Resident #11. In addition the facility failed to track/trend infectious organisms and failed to adequately notify visitors of contact precautions. The findings included: The facility admitted Resident #11 on 5/12/10 with [DIAGNOSES REDACTED]. Review of the September 2010 cumulative physician's orders [REDACTED]. Observation on 9/28/10 at approximately 4:50 PM revealed Licensed Practical Nurse (LPN) #5 entered the resident's room. After assessing the resident, he put on a pair of clean gloves and suctioned inside and around the tip of the tracheostomy opening with a [MEDICATION NAME] suction catheter. He did not wash his hands prior to putting on the gloves. With the same gloved hands that he had used to suction with the [MEDICATION NAME] catheter, he opened a new inner cannula from a box container, removed the inner cannula from the resident's tracheostomy, and inserted the new inner cannula into the tracheostomy. With the same gloved hands, he then opened the drawer to the bedside table and removed a sterile suction kit. He put one sterile glove on his left hand without removing the other gloves and proceeded to perform endotracheal suctioning to the resident. During an interview on 9/29/10 at 5:13 PM, LPN #5 verified he put on gloves without washing his hands first, put on a sterile glove over a dirty one, and touched the drawer handle and supplies with the same gloved hands used for suctioning. He stated that the reason he put the sterile glove over the dirty one was that the sterile gloves were too small and ripped causing mucus to get on his hands. Review of the policy provided by the facility entitled ""Suctioning of Tracheostomy"" (dated 11/25/97) on 9/29/10 at 12:58 revealed under Procedure...""3. Assemble equipment at bedside...4. Wash hands...7. Don sterile gloves 8. Open catheter package"". Resident #7, admitted [DATE], with [DIAGNOSES REDACTED]. Diff), Stage III Decubitus, Diabetes Mellitus. Record review on 9/28/10 at approximately 10:45am revealed a physician's orders [REDACTED]. Diff. Result of the culture on 9/16/10 reported positive for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Interview with Certified Nursing Assistant #2 on 9/28/10 at approximately 1:35pm indicated that nursing notifies staff of when a resident has an infectious disease and when there was a need to glove and/or gown before entering room. Interview with Registered Nurse #5 on 9/29/10 at approximately 9:55am indicated that when determined resident had [DIAGNOSES REDACTED] the facility notified physician, informed Responsible Party, put resident on contact isolation, placed a yellow cart outside door of resident's room, and informed staff. Asked if the facility posted signage asking visitors to see nursing before entering room. She stated that the facility does not post signage. Asked how visitors would know about need for contact precautions. Stated when visitors saw cart they were to come and speak with nursing. On 9/28/10 at approximately 1:30 PM, interview with the infection control nurse and review of the monthly infection control logs revealed that the facility failed to track/trend organisms. Further review of the infection control logs revealed that the facility tracked the number of infections and type of infection by each unit, however did not track/trend infections by room location on the units. When questioned if she had made formal infection control rounds to observe treatments and insure that staff were following infection control practices, she stated no.",2014-01-01
10293,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2010-09-30,225,D,,,IK8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled ""Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities"" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the DON verified the CNA had been transferred to another unit at the CNA's request. The DON agreed that the incident would need to be investigated had it been reported. Review of the policy provided by the facility entitled ""Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities"" dated 8/7/09 revealed under ""5. Investigation, A. All suspicious incidents will be thoroughly investigated in a timely fashion, documented via an Alleged Abuse/Incident of Unknown Origin packet, and forwarded to the required state agencies as outlined in policy 02-22, Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities"". The Policy/Procedure section stated that ""DHEC Certification and the facility administrator shall be notified immediately but not to exceed 24 hours after discovery of all alleged violations involving abuse (physical, verbal, sexual, or mental)..."". Under Abuse Reporting Procedure the ""1. Nurse or Shift Supervisor: a) Receives the complaint from a resident..., b) Assesses the complaint and interviews the complainant, c) Obtains a written statement form included in packet, d) Obtains written statement notarized or signed by two witnesses, e) Contacts shift supervisor, f) Completes incident report."" From there, the packet goes to the ""2. Shift Supervisor...3. Assistant Director of Nursing or Nurse Supervisor...,"" and then to ""4. Administration"". Interview on 9/29/10 with the Assistant Director of Nursing, who performs investigations of abuse, indicated that s/he was not aware of the alleged verbal abuse. The facility admitted Resident #30 on 05/28/2010 with [DIAGNOSES REDACTED]. Resident #30 sampled as a result of a complaint concerning skin tears. Review of Resident #30's closed medical record on 09/27/2010 revealed nursing documentation on 06/07/2010 and 07/21/2010 regarding skin tears. On 06/07/2010 a nurse's note stated, ""...F/U (follow-up) to skintear..."" Review of the Occurrence Reported dated 06/07/2010 indicated that the resident received the skin tear while participating in physical therapy. Continued review of the nurse's notes revealed a 07/21/2010 note at 2000 that stated, ""...Res (resident) has ST (skin tear) on (R) (right) elbow..."" The facility was unable to provide an Occurrence Report for the 07/21/2010 skin tear. Review of the skin integrity care plan dated 06/16/2010 did not address the skin tears.",2014-01-01
10294,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2010-09-30,280,D,,,IK8X11,"**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 update the Care Plans for 2 of 18 sampled residents reviewed for comprehensive Care Plans. Resident #13's Care Plan was not updated related to [MEDICAL CONDITION] and drug seeking behaviors; Resident #30's Care plan was not updated related to skin tears. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an interview on 9/30/10 at approximately 12:15 PM, Registered Nurse (RN) #2 stated Resident #13 had been exhibiting drug seeking behavior. According to the nurse, the resident told the physician on 9/20/10 that the [MEDICATION NAME] wasn't working any more and he subsequently discontinued it. Review of the physician's orders [REDACTED]. The nurse stated that the resident kept asking for the [MEDICATION NAME] again, so the nursing staff had to call the on-call physician that same night who gave an order for [REDACTED]. MD (physician) will evaluate in AM"". When asked what was being done to address this issue, the nurse stated the resident had been seen by Psychiatry and had a trial of [MEDICATION NAME]. Review of the ""Psych Consult and Progress Notes"" dated 3/10/10 revealed that Resident #13 had been diagnosed with [REDACTED]. According to the note ""Case discussed with staff. Pt. (Patient) had been refusing q (every) hs (Bedtime) [MEDICATION NAME] (Secondary) to ""SE"" (Side Effects) Upset stomach, [MEDICAL CONDITION] of feet which attributed to (increased) dose. Pt. would like to try another medicine & asks for [MEDICATION NAME]. I explain(ed) to her that this will not help (with) depression & Pt. is already taking [MEDICATION NAME] which is similar. Pt denies SI (Suicidal ideation). She has been cooperating with care. (No) voiced [MEDICAL CONDITION]. Pt is oriented x3. Meds (Medications) [MEDICATION NAME] 1 mg (milligram) PO (By Mouth) Q (every) AM. [MEDICATION NAME] 60 mg PO Q AM, [MEDICATION NAME] 20 mg PO BID (Twice Daily)"". The plan was to taper and discontinue the [MEDICATION NAME] and start the resident on [MEDICATION NAME] 20 mg PO Q AM, ""Refer pain meds to PCP (Primary Care Physician"", and follow up in 3 months. Review of the 6/16/10 Progress Notes revealed resident was seen and ""having fewer SE (with) the [MEDICATION NAME] No voiced [MEDICAL CONDITION]/U (follow up) in 6 mos. (months)"". When asked if the resident had been care planned for her drug seeking behavior or her delusional disorder, RN #2 said ""No"". Review of the comprehensive Care Plan on 9/30/10 revealed no mention of drug seeking behavior or delusional disorder. The facility admitted Resident #30 on 05/28/2010 with [DIAGNOSES REDACTED]. Resident #30 was sampled as a result of a complaint regarding skin tears. Review of Resident #30's closed medical record revealed nursing documentation on 06/07/2010 and 07/21/2010 regarding skin tears. Review of the skin integrity care plan dated 06/16/2010 did not address the skin tears.",2014-01-01
10295,BMC SUBACUTE REHAB CENTER,425340,1330 TAYLOR AT MARION STREET,COLUMBIA,SC,29203,2011-06-07,371,F,,,VIJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the recertification survey, based on observation, record review, review of the facility's policy entitled HACCP/FOOD SAFETY PROGRAM and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The facility failed to dispose of expired foods, failed to label foods in storage to ensure expired foods could be identified and failed to implement policies and procedures to ensure expired items were discarded appropriately. The facility also failed to sanitize the thermometer between foods while testing temperatures on the tray line. In addition, the facility failed to develop and implement a policy for thawing meat to ensure that previously frozen, thawed meats were not refrigerated for extended periods prior to cooking. The findings included: Initial tour of the kitchen was conducted on 6/7/11 beginning at 9:15 AM with the Store Room Manager, the Certified Dietary Manager (CDM) and the Executive Chef. Tour of the dry food storage area revealed a box of [MEDICATION NAME] Extra with an expiration date of 4/11 and a box of muffin mix with an expiration date of 2/16/11. In addition there were 6 boxes of corn muffin mix and 8 boxes of buttermilk biscuit mix with no expiration dates and an opened bag of macaroni with no label. During the tour, the Store Room Manager confirmed there were multiple items without expiration dates and confirmed the items should have been labeled when removed from the case boxes. During an interview at approximately 12:00 PM, the Store Room Manager stated dry goods were rotated with each delivery to ensure ""first in, first out."" He stated that he doesn't ""pay attention"" to items already on the shelf if he hasn't ordered any of that item but also stated ""I guess I should."" He also stated he did not know if there was a policy stating how often the store room should be checked for expired food items. Review of the facility's Operational Standard: Food Storage, dated April, 2002, revealed there was no policy specifying how often food items should be checked for expiration dates and no procedure for checking the dry food storage. Tour of the thawing cooler revealed 2 bags of unlabeled pork chops dated 5/30; fully cooked, vacuum packed bottom round roasts dated 5/9 (1), 5/30 (1) and 6/1 (6); fully cooked vacuum packed hams dated 5/26 (3); unlabeled vacuum packed fully cooked diced ham (13 packages); unlabeled bags of crumbled cooked bacon dated 5/25 (1) and 6/1 (2); 5 pound containers of pulled pork dated 6/1 (7); 2 unlabeled bags of chicken leg quarters dated 5/25 and 4 bags dated 6/1; unlabeled vacuum packed pork roasts dated 5/18 (1), 5/23 (1), 5/26 (8), 6/1 (10) and 2 with no date. During an interview at 11:30 AM, the CDM confirmed the dates on the thawed meats and stated the meats are usually allowed 3 days to thaw in the cooler and then 3 days to be used after being thawed. During an interview at 12:47 PM, the CDM confirmed inconsistences related to dates on the thawed meats; the clerk had informed the CDM the date on the meat package was the date the meats were received (frozen) and the CDM had stated earlier it was the date the meats were placed in the thawing cooler. The Food Service Director (FSD) confirmed there was no consistency in labeling. At 5:25 PM, the FSD confirmed there was no policy for thawing meats related to labeling or maximum amount of time thawed meats could be refrigerated before cooking. ON 6/7/11 at 11:42 PM, Cook #1 was asked to check temperatures on the tray line. The Executive Chef retrieved a new thermometer out of the packaging and Cook #1 began to check the temperatures. She checked the temperatures of spaghetti noodles, marina sauce, green beans, mashed potatoes, white rice, brown gravy, corn bread dressing, macaroni and cheese, chicken gravy, carrots and skillet apples. Cook #1 wiped the thermometer with the same napkin after each item, without turning or folding the napkin to a clean area, and did not sanitize the thermometer. The Executive Chef left the immediate area and returned with clean napkins, he stated that he sanitized the thermometer while he was retrieving the clean napkins. The Executive Chef then checked the temperatures of the cold foods at 11:50 AM: chopped boiled eggs, chicken pieces, sliced roast beef, sliced ham, sliced turkey, tuna salad, chicken salad and cottage cheese using the same napkin to wipe the thermometer between each food but did not sanitize the thermometer and again did not turn of fold the napkin to a clean area. At 11:53 the Executive Chef checked the temperatures of hot foods being kept in the warmer cabinet: ground chicken, new potatoes, marinated baked chicken, butter beans, chopped steak, hamburgers, mashed potatoes, marinara sauce, baked fish, pureed peas and green beans. Again, the thermometer was not sanitized between food items but wiped with a napkin without turning or folding the napkin to a clean area before using. During an interview at approximately 12:15 PM, the FSD stated he would expect the thermometer to be calibrated prior to starting to check food temperatures and further stated that he would expect the thermometer to be sanitized with either alcohol or sanitizer solution between each food item. At 12:21 PM the Executive Chef confirmed that neither he nor the cook had sanitized the thermometer between foods on the tray line. At 5:25 PM on 6/7/11, the FSD provided an in-service that had been conducted from 6/1/11 to 6/3/11 related to thermometers. The in-service stated, under the section titled ""Using Thermometers"" - ""Clean and sanitize thermometers before checking foods.""",2014-01-01
10296,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2010-09-14,328,E,,,DZ1T11,"**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 ensure that residents received treatments as ordered by the physician for 1 of 2 residents reviewed who had nebulizer treatments ordered (#2). Resident #2 did not receive the nebulizer treatments ordered on [DATE] until 8/17/10. The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes revealed a note on 8/12/10 at 10:15 PM stating: ""Resident noted to have cough (with) congestion. Notified MD."" The physician saw the resident on 8/13/10 and wrote in his progress note that the resident was ""... quite short of breath and feeling terrible. ..."" A treatment plan was documented in the progress note including ""Start [MEDICATION NAME] solution 2.5 mg/3mL (2.5 milligrams per 3 milliliters), (0.083%), 3 mL, Q 4 hrs. (every four hours) while awake x (times) 5 days, then prn (as needed for) wheeze. ..."" Antibiotics, nasal oxygen, a chest x-ray, and a speech therapy consult were also ordered for suspected aspiration pneumonia. The 8/13/10 Daily Skilled Nurses Note at 6 PM documented that the resident was coughing but had no complaint of pain. He was resting in bed. The nurse's note documented that the physician wrote new orders for oxygen, nebulizer treatments, and a chest x-ray. The chest x-ray was done and no infiltrates were noted. Speech Therapy evaluated the resident and changed his diet. A swallow study was scheduled for 8/16/10. The nurse's note ended with ""... No distress when eating supper. Will monitor."" Review of the physician's orders [REDACTED]. ""Chest x-ray Re: poss (possible) aspiration pneumonia ""[MEDICATION NAME] 100 mg PO (by mouth) BID (two times a day) x 10 days, 1st dose STAT ""[MEDICATION NAME] 500 mg PO BID x 10 days, 1st dose STAT ""[MEDICATION NAME] 2.5mg/3mL via neb q 4 (hours) while awake x 1 week, then PRN ""Oxygen 2 L/min (liters per minute) via nasal cannula"" This order was signed by the physician and signed by the same nurse who documented the information in the 6 PM nurse's note on 8/13/10. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nebulizer treatment was to start on 8/13/10 at 10 PM. Continued review of the MAR indicated [REDACTED]. A notation on the back of the MAR indicated [REDACTED]. Another entry in the resident's MAR for [MEDICATION NAME] showed a date of 8/14/10. It specified the same dose and schedule as the order on 8/13/10. Administration of the [MEDICATION NAME] nebulizer treatments began with the 10 AM dose on 8/17/10 and ended with the 6 AM dose on 8/24/10. Review of a list of nurses assigned to the resident from 8/13/10 to 8/17/10 showed the resident had six different nurses taking care of him on those dates. Review of the medical record showed no evidence the physician was notified of the missed nebulizer treatments. Review of the Daily Skilled Nurses Notes revealed the physician was notified of an elevated temperature of 100.6 degrees on 8/15/10. A urine culture was ordered. The documentation in the nurses' notes did not show evidence of any acute distress suffered by the resident during the period of the missed nebulizer treatments. The physician visited the resident on 8/16/10 and documented in his progress note that the resident's breathing was the same. ""... He does not feel clinically improved there. ... "" No respiratory distress was assessed. The resident's respiratory rate was regular with normal air movement. Bibasilar crackles were noted. ""... His inactivity is the cause of his crackles, based on clinical eval and xray result. Will order an incentive spirometer to the bedside and have him do that Q (every) 2H while awake. ..."" There was no new order related to starting the nebulizer treatments on 8/17/10. During an interview with the Director of Nurses (DON)on 9/14/10, she stated there was no reason for the nebulizer treatment omissions. The facility had plenty of nebulizer machines on hand (three machines were observed in the respiratory supply closet) and if one was not available, the facility's supply company was available at all times to obtain needed equipment. The DON said three staff members were counseled related to the omissions and an inservice program was planned for later in the month of September 2010 to review this and other issues.",2014-01-01
10297,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2010-09-20,272,D,,,9EZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents were comprehensively assessed related to a history of falls for 2 of 2 residents reviewed who had repeated falls (#1 and #3). Both residents had a history of [REDACTED]. The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation. She was discharged home on[DATE]. The admission nursing fall assessment showed a score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) notes revealed the resident was at risk for falls. ""She is at risk for falls related to Hx (history of) falls and Dx ([DIAGNOSES REDACTED]. The note failed to provide any history of the resident's falls, and therefore there was no evaluation of any pattern or possible triggers for the falls. The RAP note did not evaluate the resident's internal or external risk factors. The resident fell three times while at the facility, 7/27/10, 7/28/10, and 8/22/10. One fall, the one on 7/28/10, resulted in a fractured distal right clavicle. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. However, the facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. There was no evidence of a comprehensive assessment of the resident's falls either on admission or throughout the resident's stay. Resident #3 with [DIAGNOSES REDACTED]. The resident was hospitalized from 7/14 to 7/21/10 for Asthmatic [MEDICAL CONDITION] and Decompensated [MEDICAL CONDITION]. The resident received therapy and was discharged on [DATE]. An admission nursing assessment for falls revealed a score of 22. Scores above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10 stated the resident had had multiple falls. Review of the RAI of 7/25/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person with bed mobility, transfer, dressing, hygiene, and bathing. He was incontinent of bowel and bladder. The RAI showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. The RAP notes showed no further information or assessment of the resident's fall history or risks. Review of the Nurse's Notes showed the resident had 11 falls while at the facility: Review of the medical record showed no evidence that the facility assessed the resident's falls in any attempt to find a pattern and possible triggers for the falls.",2014-01-01
10298,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2010-09-20,280,G,,,9EZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of ""high risk for falls related to Hx (history of) falls, decreased mobility."" Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. Review of the medical record showed the resident had 11 falls while at the facility. The care plan showed no changes throughout the resident's stay.",2014-01-01
10299,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2010-09-20,323,G,,,9EZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistant (CNA) put the resident on the toilet. The CNA went to get a brief out of the closet. Resident #1 tried to get up alone and fell , hitting her right shoulder. The nurse's assessment showed a red area to the shoulder, and skin tears to the right wrist and left forearm. An orthopedic assessment and x-ray done on 8/6/10 showed a fractured distal right clavicle. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. An interview with the CNA providing care to the resident on 7/28/10 revealed the resident had never tried to get up by herself before when in the CNA's care. The CNA said she found out from the nurse after the fall that the resident had fallen the day before while getting up unassisted. On 8/21/10, a Nurse's Note stated the resident was alert and oriented to herself. She was up at the bedside eating breakfast and took her morning medications. ""... Informed pt to call for assistance daughter found up in BR (bathroom) had concerns of safety. ..."" A personal safety alarm for the wheelchair was ordered that day. 3. The Nurse's Note on 8/22/10 at 12 PM stated a nursing assistant found the resident on the floor, lying by the bed. Skin tears to the left forearm and elbow were noted. The documentation in the Nurse's Notes, and the incident report, failed to say if the safety alarm was in use at the time of the fall. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. The facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. The resident was discharged home on[DATE]. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22. Scores above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person with bed mobility, transfer, dressing, hygiene, and bathing. He was incontinent of bowel and bladder. The RAI showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of ""high risk for falls related to Hx (history of) falls, decreased mobility."" Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. The care plan showed no changes throughout the resident's stay. Review of the Nurse's Notes showed the resident had 11 falls without injury while at the facility: On 8/1/10, at 2 AM, the resident tried to get up and slid off the low bed. On 8/3/10, at 7:35 AM, the resident was found on the floor by his low bed. He was yelling for help and told the staff he was ""trying to get up to go to therapy."" On 8/9/10, at 5:20 AM, the resident was found lying on the floor with his head under the bed and his legs partially extended out on the right side. On 8/10/10 at 11:15 PM, the resident was found lying on the floor beside the bed with his head resting on the bed. On 8/14/10, at 4 AM, the resident was found lying on the floor beside his low bed with a pillow still under his head. On 8/15/10, at 10:45 PM, the resident rolled out of bed. On 8/18/10, at 4:30 AM, the resident was found on scooting on his stomach on the floor by his bed. He told the nurse ""he crawled out of bed and couldn't bet back in."" On 8/30/10, at 11:45 PM, the resident was found sitting on his buttocks with his back against the low bed. On 9/1/10, the resident was found on the floor in front of his wheelchair. He reported that he was trying to get something off his bedside table, leaned forward and fell . On 9/5/10, at 1:50 PM, the resident was found on the floor by his bed. ""I was going to a meeting."" On 9/6/10, at 3:40 AM, the resident was found on the floor by the bed. ""I have to go to work."" He also complained that the ""bed is curved in the middle and it messed me up."" The resident was discharged on [DATE]. Review of the medical record showed no evidence that the facility assessed the resident's falls in an attempt to find a pattern and possible triggers for the falls. The resident did have a bed in the low position but no other interventions were noted.",2014-01-01
10300,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2010-09-20,496,D,,,9EZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of a Certified Nursing Assistant's employee file and interview, the facility failed to ensure that information was sought from every State registry before allowing an individual to serve as a nurse aide for 1 of 1 employee file reviewed. The findings included: The employee file of a Certified Nursing Assistant (CNA) who was assigned to a resident who fell and was later diagnosed with [REDACTED]. The facility checked the South Carolina CNA Registry for information prior to hire, but failed to check with the Massachusetts CNA Registry. The Assistant Director of Nurses confirmed this after she spoke with Human Resources personnel.",2014-01-01
10240,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2011-09-21,314,E,,,MKPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of a facility provided article from "" Primary Intention"" which included a reference from Barr J."" Principals of Wound Cleansing"" and an facility provided article printed from the Internet related to Management of Pressure Ulcers, the facility failed to provide appropriate wound care. The Pressure ulcers for Resident #2 & #3 were not appropriately cleaned. during the observation of wound care. (2 of 3 pressure ulcer care observed). The findings included: The facility readmitted Resident #3 on 08/18/2011 with [DIAGNOSES REDACTED]. On 9/20/11 at !0:05 AM, during observation of wound care for Resident # 3, the Wound Nurse sprayed wound cleanser on the sacral ulcer and wiped the ulcer edges with a four by four gauze four times, using a clean gauze each time, but failed to clean the wound bed. The resident was then turned and repositioned on the left side and wound care to the right hip was observed. The Wound Nurse sprayed the ulcer and wiped the wound bed three times using a separate four by four gauze each time but failed to clean the periwound tissue. The facility admitted Resident # 2 on 3/14/07 with the following Diagnosis: [REDACTED]. On 9/20/11 at 3:30 PM, during observation of wound care for Resident # 2, the Wound Care Nurse (WCN) cleaned the wound from side to side. During a interview with the WCN on 9/20/11 at 2:00 PM when ask about wiping/swabbing the wound from side to side she stated "" I was told not to clean it from the center, because you don't know where you started."" When ask how she was taught to clean a wound, she stated from the center outward. The wound care nurse was observed during the survey to clean three pressure ulcers. Her methodology varied during all three procedures. The facility Nurse Consultant provided this surveyor with documentation of an article titled ""Wound Cleansing: sorely neglected? "" ( Primary Intentions Volume 14 Number 4 November 2006, page 160 ) that referenced how to achieve appropriate cleaning while scrubbing a wound by using circular motions, gradually increasing in size, always moving away from the centre. Additionally, an article printed by the facility from the Internet on 9/20/11 at 12:18 PM was given to this surveyor. This article from the National Guideline Clearinghouse related to Management of Pressure Ulcers stated: ""1. Cleanse the wound and periwound at each dressing change.....""",2014-02-01
10241,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2011-09-21,315,D,,,MKPP11,"**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 provide appropriate catheter care for Resident # 12. (1 of 2 catheter care observations conducted.) The findings included: The facility admitted Resident # 12 on 9/29/10 with the following Diagnosis: [REDACTED]. During the observation of the catheter care provided by Certified Nursing Assistant (CNA) #1 on 9/19/11 at 1:35 PM, the CNA lifted the penis by raising the catheter tubing. The catheter tubing was held approximately 2 inches from the urinary meatus. While securing the penis in an upright position by holding the catheter tubing, she then cleaned the penis using downward [MEDICAL CONDITION] from tip to the base of the penile shaft. During a interview with the CNA on 9/21/11 at 9:45 AM she did not dispute the observation.",2014-02-01
10242,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2010-10-29,225,D,,,CXO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of facility files related to an allegation of abuse and misappropriation of resident property, the facility failed to report the allegation to the State survey and certification agency for 1 of 1 allegation reviewed. On 5/5/10, Resident #1's [MEDICATION NAME] ([MEDICATION NAME]) patch was missing. All staff on duty were drug tested that day. Laboratory test results reported to the facility on [DATE] confirmed the presence of the drug in Certified Nursing Assistant (CNA) #1's system. The findings included: Resident #1 arrived at the facility on 1/22/03. His [DIAGNOSES REDACTED]. The resident suffered from chronic pain and received [MEDICATION NAME] 25 micrograms per hour via [MEDICATION NAME]. The patch was changed every 72 hours. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the investigative materials revealed LPN #1 went to the resident on the morning of 5/5/10 and applied a new [MEDICATION NAME]. She secured the patch with a dated piece of tape. The LPN was unable to find the old patch for removal. LPN #1 tried to find the old patch again at approximately 10 AM and could not. She made another attempt at 12 noon only to discover the 8 AM patch was missing. A search of the resident, his bed, and his room failed to locate the [MEDICATION NAME]. LPN #1 reported her findings to Administration. The facility conducted searches of all employees on duty. The employees were also held for drug testing. Only one employee's drug test returned with positive results for [MEDICATION NAME], CNA #1. The Bureau of Drug Control was called to investigate. CNA #1 was terminated on 5/29/10. The facility could not provide any evidence showing they reported this incident to the State survey and certification agency.",2014-02-01
10243,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2010-10-12,225,E,,,8JQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record review, interview, and review of the facility's reportable file since 4/9/10, the facility failed to report to the State survey and certification agency 4 of 8 allegations of misappropriation of resident property (Residents A, B, C, D), failed to report timely 3 of 4 allegations of misappropriation (Residents #1, E, F), and failed to thoroughly investigate 4 of 8 allegations of misappropriation (Residents A, B, C, and D). The findings included: Resident #1 reported to the facility on [DATE] that her wallet was missing. The Complaint/Grievance Report stated the resident reported that approximately $30.00 was in the wallet. The facility's initial 24 hour report also noted the resident's debit card was taken and that there had been some activity on the resident's debit card account. The initial report to the State survey and certification agency was dated 9/28/10, which exceeded the 24 hour deadline for reporting allegations of misappropriation. Review of the facility's grievance files revealed three addition allegations of misappropriation around the same time Resident #1 made her complaint. Resident A reported $4.00 missing on 9/24/10. Resident B reported $14.00 missing on 9/27/10. Resident C reported $9.00 missing on 9/28/10. Residents B and C had notations on their grievance stating ""resolved by personnel action (secondary to) cluster of similar events on Unit 200."" None of these allegations was reported to the State survey and certification agency or thoroughly investigated. Continued review of the facility reportable incidents revealed another cluster of allegations concerning misappropriation of resident property in April 2010. Resident E reported on 4/10/10 that $63.00 was missing. The resident's allegation was not reported until 4/12/10. Resident F reported on 4/16/10 that $20.00 was missing. The allegation was reported to State agency on 4/20/10. Resident D reported ""missing $"" on 4/16/10. The facility was not able to show evident that this allegation was reported or investigated by the facility.",2014-02-01
10244,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2010-10-19,225,D,,,YPDS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews the facility failed to ensure that all allegations of abuse/neglect were thoroughly investigate to prevent further abuse to residents #1 and #5. There was no documentation that the facility interviewed all staff on duty at the time of the incident (2 of 5 sample residents reviewed) The findings included: The facility admitted Resident #1 on 06/25/2010 and readmitted the resident on 07/30/2010 with [DIAGNOSES REDACTED]. Review of the facility investigation regarding a facility reported incident involving Resident #1 on 07/23/2010 revealed a statement written by Licensed Practical Nurse #1 that stated, ""...I asked her when it started hurting she said yesterday at white guy help me from my bed to my chair he was in white uniform - he was with other workers. He picked me up under my arms and lifted me to the w/c (wheelchair) - felt a little pain not much..."" The witness statement indicated the resident informed the facility staff that ""he was with other workers"". A review of the facility investigation revealed no interviews were done with the staff working at the time of the incident. The Social Services Director (SSD) stated that the facility did not have statements from staff on the unit at the time of the incident with Resident #1. The facility admitted Resident #5 on 12/20/2005 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 06/17/2010 that indicated the resident had memory problems but had no cognitive problems with daily decision making. Review of the facility grievance log revealed Resident #5 informed the facility on 08/05/2010 that a nurse, in the presence of three CNAs (certified nurse aides), grabbed her wrist and told her to move. There was no documentation the facility investigated the allegation and reported to the State Survey Agency. In an interview on 10/19/2010 at approximately 11:30 PM the DON (Director of Nursing) and the SSD (Social Services Director) confirmed the findings related to Resident #1 and #5.",2014-02-01
10245,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2010-10-27,157,D,,,K6DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician and family promptly of a change in condition which potentially required physician intervention. Resident #4, one of four residents reviewed for notification, had a temperature of 103.2 without timely physician/family notification of a change in condition. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes on 10/27/10 at 10:20 AM revealed a note dated 7/20/10 at 1:50 PM that stated ""130/76, 100.3, 78, 18. Prn (As needed) Tyl(enol) admin(istered) (with) f/u (follow up) temp (temperature) of 98.8. Pt (Patient) total care continues. Up in w/c (wheelchair) daily max assist (with) mech(anical) lift. Skin warm-tx (treatment) to sacral area continues. Moderate drainage noted (with) scant odor. Will cont(inue) to monitor..."". The next note was dated 7/21/10 at 3 AM and stated ""At 1 AM resident had rapid breathing, skin warm & moist. VS (Vital Signs) as follows 103.2, 98, 24, 136/92. PRN (As Needed) Tylenol given for (increased) temp. Recheck temp @ 3 A(M) (down) to 99.9. Respiration(s) even + nonlabored..."". There was no mention that the physician or family had been notified of the change in condition for this resident when her temperature, heart rate, and respiratory rate increased at 1 AM. The next entry was dated 7/21/10 at 10:40 AM and stated ""@ 9 am, pt alert, responsive-meds (medications) given per g-(gastrostomy) tube (without) difficulty. g tube patent (with no residual). HOB (Head of Bed) elevated per norm. Tyl(enol) PRN admin(istered) @ this time prior to wound care tx (treatment). @ 9:55 called to pt rm (room) d/t (due to) pt lethargic et facial drooping upon assessment noted pt (with) L(eft) side facial drooping, open mouth breathing-labored respirations @ 26. Lungs full, SpO2 @ 90% RA (Room Air) HR (Heart Rate) 133, B/P (Blood Pressure) 86/58. Pt temp 99.2 Ax(illary). Also noted L(eft) arm [MEDICAL CONDITION]. @ 10:05 notified Dr. Smith of change in pt status. Received order to sent to KCMC (Kershaw Medical Center) ED (Emergency Department)- report given @ 10:20. Pt daughter -- notified of pt's status change @ 10:24. Pt cont(inues) (with) increased resp(irations) et HR. Suctioned x 1 (with) 120 cc (milliliters) white frothy secretions. EMS (Emergency Medical Services) arrived @ 10:30. Pt SpO2 stable @ 90% RA..."". Review of the ""Notification of Change Nursing Note(s)"" revealed a sheet dated 7/21/10 that listed the ""Time of Incident: 1 AM, Describe Condition Change/Incident Type: (Increase) in temp 103.2, Tylenol given temp (down) 99.9...Describe the immediate Intervention: Resident had (increase) in temp- relieved (with) Tylenol, Dr. -- was notified on 7/21/10 at 10:05 AM/PM. Responsible Party (RP) --was notified on 7/21/10 at 10:24 AM/PM...Information Documented in the Nurse's Note. Yes/No (Yes was circled)"". At the bottom of the sheet was a box that listed Vital Signs as ""103.2, 98, 24, 136/92"", Skin ""Warm, moist"", Breathing ""Rapid""...and Physician Response ""KCMC eval(uate) + tx (treat)"". During an interview on 10/27/10, the Director of Nursing (DON) stated that the facility had no specific policy related to notification for changes in condition. She stated that she left it up to nursing judgement. She stated that nurses can contact their supervisor and that the facility utilizes Standing Orders. Review of the ""Springdale Health Care Center Standing Orders"" on 10/27/10 revealed under 'Medications' for ""Fever: Give Tylenol 325 mg (milligrams) 2 tablets PO (By Mouth) q4h (Every 4 hours) for temperature greater than 101. If fever persists for 24 hours, notify physician for further orders"". During an interview on 10/27/10 at 3:05 PM, the Unit Manager on the 200 Hall stated she would have called the doctor to let him know about the elevated temperature of 103.2 for Resident #4. When asked about the standing orders regarding ""Fevers"" that instructed nursing staff to give Tylenol for temperatures greater than 101 and then notify the physician if the fever persists for 24 hours, she stated that since the fever was recurring she would have let him know and would not have waited.",2014-02-01
10246,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2010-10-27,166,D,,,K6DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interview, and review of the policy provided by the facility entitled ""Grievances & Complaints"", the facility failed to actively work towards resolution of a complaint/grievance for one of one sampled residents with a grievance. Family member concerns regarding the care of Resident #4 were not addressed by the facility. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. A complaint faxed to DHEC (Department of Health and Environmental Control) Certification was reviewed on 10/26/10 prior to the survey. The complaint included a letter dated 7/29/10 addressed to the Admissions Director and Marketing Director of Springdale Health Care Center. It contained the following: ""Gentlemen: (Resident #4) is back at Springdale, as you know, and I'd like to review with you the matters regarding her care that we discussed recently. (Marketing Director) informed us that she would be placed on the ""100"" wing/hall with different nurses/staff caring for her. (Admissions Director) addressed personally taking care of/supervising her wound care, including the ""wound vac"". To prevent dehydration, her feeding tube is to be flushed multiple times daily. Insuring that the feeding tube area remains clean. Monitoring excessive therapy (exercise) on her left arm. To make sure that she isn't sitting on the affected area for prolonged periods, and that she is turned on a regular basis. That someone communicates with Dr. --, myself and/or my (other family member) for any change in her condition or care. FYI, her home caregiver --, will continue to make regular visitations with (Resident #4). I am optimistic that the ""situation"" that occurred last week has been resolved, corrected, and that (Resident #4's) care will be the best that Springdale has to offer. Please contact me immediately if any of the foregoing is incorrect or misunderstood. Thank You..."" During an interview on 10/27/10 at 2:20 PM, the Director of Nursing (DON) stated she had received a copy of the above letter but didn't remember the date it had been received. When asked if any of the concerns regarding the resident's care had been investigated, she stated that there was nothing to investigate, that the family wanted the resident moved and she had been moved. When asked if (the Admissions Director) was personally taking care of or supervising the wound care/wound vac for Resident #4, she stated that he was the Admissions Nurse and ordered medical supplies but did not personally take care of or supervise wound care. When asked, she stated that no one in particular is supervising the resident's feeding tube flushes or site care, but that the nursing staff ensures this is done. According to the DON, therapy manages the left arm exercises, and all staff routinely make sure residents are not sitting in one spot for prolonged periods and ensure that residents are turned. The DON stated these concerns were not addressed with particular staff for this resident, and that no inservices or instruction had been given to the staff because of the letter. When asked if the family member's concern regarding notifying the physician, herself, or her (other family member) had been addressed with staff caring for the resident she said no. During an interview on 10/27/10 at 2:35 PM, Social Worker #1 was asked about the above letter. She stated she had not been aware of the letter but had spoken with the family member on 9/21/10 when the family member called. She stated that the family member had concerns with odors and flies in the resident's room and wanted the resident moved to a room without carpet. She stated at the time of the call, the family member had stated that she thought the resident was going to be moved to Hall 100. According to the Social Worker, the resident was moved when a room became available. Review of a note written by the Social Worker on 9/21/10 revealed ""...Family requested for patient to be placed in a room that has tile flooring. Family informed that one is not available at this time. However, when one becomes available family will be notified and offered the room change"". Review of Interdisciplinary Progress Notes revealed Resident #4 was readmitted on [DATE] to room [ROOM NUMBER]B, and that she was moved to room [ROOM NUMBER]B on 10/12/10. During an interview on 10/27/10 at 1:40 PM, the Rehab (imitation) Director stated no one had said anything to her about Resident #4's therapy on her left arm being excessive. When asked if she had been the person they would have told about the complaint she stated that she was. Review of the policy provided by the facility entitled ""Grievances & Complaints"" dated April 2005 revealed under 'Policy', ""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 resident's family in a timely manner"". Under 'Fundamental Information', the policy stated that the Administrator was responsible for ""Resolving all grievances and/or complaints; and Coordinating compliance at the Facility with this policy...""It went on to state that ""Any resident, his or her representative, family member...may file a grievance or complaint...All grievances and complaints are investigated, resolved, and documented"". Under 'Procedure', ""2. Grievances and complaints may be submitted orally or in writing...(If a grievance is submitted orally, the facility employee taking the grievance must write it up on the report form), 3. 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 department head will submit a written report of such findings to the Administrator within 3 working days of receiving the grievance and/or complaint. The investigation and report should be completed using a Grievance/Complaint Report"", 6. The Administrator will review the finding with the person investigating the complaint to determine what corrective actions and resolutions need to be made...""",2014-02-01
10247,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2010-10-27,253,D,,,K6DC11,"On the days of the complaint inspection, based on observation, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 6 resident rooms observed. Soiled and malodorous carpets were observed in 3 of 6 resident rooms on Unit 2. The findings included: Observations on 10/26/2010 at 10:10 AM of room 209 revealed 3 large grayish brown spots on the floor under the tube feeding pole and pump; room 213 was noted with a large amount of clothes piled on a chair and a pair of bedroom shoes on the floor; both room had a musty odor throughout. Observations on 10/26/10 at 12:02 PM revealed a fly light position on the floor in room 212B near the window, the ionizer contained approximately 15 dead flies on the base, under the light. There was also a musty odor noted throughout the room. The tan carpet on the floor was worn and had stains along with darker areas that looked like black scuff marks. At 12:24 the Director of Nursing verified the findings but stated she could not smell any odors. She stated that there might be an odor, but that she smoked and didn't have a good sense of smell.",2014-02-01
10248,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2010-10-27,279,D,,,K6DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review and interview, the facility failed to development comprehensive plans of care, which addressed the needs of 1 of 6 sampled residents. Resident #3 with a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #3 on 10/15/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/26/2010 for Resident #3 revealed a Interdisciplinary Progress Note dated 10/23/2010 at 1:00 PM that stated, ""Res (resident) noted with nephrostomy valve leaking. Supervisor notified and MD made aware. MD order given to tape around valve to seal and to monitor until Monday and let nephrologist address then. Urine draining in nephrostomy bag without problems..."" A care plan dated 10/25/2010, noted the following problem area: ""Is at risk for injury related to falls as evidence by...has nephrostomy with drng (drainage) bag and suprapubic cath (catheter)""; ""Admits related to weakness from acute hospital stay...suprapubic cath and groin pain""; ""Potential for pain related to [DIAGNOSES REDACTED]. staff for ADL's (activities of daily living) related to: suprapubic cath in place..."" The care plan identified the left nephrostomy tube as a suprapubic catheter. The plan of care did not document that Resident #3 had a left nephrostomy tube in place or the need to monitor on a routine bases the care of the tube and insertion site. The Director of Nursing verified the resident was not care plan for a left nephrostomy tube.",2014-02-01
10249,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2010-10-27,309,D,,,K6DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observation, the facility failed to assure each resident received care and services in accordance with the plan of care as ordered by the physician. Resident #1 had current physician orders [REDACTED]. Resident #3 with an order documented in the Interdisciplinary Progress Notes for a follow-up with the nephrologist related to a leaking nephrostomy tube that was not transcribed and carried out. (2 of 6 sampled residents reviewed for care and services related to following physician orders.) The findings included: The facility admitted Resident #1 on 10/04/2010 with [DIAGNOSES REDACTED]. As a result of a complaint the closed medical record for Resident #1 was reviewed on 10/26/2010, a physician's orders [REDACTED].#1 complained of loose stools through the night and the standing order for Immodium was initiated, there was no further documentation related to loose stools until 10/10/2010. A late entry dated 10/12/2010 at 8:00 PM for 10/10/2010 4:00 PM stated, ""Resident c/o (complains of) loose stool. Medicated with Immodium, ineffective continues to have loose stool. MD aware n/o (new order) received: obtain stool sample, decrease TF (tube feed) 50 cc/hr (centimeters/hour); have dietician assess."" On 10/10/2010 the Resident #1 was transferred to the hospital at the request of the family due to their concerns related to her having loose stools. Review of the Activities of Daily Living (ADL) Flow Record showed Resident #1 had extra large stools on all three shifts 10/08/2010; had no stool on the 11-7 shift, an extra large stool on the 7-3 shift and a small stool on the 3-11 on 10/09/2010; had extra large stools on all three shift on 10/10/2010. Review of the 24 hour report from 10/08/2010 thru 10/10/2010 documented on 10/08/2010 for the ""Day"" shift (7-3) ""c/o loose stools, initiated s.o. (standing order) Immodium...""; the 24 hours reports revealed no further documentation related to Resident #1 having loose stools. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]> give 2 mg after each loose stool not to exceed 16 mg in 24 hrs."" The MAR indicated [REDACTED]'s standing orders were not followed related to the administration of [MEDICATION NAME]. The facility admitted Resident #3 on 10/15/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/26/2010 for Resident #3 revealed a Interdisciplinary Progress Note dated 10/23/2010 at 1:00 PM that stated, ""Res (resident) noted with nephrostomy valve leaking. Supervisor notified and MD made aware. MD order given to tape around valve to seal and to monitor until Monday and let nephrologist address then. Urine draining in nephrostomy bag without problems..."" Review of the physician's orders [REDACTED]. In an interview with the surveyor on 10/26/2010 at approximately 11:45 AM the Director of Nurses confirmed the ordered had not been written. Resident #3 was sent to the emergency roiagnom on [DATE]; the valve was replaced and a culture was obtained.",2014-02-01
10250,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2010-10-26,157,D,,,M5SK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated she did not accompany the physician nor visually see the physician examine the resident. LPN # 1 also stated she called the resident's family and left a message. However, there was no documentation either by the nurse or the physician that had occurred. Review of the facility provided policy for condition change stated: ""Any staff member who notices a resident/patient status change shall immediately notify the appropriate licensed personnel. After assessing the resident/patient, the licensed personnel shall contact the physician immediately regarding status change. Family members and or guardians...will be notified, except when the change in status regards such routine lab work, diet changes. and/or minor medication changes. ....Notification of the appropriate individuals is to be documented in the medical record. Documentation on the 24 hour report does not replace documentation in the medical record. Facility policy titled Documentation: Charting stated ...all pertinent information will be charted on each individual/patient/resident in accordance with accepted professional standards and practices. The records will be a complete, accurate and functional representation of the actual experience of the patient/resident. ...The chart is a legal document and must be kept up-to-date at all times. ...Pertinent information requiring documentation will include, but not be limited to the following:....A significant change in physical, mental or psychosocial status...clinical complications related to disease status...new behaviors.""",2014-02-01
10251,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2010-10-26,281,D,,,M5SK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility provided policy for documentation, the facility failed to meets professional standards of quality. Resident # 11 was documented as having a rapid onset of illness with elevated temperature and foul smelling emesis at 2:45PM. At 6PM, a facility staff member documented the effect of medications administered. There was no further documentation of the resident until 355AM, the following morning when the resident was mottled, with unstable vitals signs and transferred to acute care. A History and Physical completed by the attending physician failed to address a complete assessment of the resident. The findings included: The facility admitted Resident # 11 on [DATE]. The resident's [DIAGNOSES REDACTED]. On [DATE], a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on [DATE] at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. Licensed Practical Nurse # 1 documented she administered [MEDICATION NAME] two times that day (at 8:30AM and 2PM) and Tylenol at 2PM for and elevated temperature. The last documented complete physical assessment of the resident was at 2:45PM on [DATE]. Review of the 24 hour report and nursing worksheet contained no additional information. Licensed Practical Nurse # 2 documented on the back side of the Medication Record that Tylenol and [MEDICATION NAME] were repeated at 6PM and were ""effective."" No further documentation of the resident's condition was found. The next documentation of an assessment of the resident's condition occurred at 3:55AM on [DATE] when the resident was transferred to acute care and admitted to the hospital. The admission History and Physical obtained from the hospital stated the resident was to be admitted with [DIAGNOSES REDACTED]. The resident expired while in the hospital on [DATE]. The Discharge summary stated: ""...was noted to have a fever and some vomiting. He had no urinary output and was sent to the emergency room for evaluation. He was evaluated in the ER (emergency room ) and found to have a positive troponin level and elevated D-Dimer He had a urinary tract infection with TNTC (too numerous to count) white cells. ...Patient was admitted to the Critical Care Unit,, He was placed on IV antibiotics....Patient's troponin level continued to rise, as high as 80. He was evaluated by Cardiology, who felt his prognosis was poor due to the size of his MI ([MEDICAL CONDITION] Infarct). On [DATE], at 5PM, during an interview with the attending physician, he stated he had cared for the resident while in the hospital. The physician stated he felt the resident had suffered a [MEDICAL CONDITION] probably secondary to his urinary tract infection. He further stated it was believed that the initial [MEDICAL CONDITION] had occurred ,[DATE] hours prior to admission based on the lab results. When asked if the resident would have exhibited symptoms, he stated ""some do and do not"". He stated the resident denied having a [MEDICAL CONDITION] and that not all residents experience pain- 50% have no pain. The physician stated at that time he did not recall being called or informed of the resident's initial illness. He acknowledged being in the facility on that day but if he had seen the resident, it would have been because he was"" sitting in the hallway"" as was his usual habit. During the interview, the physician also concurred with the surveyors concern related to the lack of documentation of nursing assessment from 6PM to 3:55AM. In review of the closed medical record, a History and Physical dated [DATE] lacked recorded vital signs; did not address the residents past history; mental disease; kidney function; rehabilitation potential; the resident's [MEDICAL CONDITION] or use of a Foley catheter. It failed to document a complete list of the resident's known diagnoses. During an interview with attending physician, he stated he agreed the History and Physical was ""sparse"". The physician stated he had been informed of the surveyors concern prior to the interview. The physician stated he did not like the form, did not know who had developed it, and did not usually answer all the areas addressed on the form. He stated based on the surveyors' concern, it would be a ""good time"" to change the form. Facility policy titled Documentation: Charting stated ...all pertinent information will be charted on each individual/patient/resident in accordance with accepted professional standards and practices. The records will be a complete, accurate and functional representation of the actual experience of the patient/resident. ...The chart is a legal document and must be kept up-to-date at all times. ...Pertinent information requiring documentation will include, but not be limited to the following:....A significant change in physical, mental or psychosocial status...clinical complications related to disease status...new behaviors.""",2014-02-01
10252,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2010-10-26,428,D,,,M5SK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the consulting pharmacist failed to identify that Resident # 11 with known bradycardia was not having a pulse taken prior to administration of the medication. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having known Bradycardia. The resident was ordered by the physician to receive Metoprolol 12.5 milligrams daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pharmacist was questioned as to why there had not been a previous recommendation to take the resident's pulse prior to the administration of the medication, especially since she had acknowledged the resident's known bradycardia. The pharmacist stated that some facilities had policies which required a pulse be obtained prior to the administration of this class of drug, but this facility did not. On 10/25/10 at 5PM, during an interview with the attending physician, he stated he was not aware the resident's pulse was not being taken prior to the administration of the medication. The Nursing Drug Handbook 2011 Edition available as a resource for the nurses on the nursing unit, stated on page 383: ""Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately."" There was no documentation found that the resident's pulse was being obtained prior to the administration of the Metoprolol or that the consulting pharmacist had reported the irregularity to the physician.",2014-02-01
10253,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2010-10-26,156,B,,,M5SK11,"On the days of the survey, based on record review and interview, the facility failed to provide timely Notice of Medicare Provider Non-Coverage notification for 4 of 5 residents reviewed for Change in Pay Source. The findings Included: Review of residents files for change in pay source revealed four of five residents had not received timely notification of Medicare Provider Non-Coverage. Resident A's Notice of Medicare Provider Non-Coverage indicated that effective 1/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until 1/11/2010. Resident B's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/10. Resident C's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/2010. Resident D's Notice of Medicare Provider Non-Coverage indicated that effective 1/14/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 1/14/2010. During an interview with the Business Office Manager (BOM) on 10/25/10 at approximately 3:30 PM he/she stated "" They wanted to go home that day, so we did not have time to give notice"". The medical records for residents B and C showed a form titled Notification of Therapy Change which was dated 6/2/10 for resident C. (7 days in advance). and Resident B's form was dated 6/7/10. (4 days in advance). The BOM stated when asked what this form was for, ""that is how they let us know the time is ending.""",2014-02-01
10254,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,157,G,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: ""07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP (?) P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ... ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..."" On 10/12/2010 at approximately 2:15PM, during an interview with the Family Nurse Practitioner she stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician.",2014-02-01
10255,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,281,G,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; ""opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: ""07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP--, P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ...ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..."" Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/2010 at approximately 2:15 PM, during a telephone interview with the surveyor the Family Nurse Practitioner stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician.",2014-02-01
10256,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,312,D,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, ""scratches won't leave band aid on."" On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing.",2014-02-01
10257,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,280,D,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she ""slid"" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated ""8-22-10 at 7:45 AM"". Under ""Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage."" was a handwritten note. ""Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor..."". The ""Additional comments and/or steps taken to prevent recurrence:"" revealed ""Morse Fall Scale"". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been ""..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she ""slid out"". She was out of site for app(roximately) 2 minutes"". The ""Additional comments and/or steps taken to prevent recurrence:"" revealed ""Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ..."". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed ""Resident found sitting on floor in front of chair"". The ""Additional comments and/or steps taken to prevent recurrence:"" revealed ""Morse Fall"". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed ""Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse"". There were no additional comments listed. Review of the Care Plan dated 08/30/2010 revealed that Resident #1 had been identified as being ""At risk for falls r/t (related to) a hx (history) of falls, ""Morse falls score 75"". Under ""Last fall date"" was handwritten in ""9/1/10- slid out of w/c, 9/13/10-slid out of chair, 9/14/10-slid out of w/c"". The Approaches used were typed and included ""1) Encourage resident to use call light, 2) Encourage resident to ask for assistance with transfers as needed, 3) Observe frequently when up and OOB (Out of bed), 4) 1/2 Siderails up X 2 to assist with mobility, and to define the parameters of the bed, 5) Orient to surroundings as appropriate, 6) Review medications for the continued need, appropriateness dosage, continued effectiveness, 7) Perform ongoing assessment of any physical or mental health status changes, 8) Uses low bed to reduce the risk for falls, 9) Use Morse Falls scale to determine risk for falls, 10) Call light in reach"". During an interview on 10/12/2010 at 4:05 PM, the Minimum Data Set (MDS) Coordinator stated that she had handwritten the updates regarding the resident sliding out of the chair onto the Care Plan. She stated she had updated this information for the Director of Nursing (DON) since the Nurse Manager had been out on leave. She stated the Nurse Manager was responsible for updating the approaches used and that the DON had taken over this duty since the Nurse Manager had been out. The MDS Coordinator stated she only updated the Care Plan once a year r/t changes the Nurse Manager had already made. During an interview on 10/12/2010 at 4:15 PM, the DON verified the approaches had not been changed related to Resident #1's repeated ""sliding"" out of chairs and stated it was probably because there had been nothing to change.",2014-02-01
10258,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,272,G,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a ""fading discoloration"" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that ""During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the ""stand-up"" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury"". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under ""Assistive Aides:"" wheelchair alarm and bed alarm had been checked. Review of ""Weekly Nursing Assessment(s)"" dated 8/22/2010 through 9/19/2010 revealed under ""ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help"". There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 8/16/2010 through 9/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: ""8-19-10...Staff x 2 put resident to bed"", ""8-20-10...Staff x 2 assisted res(ident) to bed"", ""8-23-10...Staff x 2 assisted to bed..."", ""8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed"", ""9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut"". During a phone interview with the surveyor on 10/12/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 9/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview with the surveyor on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she ""knew"" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to ""see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet"". During an interview with the surveyor on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/10 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under ""Transfer"" as a ""3"" requiring extensive assistance with ""3"" two + persons physical assist. Under ""Modes of transfer"" she had been coded as ""Lifted mechanically"". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that ""they were certified"". Review of the interdisciplinary Care Plan revealed that Resident #1 had the problem of ""ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive"" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010 with the surveyor on 10/12/2010, the Physical Therapist stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/10 ""SPT"" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2"" and for 09/22/10 ""Bed Chair Max(imum)/Mod(erate) x 2"". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During an interview with the surveyor on 10/12/10 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lifts. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed, under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs. The facility admitted Resident #3 on 04/14/2006 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] thru 10/09/2010 showed under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. Review of the CNA Care Plan Guide for Resident #3 revealed no mention of the level of assistance required for transfers or a mode of transfer. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] revealed Resident #3 coded under Transfer as a (4) total assistance with (3) two persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 06/21/2010 and updated 09/14/2010 revealed that Resident #3 required assistance with Activities of Daily Living. Interventions included sits and transports in a Geri-chair daily; there was no mention of transfer needs.",2014-02-01
10259,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,225,E,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated ""8-22-2010 at 7:45 AM"". Under ""Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage."" was a handwritten note. ""Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor..."". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been ""..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she ""slid out"". She was out of site for app(roximately) 2 minutes"". The ""Additional comments and/or steps taken to prevent recurrence:"" revealed ""Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ..."". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room and staff pretty much knew what had happened. The ""Additional comments.."" section was brought to her attention which indicated that the alarm was in place but didn't sound. The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 09/01/2010 at 0800 which stated, ""Approx (approximately) 5 cm (centimeter) reddish, brown discoloration noted inner side on lt (left) knee. Denies discomfort at site. Noted to cross and uncross legs freq (frequently) when up in chair."" On 09/22/2010 at 2100 a Nurse's Note stated, ""Staff called to room to observe a purple bruise to (L) (left) upper arm above elbow. Intact with no c/o (complaint) pain or discomfort."" There were no incident reports related to the two incidents and they were not investigated and/or reported to the state survey agency. The facility admitted Resident #3 on 04/14/2006 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 07/11/2010 at 8 AM which stated, ""CNA (certified nurse aide) reported large purple bruise on upper outer (R) (right) arm. No s/s (signs/symptoms) of pain noted. Called nephew..."" The facility admitted Resident #5 on 07/21/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 10/05/2010 at 11:30 that stated, ""Res. (resident) up in halls with walker without prob (problem) - no limping, denies discom (discomfort) site of bruising top of lt (left) foot."" On 10/06/2010 at 0630 a Nurse's Note stated, ""...Resident picked up walker and one leg of walker was placed on top of foot (L) (left) foot and was ready to place her weight down on it. May have been cause of bruising and swelling on top of foot seen yesterday..."" The incident was not investigated and/or reported to the state survey agency. During an interview with the surveyor on 10/12/2010 at approximately 11:45 AM, the Assistant Director of Nursing (ADON) stated she was not aware of the incidents related to resident #2 on 09/01 and 09/22/2010, no incident reports were made. When asked about Resident #3 she provided an investigation. The incident was not reported to the state survey agency. During an interview with the surveyor on 10/12/2010 at approximately 12:15 PM the Unit 3 Unit Manager confirmed the only observation documented concerning Resident #5 placing her walker on top of her left foot occurred on 10/06/2010 after the initial injury. The Unit Manager confirmed the incident had not been investigated and/or reported to the state survey agency.",2014-02-01
10260,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,253,D,,,GYKK11,"On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained.",2014-02-01
10261,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2010-10-12,323,G,,,GYKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a ""fading discoloration"" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, ""During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the ""stand-up"" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury"". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under ""Assistive Aides:"" wheelchair alarm and bed alarm had been checked. Review of ""Weekly Nursing Assessment(s)"" dated 08/22/2010 through 09/19/2010 revealed under ""ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 08/16/2010 through 09/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: ""8-19-10...Staff x 2 put resident to bed"", ""8-20-10...Staff x 2 assisted res(ident) to bed"", ""8-23-10...Staff x 2 assisted to bed..."", ""8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed"", ""9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut"". During a phone interview on 10/21/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 09/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she ""knew"" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to ""see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet"". During an interview on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/2010 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under ""Transfer"" as a ""3"" requiring extensive assistance with ""3"" two + persons physical assist. Under ""Modes of transfer"" she had been coded as ""Lifted mechanically"". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that ""they were certified"". Review of the interdisciplinary Care Plan dated 08/30/2010 revealed that Resident #1 had the problem of ""ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive"" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010, the Physical Therapist #1 stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/2010 ""SPT"" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2"" and for 09/22/2010 ""Bed Chair Max(imum)/Mod(erate) x 2"". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During the interview, the Physical Therapist was asked if PT provided any training on the use of the lifts. She stated that there had been an inservice done on 09/2/2010 by PT. She stated the training was in response to a resident that was supposed to be non-weight bearing. She stated PT spoke mostly about how to transfer residents with different weight bearing statuses, body mechanics, and hip precautions (what type of care a person with a total hip replacement requires). She stated there were no demonstrations on the use of the lift, but that it was mentioned -""If they needed to use the lift, go ahead"". When asked if she had received any training on the use of the lift, she stated she had not received training in this facility, but that she had in other facilities she's worked in. She stated she had not trained any staff in the use of the lift. During interviews with the nursing staff, CNAs were asked about training received on the use of the mechanical lift and how they determined the amount of transfer assistance needed for a resident. Two CNAs indicated that they had not been provided with written instructions on how to use a mechanical lift and that CNAs that trained newly orienting CNAs did not use any set check list to instruct them on lift procedures. During a phone interview on 10/12/2010 at 11:45 AM, CNA #1 was asked if she had received any training on how to use a mechanical lift. She replied that when she did clinicals at the facility, she was taught how to use them. She stated once employed by the facility, she received training in orientation where she was shown how to use the lift by another CNA. When asked how she determined which residents needed to use the lift, she replied that you could tell the ones with more weight than the others. She stated that there was no paper documentation to tell her which residents needed to use a lift, that this was common sense. During an interview on 10/12/2010 at 1:15 PM, CNA #2 stated that she had been working at the facility for [AGE] years. She stated that staff receives inservices on the use of the mechanical lift whenever they get a new one. She stated that CNAs train other CNAs in the use of the lift but that no check off sheets or written instructions are used. When asked what she would do if she didn't know how to transfer a resident, she stated she would first ask the nurse, then ask PT. When asked if she would refer to the CNA Care Plan she said she would. During an interview on 10/12/2010 at 1:52 PM, CNA #3 stated that she had been employed at the facility for approximately 2 years. She stated she had been trained on the use of mechanical lifts during orientation. She stated she did not remember the CNA who trained her, but that she had been told how to use the lift, showed how to use the lift, and had to demonstrate the lift procedure back to her trainer. She was not aware of any check off sheet related to the lift procedure that had been used or turned in. When asked how she determined what type of assistance is required with resident transfers and if a lift is used, CNA #3 stated that she would first ask the nurse or other staff. Then she would look at the CNA Care Plan, which is located in the PCR book at the nursing station. During an interview on 10/12/2010 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lift. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. She verified there were no formal assessments in place for the use of mechanical lifts. When asked how CNAs were trained in the use of the mechanical lift, she stated mentor CNAs checked them off during orientation. She was unable to provide any check off sheets or policies/procedures related to the use of the mechanical lift. She was asked to provide documentation of training for the mentor CNAs but did not provide any. When asked if there was a facility designated inservice trainer, she stated that there was not one, but that the Secretary and ADON kept up with staff training. When asked if any inservices or training had been provided related to using mechanical lifts since the incident with Resident #1's broken leg, she stated that there was an inservice scheduled for October 21st. She stated the inservice was being done in response to the incident with Resident #1 and was going to address the use of lifts and fire safety. Prior to the exit conference, the DON stated she had forgotten about an inservice regarding the proper use and function of the Sara Lift and the Marissa Lift that had been done in July 2010 and provided a copy. The inservice report stated that a demonstration had been done by therapy in which ""The actual lifts were brought into the room and several employees acted as residents to properly demonstrate the use and function of these lifts"". The inservice sheet did not contain any checklist or written procedures that had been communicated to the staff during the inservice. The signature sheet included CNAs #1, #2, and #3. During an interview on 10/12/2010 at approximately 5:00 PM, the Assistant Director of Nurse's (ADON) stated that inservices related to the mechanical lift devices were done periodically by therapy. She stated that CNAs who have been here a long time and who were very knowledgeable about lifts train new CNAs during orientation. She stated that the licensed nursing staff does not train the CNAs on the use of the mechanical lifts. The ADON stated that ""mentor"" CNAs use a ""Nurse's Aide Checklist For Orientation"" and provided a copy for review. She stated that CNAs get checked off on the use of mechanical lifts under the heading ""Safety devices"" and ""Comfort of patients"". Review of the checklist under those headings revealed no mention of the use of a lift. When asked how the CNAs were supposed to know this information pertained to the use of a mechanical lift (since there was no mention of a mechanical lift), the ADON stated she guessed they wouldn't. She was unable to provide a check off sheet or any other documentation to show what information the mentor CNAs were using to train new CNAs regarding how the mechanical lift should be operated. Review of the PCR book, which included all the PCR's for Unit 3 revealed a communication in the front of the book dated 3/28/2006 that stated ""Residents are to be lifted using one of the lifts or a gait belt. No exceptions. This is to protect the staff as well as the residents. Corrective action will be taken if this is not followed. Thank you for your cooperation!"" During an interview at 5:35 PM, the DON, when asked relative to the above communication if the philosophy of the facility had been and now was to use the lift as much as possible to prevent injury, answered ""yes"". The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed under ADL's (Activities of Daily Living), that the resident transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 dated September 2010 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs.",2014-02-01
10262,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2010-10-18,280,D,,,DFY111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 4 sampled residents reviewed for Comprehensive Care Plans. Resident #1's Care Plan had not been updated regarding approaches used for proper positioning and to prevent and/or care for Pressure Ulcers. The findings included: The facility admitted Resident #1 on 09/06/2002 and readmitted her on 12/10/2004 with [DIAGNOSES REDACTED]. Observation on 10/18/2010 at 12:35 PM revealed the resident lying on a specialty mattress with the head of bed elevated. Review of the cumulative Physician order [REDACTED]. Review of the Physician/Nurse Practitioner Progress Notes on 10/18/2010 at 1:15 PM revealed the following: 06/16/2010- ""S(ubjective): Resident had an area of skin compromise noted to her sacrum. Initial treatment was the use of [MEDICATION NAME] although wound treatment nurse reports the skin was intact at that time. However, we were called to see the resident today due to changes in the sacral wound...P(lan): ...Also, initiate a specialty mattress surface for the resident to minimize skin breakdown and to offload this area"". 07/12/2010- ""Patient is an elderly white female with a known history of advanced dementia, ... and essentially total care for activities of daily living (ADLs) and instrumental activities of daily living (IADLs)..."". 07/14/2010- ""Chief Complaint: Pressure Area. S(ubjective): Resident is frail and debilitated, cachectic, with wound on her sacrum...O(bjective): The wound is open...Heels are intact... P(lan): ...Keep resident turned and positioned..."". 07/28/2010- ""P(lan): She is on double shot protein q.i.d. (4 Times daily)...Heels are intact...Encourage turning and repositioning"". 08/09/2010- ""P(lan): ...Keep resident turned and repositioned"". 08/30/2010- ""P(lan):...Encourage turning and repositioning, although due to her frailty and debility would contribute greatly to poor wound healing. She is also very thin..."". 09/29/2010- ""Chief complaint: Pressure areas. S(ubjective): Resident was seen by this provider for follow up of a pressure area on her sacrum. She has developed other areas of skin compromise. O(bjective): ... On the left outer heel is a smaller wound that measures approximately .1 cm (centimeters) The wound is dark brown, purple coloration, with peeling edges. No open areas at this time...P(lan): Encourage turning and repositioning....She is already on double shot protein..."". Review of the Care Plan for Resident #1 on 10/18/2010 at approximately 1:40 PM revealed page 13 of the Care Plan folded over. Written on the fold was ""7/7/10 New Skin Integrity Care Plan Printed"". On the folded page were approaches listed for the problem of being at risk for impaired skin integrity with the ""Date(s)"" listed as 10/13/2009, 01/04/2010, and 04/06/2010. The ""Goal"" was that ""Resident's skin will be free from irritation and breakdown"" with an evaluation date of 07/06/2010. The approaches listed included ""Turn and reposition every 2 HRS (hours), Assess nutritional status, Keep skin dry and clean, Assess skin condition PER POLICY, float heels as ordered, ..."". Further review of the Care Plan for Resident #1 revealed there was an entry dated 07/14/2010 that addressed the problem of being at risk for impaired skin integrity related to skin tears, but it did not include approaches to prevent or care for pressure ulcers. Continued review revealed ""Problem Start Date: 07/07/10, Resident has a pressure ulcer Stage III to sacrum"". The goal was listed as ""Resident's ulcer will decrease in size and ulcer will not exhibit signs of infection..."". The approaches listed included the following: ""Use pads or briefs to maintain personal hygiene and dignity, Keep clean and dry as possible. Minimize skin exposure to moisture, Keep linens clean, dry, and wrinkle free. Conduct a skin inspection weekly, and daily per policy. Report any signs of any further skin breakdown. Assess pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin. Follow wound care nurse and provider's recommendations and orders related to dressing changes. Provide incontinence care after each incontinent episode."" There was no mention of the Nurse Practitioner's recommendation to keep the resident turned and repositioned, that the resident used a specialty mattress, that Resident #1's heels were to be floated, or that the resident should be in her geri-chair with foam cushion for proper positioning while out of bed. During an interview on 10/18/2010 at 1:48 PM, one of the Minimum Data Set (MDS) Coordinators (Registered Nurse #1) reviewed the Care Plan and verified that the folded page was not included in the current Care Plan. She verified that there was not a ""7/7/10 New Skin Integrity Care Plan"" and that the current Care Plan did not address turning and repositioning the resident or floating the resident's heels. She stated that another MDS Coordinator had been responsible for updating Resident #1's Care Plan and that this nurse had just started in July. She stated she would look to see if there were any more pages that should have been included in Resident #1's Care Plan. Upon return, she did have some pages to add, but none related to skin breakdown or pressure ulcer care.",2014-02-01
10263,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2010-10-18,157,D,,,DFY111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled ""Physician Communication Grid"", the facility failed to notify the physician with changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated ""9-15-10"" that stated ""Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)"". Under this was written ""crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd"". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured ""Length 5.0, Width 8.0, depth 1.0, Undermining 3.9"". On 9/29/10 the wound had increased in size to ""Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1"". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured ""Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8""; and one dated 10/14/2010 that stated ""Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1"". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. During an interview on 10/18/2010 at approximately 12:00 Noon, the Director of Nursing (DON) reviewed the wound measurements for September and October 2010 and verified the wound had increased in size from 09/22 to 09/29/2010. After reviewing the chart, she verified there were not any Physician/Nurse Practitioner Progress Notes that addressed the wound for the above referenced time periods. When asked about any other progress notes that may not have been in the chart, the DON asked another staff member to check, but was unable to provide any additional progress notes that indicated the Physician/Nurse Practitioner was aware of the worsening pressure ulcer. She stated that the nursing staff talks with the Nurse Practitioner/Physician when they come in twice a week, but they weren't aggressively treating the resident because she was on hospice. During an interview on 10/18/2010 at 4:15 PM, the Nurse Practitioner was asked about the resident's worsening pressure ulcer. She was given the measurements for the following dates and was told that the pressure ulcer had increased in size on 09/29/2010 and had continued to increase in size according to the documentation for 10/07/2010 and 10/14/2010. She was told that there had been no documentation of physician notification and when asked if she would have expected the nursing staff to call and notify her or the physician, she stated ""yes"". Review of the policy provided by the facility on 10/22/2010 entitled ""Physician Communication Grid"" revealed an entry for ""Pressure Ulcers"". Under the heading ""Treatment Required within 4 Hours (If no response within 4 hours call medical director)"" was listed ""New Stage III or higher, any break in skin associated with fever or signs of infection"". Under the heading ""Routine Physician Notification"" was ""New Stage II or less"". There was no mention of notification for enlargement of existing Pressure Ulcers. The facility initially admitted Resident #4 on 08/11/09 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Record review on 10/18/2010 at 9:23 AM revealed a Nurse's Note dated 09/19/2010 that stated ""Aide doing AM (Morning) care noticed open area to L(eft) heel. Came + got me. Open area bleeding slightly. No drainage noted. Cleansed (with) NS (Normal Saline) + dressed (with) safe gel foam pad + Kerlix. No C/O (complaints) of pain/discomfort voiced"". Review of the Wound Treatment and Progress Record dated October 2010 revealed an order dated 09/19/2010. Under ""Treatment"" was written ""Cleanse L(eft) heel (with) NS (Normal Saline) or wound cleanser, apply sm (all) amt (amount) wound gel (with) dry dsg (dressing). Secure (with) tape. May cover loosely (with) gauze, (Change) qd (daily) & PRN (When needed). On the back of the Wound Treatment and Progress Record were two entries. One entry dated 10/07/2010 documented the wound as being ""Length 1.8, Width 2.4"". The other entry was dated 10/14/2010 and documented ""Length 4.6, Width 7.0"". There were no other entries on the sheet. Observation of the dressing change to the left heel on 10/18/2010 revealed that the ulcer was located on the left lateral side of the left foot and went up the backside of the heel. The ulcer had some depth in the center of the wound along with a black discoloration along the top edge of the wound. According to the Treatment Nurse (LPN #1), she usually measured wounds once a week. When asked, she stated that she would normally measure any new areas of depth, but verified that she had not done so for the area on the resident's left heel. According to LPN #1, the Nurse Practitioner (NP) had not been informed about the new area of depth on the left heel. She stated that the NP would be there today and she would have the NP look at the wound. Review of the Physician/Prescriber Telephone Orders for October 2010 at approximately 9:00 AM revealed no orders related to the left heel ulcer. Further review of October's Nurse's Notes revealed no mention that the physician or Nurse Practitioner (NP) had been notified that the left heel ulcer had gotten worse. Review of the Physician/Nurse Practitioner Progress notes revealed a note dated 10/05/2010 that stated ""...His areas have opened back up on both heels"" and ""Both heels have darkened skin with blisters and drainage, serous. Right seems larger than the left"". There were no other Physician/Nurse Practitioner progress notes for October 2010 provided by the facility. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. Review of the policy provided by the facility on 10/22/2010 entitled ""Physician Communication Grid"" revealed an entry for ""Pressure Ulcers"". Under the heading ""Treatment Required within 4 Hours (If no response within 4 hours call medical director)"" was listed ""New Stage III or higher, any break in skin associated with fever or signs of infection"". Under the heading ""Routine Physician Notification"" was ""New Stage II or less"". There was no mention of notification for enlargement of existing Pressure Ulcers.",2014-02-01
10264,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2010-10-18,514,E,,,DFY111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)"". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN"". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN"". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN"". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN"". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 verified these blanks. Review of multiple Medication Flowsheets revealed that narcotic medications had been initialed as having been given when there was no documentation to corroborate this in the Narcotic and Hypnotic Record. There were also instances of medications being signed out on the Narcotic and Hypnotic Record, which were not documented on the Medication Flowsheet as having been given to the resident. The following documentation was reviewed and verified by Registered Nurse (RN) #2 on 10/17/2010. Review of Resident A's October 2010 Medication Flowsheet revealed an order dated 09/11/2010 that stated ""[MEDICATION NAME] ([MEDICATION NAME])- Schedule IV Tablet; 0.5 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 4hrs PRN)"". This was initialed on the front of the Medication Flowsheet as having been given on 10/10/2010 at 6:30 PM. On the back of the flowsheet, was an entry dated 10/10/10 that stated that [MEDICATION NAME] 0.5 mg had been given at 6:30 PM for agitation. However, the narcotic log documented that [MEDICATION NAME] 0.5 mg had only been signed out at 2 PM on 10/10/2010. There was nothing on the Medication Flowsheet to indicate the resident received any [MEDICATION NAME] at 2 PM. There was another separate entry that revealed that [MEDICATION NAME] 0.5 mg had been initialed as having been given on the Medication Flowsheet for 10/03/2010 at 9 PM, however, the Narcotic and Hypnotic Record did not have an entry for that date and time. Review of the Narcotic and Hypnotic Log for Resident A revealed ""[MEDICATION NAME] 0.5 mg, Take 1 Tab by mouth every 4 hours as needed"". Further review revealed that [MEDICATION NAME] 0.5 mg had been signed out on the log on 10/07/2010 at 9 AM and 10/15/2010 at 4:45 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Another order for Resident A, dated 09/21/2010, was listed on the Medication Flowsheet as ""[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab (tablet); Oral TID- Three Times A Day"". The scheduled times were listed as 9 AM, 1 PM, and 9 PM. Review of the Medication Flowsheet revealed initials in the 10/06/2010, 9 PM square. However, review of the Narcotic and Hypnotic Record revealed that the medication had not been signed out for that date and time. There was another order dated 9/13/10 that stated ""[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab; Oral PRN-As Needed"". Review of the Narcotic and Hypnotic Record revealed that the medication had been signed out on 10/03/2010 at 1700 but this had not been documented as having been given on the Medication Flowsheet. Review of Resident B's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record revealed that [MEDICATION NAME] 1 mg had been signed out on 10/11/2010 at 10 AM, 10/13/2010 at 9:30 AM, and on 10/16/2010 at 9 PM. However, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Review of Resident C's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for ""[MEDICATION NAME] 10 mg Tablet SUB (Substitute) FOR: AMBIEN"" revealed that the medication had been signed out on 10/16/2010 at 9 PM, however, the Medication Flowsheet was blank for that date and time. Review of Resident D's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for the medication revealed [MEDICATION NAME] 0.5 mg had been signed out on 10/3/2010 at 9 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at this time. Review of Resident E's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the resident's Narcotic and Hypnotic Record for ""[MEDICATION NAME](one) W(ith) APAP 7.5-500 mg Tablet, Take 1 Tab by mouth every 4-6 hours as needed"" revealed that the medication had been signed out on 10/9/2010 at 9 PM and on 10/11/2010 at 9 PM. The Medication Flowsheet, however, was blank and did not document any [MEDICATION NAME] as having been given for these dates. Review of Resident F's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Further review revealed another entry for ""[MEDICATION NAME]-[MEDICATION NAME]- Schedule III Tablet; 10-500 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 6hrs PRN)"". Review of the Narcotic and Hypnotic Record for the medication revealed that the medication had been signed out on 10/09/2010 at 8 AM, 1:30 PM, and 5 PM only. The Medication Flowsheet for the PRN Hydocodone-[MEDICATION NAME] was blank and did not indicate a 5 PM dose had been given on this date. The nurse had initialed the medication as having been given on the routine (Three Times Daily) entry for 10/09/2010 at 9 AM, 1 PM, and 9 PM; however, there was no 9 PM entry on the narcotic log. Further review revealed this same medication had been signed out on the narcotic log on 10/11/2010 at 9AM, 1 PM, 5 PM, and 9 PM; however, there was no documentation on the Medication Flowsheet that a PRN dose had been given at 5 PM.",2014-02-01
10265,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2010-10-18,314,D,,,DFY111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled ""Physician Communication Grid"", the facility failed to assess and address with the physician changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated ""9-15-10"" that stated ""Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)"". Under this was written ""crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd"". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured ""Length 5.0, Width 8.0, depth 1.0, Undermining 3.9"". On 9/29/10 the wound had increased in size to ""Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1"". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured ""Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8""; and one dated 10/14/2010 that stated ""Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1"". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. During an interview on 10/18/2010 at approximately 12:00 Noon, the Director of Nursing (DON) reviewed the wound measurements for September and October 2010 and verified the wound had increased in size from 09/22 to 09/29/2010. After reviewing the chart, she verified there were not any Physician/Nurse Practitioner Progress Notes that addressed the wound for the above referenced time periods. When asked about any other progress notes that may not have been in the chart, the DON asked another staff member to check, but was unable to provide any additional progress notes that indicated the Physician/Nurse Practitioner was aware of the worsening pressure ulcer. She stated that the nursing staff talks with the Nurse Practitioner/Physician when they come in twice a week, but they weren't aggressively treating the resident because she was on hospice. During an interview on 10/18/2010 at 4:15 PM, the Nurse Practitioner was asked about the resident's worsening pressure ulcer. She was given the measurements for the following dates and was told that the pressure ulcer had increased in size on 09/29/2010 and had continued to increase in size according to the documentation for 10/07/2010 and 10/14/2010. She was told that there had been no documentation of physician notification and when asked if she would have expected the nursing staff to call and notify her or the physician, she stated ""yes"". Review of the policy provided by the facility on 10/22/2010 entitled ""Physician Communication Grid"" revealed an entry for ""Pressure Ulcers"". Under the heading ""Treatment Required within 4 Hours (If no response within 4 hours call medical director)"" was listed ""New Stage III or higher, any break in skin associated with fever or signs of infection"". Under the heading ""Routine Physician Notification"" was ""New Stage II or less"". There was no mention of notification for enlargement of existing Pressure Ulcers. The facility initially admitted Resident #4 on 08/11/09 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Record review on 10/18/2010 at 9:23 AM revealed a Nurse's Note dated 09/19/2010 that stated ""Aide doing AM (Morning) care noticed open area to L(eft) heel. Came + got me. Open area bleeding slightly. No drainage noted. Cleansed (with) NS (Normal Saline) + dressed (with) safe gel foam pad + Kerlix. No C/O (complaints) of pain/discomfort voiced"". Review of the Wound Treatment and Progress Record dated October 2010 revealed an order dated 09/19/2010. Under ""Treatment"" was written ""Cleanse L(eft) heel (with) NS (Normal Saline) or wound cleanser, apply sm (all) amt (amount) wound gel (with) dry dsg (dressing). Secure (with) tape. May cover loosely (with) gauze, (Change) qd (daily) & PRN (When needed). On the back of the Wound Treatment and Progress Record were two entries. One entry dated 10/07/2010 documented the wound as being ""Length 1.8, Width 2.4"". The other entry was dated 10/14/2010 and documented ""Length 4.6, Width 7.0"". There were no other entries on the sheet. Observation of the dressing change to the left heel on 10/18/2010 revealed that the ulcer was located on the left lateral side of the left foot and went up the backside of the heel. The ulcer had some depth in the center of the wound along with a black discoloration along the top edge of the wound. According to the Treatment Nurse (LPN #1), she usually measured wounds once a week. When asked, she stated that she would normally measure any new areas of depth, but verified that she had not done so for the area on the resident's left heel. According to LPN #1, the Nurse Practitioner (NP) had not been informed about the new area of depth on the left heel. She stated that the NP would be there today and she would have the NP look at the wound. Review of the Physician/Prescriber Telephone Orders for October 2010 at approximately 9:00 AM revealed no orders related to the left heel ulcer. Further review of October's Nurse's Notes revealed no mention that the physician or Nurse Practitioner (NP) had been notified that the left heel ulcer had gotten worse. Review of the Physician/Nurse Practitioner Progress notes revealed a note dated 10/05/2010 that stated ""...His areas have opened back up on both heels"" and ""Both heels have darkened skin with blisters and drainage, serous. Right seems larger than the left"". There were no other Physician/Nurse Practitioner progress notes for October 2010 provided by the facility. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. Review of the policy provided by the facility on 10/22/2010 entitled ""Physician Communication Grid"" revealed an entry for ""Pressure Ulcers"". Under the heading ""Treatment Required within 4 Hours (If no response within 4 hours call medical director)"" was listed ""New Stage III or higher, any break in skin associated with fever or signs of infection"". Under the heading ""Routine Physician Notification"" was ""New Stage II or less"". There was no mention of notification for enlargement of existing Pressure Ulcers.",2014-02-01
10194,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,441,E,,,A4CW11,"On the days of the survey, based on observation and interview, the facility failed to sanitize residents' personal laundry. The findings included: During observation on 9/14/10 at approximately 1:36 PM, Laundry Aid #1 loaded multiple residents' personal laundry into the washer and set the cleaning solution pump on ""F1."" The sign posted on the wall stated F1 solution was without bleach. During an interview at that time, the laundry aid stated she always used setting 1 for residents' personal clothes so they wouldn't be damaged. At 1:46 PM, during an interview, the Area Mechanic stated the water in the washer was between 115 and 120 degrees. He further stated the water used to be at 180 degrees but, after changing chemicals, they had been told the water temperature didn't need to be that high. At approximately 3:08 PM on 9/14/10, the Director of Environmental Services confirmed that the F1 setting did not include bleach and stated the (solution) pump should have been set on the F2 setting which added bleach after five minutes. Review of the detergent container did not reveal that the detergent contained any sanitizer. The Director of Environmental Services did not provide any additional information that the detergent had any bateriocidal properties.",2014-03-01
10195,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,333,D,,,A4CW11,"**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 ensure that one of 20 residents reviewed for medication assessment was free of significant medication errors. Potassium was not administered as ordered to Resident #6 for a period of 5 days. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was ""nil"" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed 7-19-10 physician's orders [REDACTED]. Review of the 7-19-10 Basic Metabolic Profile revealed the following results: Sodium = 130 LOW (reference 135-145 mmol/L); Potassium = 4.9 (reference 3.6-5.0 mmol/L); Chloride = 95 LOW (reference 101-111 mmol/L); Blood Urea Nitrogen = 52 HIGH (reference 6-20 mg/dl); Creatinine = 1.8 HIGH (reference 0.5-1.2 mg/dl). Review of the 7-10 Documentation Record (Medication Administration Record/MAR) revealed that the medication was held as ordered and that the [MEDICATION NAME] was resumed on 7-27-10. The Potassium (20 milliEquivalents daily) was not initialed on the MAR indicated [REDACTED]. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses verified that the medication had not been initialed as given for the five day period as noted. She stated she had been unaware of the omissions, no medication error report had been completed, and the physician had not been notified. She reviewed the record and verified that no recent Potassium level had been drawn.",2014-03-01
10196,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,315,E,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled ""Skills Checklist for Suprapubic Catheter Care"", the facility failed to ensure appropriate treatment and services for residents with catheters. The Certified Nursing Assistant (CNA) failed to properly anchor the suprapubic catheter tubing during catheter care for Resident #2, one of three residents observed with catheter care. Also, the facility failed to assess oral intake and urinary output as indicated by residents' medical condition for one of two sampled residents reviewed with an indwelling Foley catheter and Care Plan for intake and output monitoring. Resident #6, with a history of fluid imbalance and [MEDICAL CONDITION], had incomplete intake and output documentation. The findings included: The facility admitted Resident #2 on 10/22/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 9/14/10 at 12:23 PM revealed CNA(Certified Nursing Assistant) #2 cleaning, rinsing, and drying the catheter tubing. She held the tubing between her index finger and thumb, approximately 4 inches from the insertion site, and anchored it to the resident's thigh while wiping down the tubing. The CNA cleansed from the insertion site distally toward where she held the catheter, causing undo tension on the catheter tubing. During an interview on 9/15/10 at 11:25 AM, CNA #2 verified she had anchored the catheter tubing at the resident's thigh instead of at the insertion site while performing catheter care. She stated she thought she was supposed to anchor the tubing to the thigh. Review of the policy entitled ""Skills Checklist for Suprapubic Catheter Care"" on 9/15/10 revealed ""...6. Apply soap to one wet cloth, 7. Hold tubing (Without pulling) in other hand, 8. Wash around one side of tubing with soapy cloth-, 9. Using a different, clean part of cloth- wash around the other side of the Tubing, 10. Hold the tubing closest to the body to anchor it and prevent it from being pulled, 11. Using a different, clean part of cloth- wrap cloth around tubing (while holding with other hand) and wash tubing at least 4 inches away from body...14. Rinse one side of the insertion site ___/other side of tubing ___/the tube at least 4 inches___(while anchoring the tubing)___...16. Dry with clean cloth- one side of insertion site ___/other side of insertion site __/ around tubing and out 4 inches ___/ while anchoring tubing___."" The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was ""nil"" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed significant weight loss noted on both the 11-16-09 Admission and 7-22-10 Quarterly Minimum Data Set Assessments. Weight records revealed an admission weight of 242 pounds and a 7-10 weight of 129.3 pounds. Further review revealed stabilization after the most recent assessment. The resident was admitted with and continued to have an indwelling Foley catheter. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses (DON) attributed the majority of the weight loss to a dramatic decrease in [MEDICAL CONDITION] after admission (related to the [DIAGNOSES REDACTED]. Review of the current Care Plan revealed approaches including monitoring for [MEDICAL CONDITION] and recording intake and output every shift. Review of Intake and Output (I&O) Records revealed that urinary output was inconsistently monitored. For the month of 7-10, 31 of 31 days had omissions of recorded output. For 8-10, 30 of 31 days were incomplete. 13 of 13 days were incomplete in 9-10, through the dates of the survey. There was no output recorded for 7-31-10 7AM-3PM shift through 8-1-10 11PM-7AM shift (6 consecutive shifts), from 8-28-10 7AM-3PM shift through 8-31-10 7AM-3PM shift (10 consecutive shifts), and from 8-31-10 11PM-7AM shift through 9-3-10 7AM-3PM shift (8 consecutive shifts). Review of the diet card on 9-14-10 at 12:05 PM indicated that the resident was on a 1500 ml (milliliter) fluid restriction. As the tray was delivered, Certified Nursing Assistant (CNA) #4 stated she would ""go get the coffee"" as per the resident's request. During an interview at this time, CNA #4 reviewed the diet card and stated that she thought the resident was on a fluid restriction. The CNA verified that the diet card noted and that the resident received only 5 ounces of soup and 1/2 cup of iced tea as fluids for that meal. CNA #4 also verified that the resident had a water-filled pitcher at the bedside. A water pitcher had also been observed at the residents bedside on 9-13-10 at 9:35 PM and on 9-14-10 at 10:15 AM. At 12:30 PM on 9-14-10, Licensed Practical Nurse (LPN) #2 verified that a resident on fluid restriction should not have a water pitcher at the bedside and that intake and output should be monitored. I&O records were reviewed and 23 of 31 days in 7-10, 27 of 31 days in 8-10, and 11 of 13 days in 9-10, through the dates of the survey, were recorded with intakes of greater than 1500 ml. No current physician's orders [REDACTED]. During an interview on 9-15-10 at 9:35 AM, LPN #5 verified that Resident #6 should have had her intake and output monitored every shift. She stated that nurses wrote this information on the daily assignment sheet. CNAs were to record the intake and output at the end of their shifts. The Ward Secretary was responsible to ""get the I&O and record it"" on the Intake and Output Records. During the interview on 9-15-10 at 9:40 AM, the DON confirmed that Resident #6 had not been on a fluid restriction ""for quite some time...She was on a restriction when first admitted due to [MEDICAL CONDITION] (skin) all over her body..."" The DON stated that the diet card had been corrected. She verified the Care Plan to monitor the intake and output and confirmed that the reports were incomplete.",2014-03-01
10197,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,332,D,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.5 %. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 9/13/10 at 8:36 PM, during observation of medication pass, Registered Nurse (RN) #5 was observed to administer two Klor-Con 10 (Potassium Chloride Extended Release) tablets and 7 other medications to Resident #10. During an interview on 9/13/10 at 8:48 PM, RN #5 revealed that supper trays arrived on the unit at about 6 PM and that Resident #10 had eaten in his room (approximately 2 and one-half hours before the potassium was administered). The Drug Facts and Comparisons book, page 49 (Potassium Replacement Products), states (under ""Patient Information""): ""May cause GI (gastro-intestinal) upset; take after meals or with food and with a full glass of water."" Error #2: On 9/13/10 at 9 PM, during observation of medication pass, RN #2 was observed to administer one drop of [MEDICATION NAME] Ophthalmic Solution and one drop of [MEDICATION NAME] Ophthalmic Solution to the right eye of Resident A with one minute and 56 seconds between the two drops. RN #2 then administered one drop of the same two eye drops to the resident's left eye with 2 minutes and 4 seconds between the 2 drops. The Drug Facts and Comparisons book, page 1725, states (under ""General Considerations in Topical Ophthalmic Drug Therapy""): ""Because of rapid lacrimal drainage and limited eye capacity, if multiple drop therapy is indicated, the best interval between drops is 5 minutes. This ensures that the first drop is not flushed away by the second or that the second drop is not diluted by the first."". Error #3: On 9/14/10 at 7:47 AM, during observation of medication pass, RN #1 was observed to instill one drop of [MEDICATION NAME] Ophthalmic Suspension into each eye of Resident B without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under ""General Considerations in Topical Ophthalmic Drug Therapy""): ""Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug."". During an interview on 9/14/10 at 9:53 AM, RN #1 confirmed she did not shake the [MEDICATION NAME] Ophthalmic Suspension before instillation into the resident's eyes. Observation of the [MEDICATION NAME] Ophthalmic Suspension bottle revealed that there was no auxiliary ""Shake Well"" label attached to the bottle. During an interview on 9/14/10 at 10:43 AM, the facility's Consultant Pharmacist stated that she doesn't supply medications to the facility but agreed that there should be a ""Shake Well"" auxiliary label attached to the [MEDICATION NAME] bottle.",2014-03-01
10198,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,225,D,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled ""Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property"" dated 2/09, the facility failed to complete a thorough investigation for one of one reportable incidents reviewed for misappropriation of funds. The findings included: One of three reportable incidents reviewed on 9/15/10 revealed that a resident reported $44.00 missing from his room on 9/7/10. According to the DHEC (Department of Health and Environmental Control) Five-Day Follow-Up Report dated 9/13/10, ""He had noticed this the week prior to the report"". Under ""Witnesses and other Staff on duty at time of/or prior to Reportable Incident:"", there was nothing written. According to the report, the missing money had been reported by the facility to the Union County Sheriff's Office on 9/8/10. The ""Summary Report of Facility Investigation:"" stated ""(Resident) keeps various items in the basket where he reported the money had been stored. (Numerous pieces of mail, straws, playing cards, and various other items). He has been reminded again to lock up any large amounts of money."" Attached to the Five-Day Follow-Up Report was a letter dated May 4, 2010 from the Administrator addressed to residents and their families reminding them that the facility could store valuables and that residents are encouraged to not keep any items of personal or monetary value in their room. The letter went on to state that ""The facility will take every precaution to protect belongings but cannot be accountable for valuables left in resident rooms"". There were no resident or staff statements attached or evidence of a thorough investigation being completed. During an interview on 9/15/10 at approximately 12:30 PM, the Social Services Director (SSD) stated the resident had a history of [REDACTED]. After reviewing the Five-Day Follow-Up Report, she verified there were no resident or staff statements included. When asked if she had asked any of the staff about the missing money, she said ""We felt like, they know to report. We thought it would be ineffective to ask each one."" She went on to state that they had thought it best if the Sheriff's Department handled it. The SSD stated staff receive inservices on misappropriation. She then stated they did ask staff present at the time of the report if anyone knew about missing money, however, they did not get any statements and did not check to see which staff may have been on duty at the time of the alleged incident. The SSD had questions about where to draw the line as far as who to interview during an investigation. Review of the policy entitled ""Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property"" on 9/15/10 revealed ""Investigation procedures for allegations of misappropriation of resident property are as follows: ...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: a. An interview with the person reporting the missing items, b. A search of the resident's room for the missing items, c. an interview with the resident, as medically appropriate, e. An interview with the alleged individual accused of taking the residents' property, if known, f. Interviews with staff members, g. Interviews with the resident's roommate, family members, and visitors as appropriate..."".",2014-03-01
10199,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,323,D,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, ""DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED"". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : ""RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness"". SAFETY STATEMENTS on the MSDS read: ""Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges."" HANDLING AND STORAGE SECTIONS of the MSDS stated, ""STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). Keep container lightly closed and upright when not in use to prevent leakage."" ""HANDLING: Use only with adequate ventilation. Avoid breathing of vapor of spray mist. Avoid contact with skin and eyes. Wear OSHA standard goggle or face shield. Wear gloves, apron, and footwear impervious to this material. Wash clothing before reuse. Avoid free fall of liquid. Empty container very hazardous!"" Residents in nearby rooms #17 and #15 were using oxygen at the time of the random observation and a fan was blowing in the hall by the shower room with the observed Paint Thinner. In an interview on 9/14/10 at 11:00 AM with the Administrator and Environmental Services Manager they recognized the paint thinner as a hazardous chemical and removed if from the premises promptly. The Administrator stated they had contracted painters to repaint the facility halls and the Paint Thinner was left by the painters who were currently using the product. He stated that he had informed them prior to the start of the painting of the halls to remove unattended hazardous chemicals while painting the facility. He did not have a formal, written contract with the paint company, or evidence of this instruction. Following completion of tracheal suctioning and care on 9-14-10, Registered Nurse (RN) #1 removed the two-tiered wired basket cart containing all tracheostomy suctioning and care supplies from Resident #3's room. She stated that it was routinely stored in the resident's bathroom. The cart contained two 16 ounce bottles of Hydrogen Peroxide which were labeled, ""Harmful if swallowed. Keep out of the reach of children."" On 9-15-10 at 10:45 AM, Licensed Practical Nurse (LPN) #4, while preparing to perform tracheostomy care for Resident #3, stated that she had obtained the cart containing the H2O2 and other supplies from the unlocked resident bathroom. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 9-14-10 at 1:55 PM revealed that resident was assessed at high risk for falls on the most recent Fall Risk Assessment completed on 7-20-10. The 7-22-10 Care Plan noted that the resident was to have a ""Low bed with mats"". The 7-22-10 Quarterly Minimum Data Set Assessment noted the resident with both short- and long-term memory problems and varying mental function. On 9-13-10 at 9:35 PM, the resident was observed in a low bed, but without mats in place. The resident was observed in a regular height bed without mats on 9-14-10 at 9 AM, 10:15 AM, 12:05 PM, 1:30 PM, and 3:50 PM. During an interview on 9-14-10 at 4 PM, Certified Nursing Assistant (CNA) #1 stated that she did not know how long the resident had not had the low bed/mats. She was aware that the resident was supposed to have them ""because it's on the Basic Care Sheet (CNA Care Plan)."" During an interview on 9-14-10 at 3:50 PM, RN #2 checked the Documentation Record and verified that it indicated that the resident was to have a low bed with mats. The form noted ""FYI"" next to the intervention which RN #2 stated meant that the nurse was to check to assure the item was in place. She went to the resident's room and verified that the resident was in a regular height bed without mats. The nurse was unable to lower the bed and was unable to locate mats in the room for the resident.",2014-03-01
10200,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,309,E,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to follow physician's orders for application of Knee High TED (antiembolism stockings) Hose for Resident # 11, 1 of 4 residents reviewed with orders for TED Hose. The facility also failed to include provision of Services from a Chaplain and Social Services in the care plan and no documentation of visits from these disciplines were found in the record for Resident #18, 1 of 2 resident's reviewed receiving Hospice Services . The findings included: The facility admitted Resident #11 on 4/26/04 with [DIAGNOSES REDACTED]. Record Review on 9/14/10 at approximately 6:15 PM revealed a Physician's Order for ""Knee high TED hose on in the morning before getting out of bed & (and) remove at bedtime ([MEDICAL CONDITION])"" with a start date of 9/16/08. Observation of the resident at 6:25 PM on 9/14/10 revealed the resident was not wearing TED Hose. During an interview on 9/15/10 at 1:15 PM, the resident stated she had never had any stockings and that she did have swelling in her feet ""sometimes."" Review of the resident's Minimal Data Set revealed the resident was coded as not having any short or long term memory problems. The resident was named on the list provided by the facility of Interviewable Residents and she was a member of the Resident Council. Record Review on 9/15/10 at approximately 1:30 PM revealed that the TED Hose had been signed off daily for August and September, including being signed off for being applied the morning of 9/15/10. During an interview on 9/15/10 at approximately 2:15 PM, Registered Nurse (RN) #4 stated she had just received a new pair of TED Hose for the resident the previous week. Upon observation of the resident, RN #4 confirmed the resident was not wearing TED Hose. RN #4 was unable to locate any TED Hose in the resident's drawers. When informed of the resident's statement that she had never had any stockings, RN #4 stated: ""She's usually pretty with it."" During an interview on 9/15/10 at approximately 2:45 PM, Physical Therapy Assistant #1 stated Resident #11 was being seen 3 times per week by Physical Therapy and the treatment included leg exercises. She further stated that she had not observed the resident wearing TED Hose for at least the last month. The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of Resident #18's record on 9/15/10, revealed no documentation of Chaplain or Social Service visits since the resident was admitted to Hospice. Review of the resident's facility and Hospice care plans revealed no care plan for Chaplain or Social Services. During an interview with RN #4 at approximately 12:00 PM, she stated she knew of no other place there would be any documentation from the Hospice staff other than in the chart. At approximately 12:30 PM on 9/15/10, the Director of Nursing stated she had spoken to the Hospice provider in the past regarding keeping information in the residents' charts in the facility and not just in the Hospice office. She stated the Director of Social Services might know if there was any documentation located anywhere else. During an interview on 9/15/10 at 1:22 PM, the Social Services Director stated she did not know of any documentation other than what was located in the chart and confirmed there was no documentation in the record of Chaplain or Social Service visits. Review of the Hospice Contract revealed the Hospice Provider was responsible for providing medical social services and counseling services (including bereavement,...and spiritual counseling.) It further stated that ""Hospice shall furnish Nursing Facility with a copy of the Hospice Plan of Care"" and any modifications to the plan of care.",2014-03-01
10201,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,322,D,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility's policies entitled ""Gastrostomy Tube Check List"" and ""Procedure for Cleaning 60 cc (cubic centimeters) Syringes Used for Resident Feeding"", the facility failed to utilize universal precautions and clean technique when flushing the Gastrostomy (G-) Tube and when cleaning and storing the piston syringes and gravity set for 2 of 3 residents observed for Gastrostomy Tube flushes. The findings included: The facility admitted Resident #5 on 7/17/09 with [DIAGNOSES REDACTED]. On 9/14/10 at approximately 12:33 PM, Licensed Practical Nurse (LPN) #6 was observed by two surveyors providing a Gastrostomy Tube flush before and after medication administration without washing her hands prior to initiating the procedure. LPN #6 opened the Medication cart, retrieved a bottle of liquid Tylenol from the drawer and poured 20 milliliters (ml) of Tylenol into a medication cup. LPN #6 proceeded to the resident's room, knocked, entered the room and filled the 2 empty medicine cups with 30 ml of water from the sink and placed all 3 medicine cups on the over-bed table. She then closed the door, opened a plastic bag and placed it on the foot of the bed and donned a pair of non-sterile gloves. LPN #6 proceeded to check for and replace residual, checked for placement of the [DEVICE], and administered the 30 ml flush, the medication and ended with another 30 ml flush. Upon completion of the procedure, the piston syringe was rinsed and placed wet, back into the bag. Review of the ""Gastrostomy Tube Check List"" provided by the facility on 9-14-10 revealed ""2. Placement check: Check placement before flushes,...Gather supplies..., Explain procedure to Resident, Provide Privacy, Wash Hands, (apply) Non-sterile gloves, ..."" The facility admitted Resident #3 on 4-8-01 with [DIAGNOSES REDACTED]. Prior to observation of a Gastrostomy (G-) feeding and flush on 9-14-10 beginning at 9:55 AM, two Certified Nursing Assistants exited the resident's room after completing AM care, including incontinent care. Registered Nurse (RN) #1 proceeded to prepare the resident for a gravity feeding. She checked placement using a 60 cc (cubic centimeter) piston syringe and then infused 30 cc of water via gravity through the barrel of the syringe. The RN then connected the gravity feeding tubing to the [DEVICE] and set the clamp so as to infuse it slowly. She then took apart the piston syringe and placed it in the sink. She removed the gloves she had used during the procedure, rinsed the syringe with water, placed the piston in the barrel of the syringe, and stored it together, wet, in its original packaging. At 10:30 AM, RN #1 disconnected the gravity feeding set and hung the capped tubing on the feeding pole. She neglected to rinse out the feeding set, allowing feeding to remain in the tubing and bottom of the bag. When asked if this was how the set was stored until the next feeding, the RN replied, ""Yes."" The nurse completed the water flush via gravity using the barrel of the feeding syringe. After completing the procedure, RN #1 again placed the piston and barrel of the feeding syringe into the sink. She removed the gloves she had used during the procedure, rinsed the syringe with water, placed the piston in the barrel of the syringe, and stored it together, wet, in its original packaging. RN #1 verified that this was the procedure she always followed. During an interview on 9-15-10 at 10 AM, the Director of Nurses stated that the facility policy did not address handling of the piston syringe or gravity feeding set. She stated that the syringe should not have been placed in the sink and that the feeding should have been rinsed out of the gravity set and not allowed to remain until the next feeding time. On 9-15-10 at 1 PM, RN #1 verified the procedure as above noted. During an interview on 9-15-10 at 12:05 PM, the Administrator stated there was no evidence on file that RN #1 had been trained on the proper procedure for [DEVICE] feeding/flush. Review of the facility's policy entitled ""Gastrostomy Tube Checklist"" on 9-15-10 revealed no reference to cleansing or storage of the piston syringe or gravity feeding set. Review of the Infection Control Manual on 9-15-10 revealed a policy entitled ""Procedure for Cleaning 60 cc Syringes Used for Resident Feeding"" which stated: ""...3. The syringe is washed and cleaned thoroughly with dispenser soap and water and rinsed well in hot water subsequent to use. Be sure not to place the syringe in the sink. 4. The syringe is stored separate (barrel and syringe) on a clean paper towel and covered with a clean towel and allowed to air dry...7. Syringes used for tube feeding are cared for in the same manner as described above...""",2014-03-01
10202,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,328,D,,,A4CW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to follow the Physician's Orders for the administration of oxygen for 1 of 4 sampled residents reviewed with oxygen. Resident # 18 oxygen rate was observed above the stated physician's order. The findings included: The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of the record on 9/15/10 at approximately 11:00 AM revealed a Physician's order for O2 (oxygen) at 2 liter per minute (lpm) via NC (nasal cannula.) Review of the Hospice Nursing Visit Note revealed the Hospice nurse had documented the oxygen at 3 lpm via NC on 9/15/10, 9/8/10 and on 8/23/10. Review of the Documentation Record (MAR) revealed facility nursing staff was signing off the O2 at 2 lpm via NC each shift including the days of the survey. Observation on 9/15/10 at approximately 11:30 revealed the oxygen was flowing at approximately 3 1/2 lpm via NC. At approximately 1:00 PM on 9/15/10, Registered Nurse (RN) # 4, verified the oxygen was flowing at 3 1/2 lpm via NC. Upon questioning, she stated ""I'd have to check the MAR (Documentation Record) but I'm pretty sure it's supposed to be at 2 (lpm)."" RN #4 also reviewed the record and confirmed the Physician's Orders and the MAR indicated and could not locate any new order to increase the flow rate. During an interview on 9/15/10 at 2:28 PM, the Hospice Nurse stated the oxygen was supposed to be at 2 lpm and had been since admission to Hospice. She stated she thought the oxygen flow rate had inadvertently been changed on 9/15/10 when the Certified Nursing Assistant had reached to turn the oxygen back on after the resident's AM care had been completed. She stated the 3 lpm documented on the Nursing Visit Note for 9/15/10 had been a documentation error only. The Hospice Nurse later changed the documentation on the 9/8/10 Nursing Visit Note from 3 lpm to 2 lpm and did not date the change.",2014-03-01
10203,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2010-09-15,468,E,,,A4CW11,"On the days of the survey, based on observation and interview, the facility failed to equip multiples areas in the corridors with handrails. The findings included: On 9/15/10 at approximately 1:55 PM, multiple areas leading into or on corridors were observed without handrails affixed to the walls. Areas included, but were not limited to: -an area approximately 3 1/2 feet at the entrance to Rocky Road Hall on the left and right sides of the hall -an area approximately 3 1/2 feet at the entrance to Rainbow Row Hall on the right side of the hall -approximately 5 feet across from the Unit I Nurses Station -a section approximately 8 feet long in a corridor behind the Unit I Nurses Station -the entire length of the corridor connecting Unit I and Unit II on both sides of the hallway -two 5 foot sections and two 3 1/2 foot sections on Unit II at the Nurses Station and several other areas leading into the 3 halls from the nurses station. During an interview on 9/14/10 at approximately 4:15 PM, the Maintenance Director verified multiple areas were without handrails and stated that the corridor between Units I and II had never had handrails as far as he knew. He also stated that the area behind the Unit I Nurses Station ""looks like there used to be one there.""",2014-03-01
10204,"FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC",425016,208 JAMES STREET,ANDERSON,SC,29625,2010-11-08,323,G,,,CCT011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review, interviews, review of the facility's policy on Falls, and review of the facility's inservices, the facility failed to assure each resident was free of accidents as was possible for 1 of 6 sampled residents. Resident #1 sustained 3 falls in 3 days without new interventions implemented. Resident #1 fell on ,[DATE], 7/30 (sustained injuries to the face and mouth) and on 8/1/2010, no interventions were implemented until 8/2/2010. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as needing extensive 1 person assistance with transfers and bed mobility and completely dependent for locomotion on and off the unit. Resident #1 was also coded as dependent for eating, dressing, hygiene, and bathing with no behaviors coded as occurring during the assessment period. The resident was coded as receiving Hospice services. Resident #1 was not coded as having any accidents within 180 days. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 ""fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury."" A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was ""observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..."" Further review revealed an entry dated 8/1/2010 at 6 AM, ""slid off of the bed on to floor, Resident observed sitting on floor with back against bed."" On 8/2/2010 at 11 AM, the nurses' note indicated an order was obtained for a bed alarm and 1/2 lap tray. Review of the care plan revealed a risk for injury (falls) related to weakness, history of syncope, dementia and seizures was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included ""observe frequently, call light within reach..., provide assistive devices for mobility, provide assistance with mobility, review circumstances of how falls occur to try to eliminate further falls, keep floor/pathway free of debris, notify MD/hospice PRN (as needed)."" The care plan was updated on 7/29/2010 with a handwritten note to ""observe res(ident) frequently when up."" The care plan was not updated with the 7/30/2010 fall nor the 8/1/2010 fall. On 8/2/2010 the bed alarm was written on the care plan, however the lap tray was not added. The care plan did not include new or appropriate interventions to prevent Resident #1 from falling after he sustained several falls on 7/29/2010, 7/30/2010 and 8/1/2010. Review of the MD Progress Notes dated 8/2/2010 indicated that Resident #1 was assessed by the physician, however there was no documentation relevant to the falls on 7/29, 7/30 or 8/1/2010. Review of the physician's orders [REDACTED]. No other orders were written related to the falls on 7/29, 7/30 or 8/1/2010. Review of the Medication Administration Record (MAR) revealed that the bed alarm and lap tray were added on 8/2/2010 and then signed for each shift. Review of the Nursing Admission Screen dated 6/29/2010 revealed that Resident #1 scored a ""12"" on the Fall Risk Screen, indicating he was at ""high risk"" for falls. Resident #1 had another Fall Risk Screen completed on 7/7/2010 scoring a ""12"", indicating he was still at high risk for falls. The interventions listed were ""staff observes freq(uently), no hx (history) of falls."" Review of the incident reports related to each fall revealed: On 7/29/2010 at 12:00 PM, Resident #1 was in the hallway with he ""tipped forward out of wheelchair, caught himself with his arms and his R(ight) forehead the floor. No injuries or report of pain. Hospice nurse notified."" ""Steps taken to prevent recurrence: 1/2 lap tray for w/c (wheelchair) on 8/2/2010."" An incident report dated 7/30/2010 at 5 PM, indicated the ""resident was observed lying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..."" ""Steps taken to prevent recurrence: bed alarm ordered on [DATE]."" An incident report dated 8/1/2010 at 6 AM revealed Resident #1 was ""trying to get up and slid off of the bed. Resident observed sitting on floor with back resting against bed...no injury observed."" ""Steps taken to prevent recurrence: bed alarm ordered on [DATE]."" During an interview on 11/8/2010 at 10:00 AM, CNA (Certified Nursing Assistant) stated #1 that she routinely cared for Resident #1. CNA #1 stated that she witnessed the resident fall on 7/29/2010. She further stated that she knew he had a bed alarm and 1/2 lap tray put in place but was unsure as to when they were placed. During an interview on 11/8/2010 at 10:15 AM, LPN Supervisor (Licensed Practical Nurse) #1 stated she was present for Resident #1's fall on 7/30/2010. She stated that she assessed the resident after the fall and filled out the incident report. She stated that Resident #1's dentures were broken and he was bleeding from his gums. She stated that she did not implement an intervention to prevent further falls and stated that she thought it ""was ok to wait on the DHS."" She stated that it was routine practice to wait for the DHS to implement a new fall prevention intervention. LPN #1 confirmed there was a delay in implementing appropriate fall prevention devices. During an interview on 11/8/2010 at 10:30 AM, LPN #2 stated that she was present for Resident #1's fall on 8/1/2010. She stated that she was aware of his previous two falls and stated that the resident did not have any fall prevention devices in place. LPN #2 stated that she found the resident on the floor in his room. She further revealed that the intervention she implemented was to ""observe frequently."" LPN #2 confirmed that this was not a new intervention. LPN #2 confirmed that there was a delay in implementing appropriate fall prevention devices. During an interview on 11/8/2010 at 11:30 AM, RN (Registered Nurse) #1 stated that she was present for Resident #1's fall on 7/29/2010. RN #1 stated that he was in orientation at the time of the fall. She further stated that she did not know that she was supposed to implement intervention after each fall to prevent further falls from occurring. RN #1 confirmed there were no interventions put in place after the fall and confirmed that there was a delay in implementing appropriate interventions. During an interview on 11/8/2010 at 12 PM, the Medical Director stated that when a resident falls he would expect the staff to assess the resident, notify him via phone or fax, execute routine procedure (i.e. vital signs, incident reports etc.). The Medical Director then stated that Resident #1 should have had an intervention put in place after he sustained the fall on 7/30/2010 that resulted in injuries to the face. The Medical Director also stated that the intervention should have been implemented immediately and not waited. During an interview on 11/8/2010 at 8:50 AM, the DHS stated that nursing should have implemented an intervention immediately after Resident #1's falls on 7/29, 7/30 and 8/1/2010. The DHS further stated that staff was waiting on her to implement interventions and she stated that she was aware that this practice was not appropriate. The DHS also indicated that the care plan coordinator was to update the care plans with each fall and add interventions. The DHS stated that she was first made aware of the concern related to untimely interventions related to falls when she reviewed Resident #1's record at the end of September 2010. The DHS confirmed there was a delay in implementing Resident #1's fall prevention interventions. .",2014-03-01
10205,"FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC",425016,208 JAMES STREET,ANDERSON,SC,29625,2010-11-08,280,G,,,CCT011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews, the facility failed to assure 1 of 6 resident's care plans were reviewed and revised appropriately. Resident #1's care plan was not reviewed and revised with each fall. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 ""fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury."" A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was ""observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..."" Further review revealed an entry dated 8/1/2010 at 6 AM, ""slid off of the bed on to floor, Resident observed sitting on floor with back against bed."" On 8/2/2010 at 11 AM, the nurses' note indicated an order was obtained for a bed alarm and 1/2 lap tray. Review of the care plan revealed a risk for injury (falls) related to weakness, history of [MEDICAL CONDITION], dementia and [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included ""observe frequently, call light within reach..., provide assistive devices for mobility, provide assistance with mobility, review circumstances of how falls occur to try to eliminate further falls, keep floor/pathway free of debris, notify MD/hospice PRN (as needed)."" The care plan was updated on 7/29/2010 with a handwritten note to ""observe res(ident) frequently when up."" The care plan was not updated with the 7/30/2010 fall or the 8/1/2010 fall. On 8/2/2010 the bed alarm was written on the care plan, however the lap tray was not added. The care plan did not include new or appropriate interventions to prevent Resident #1 from falling after he sustained several falls on 7/29/2010, 7/30/2010 and 8/1/2010. Review of the incident reports related to each fall revealed: On 7/29/2010 at 12:00 PM, Resident #1 was in the hallway with he ""tipped forward out of wheelchair, caught himself with his arms and his R(ight) forehead the floor. No injuries or report of pain. Hospice nurse notified."" ""Steps taken to prevent recurrence: 1/2 lap tray for w/c (wheelchair) on 8/2/2010."" An incident report dated 7/30/2010 at 5 PM, indicated the ""resident was observed lying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..."" ""Steps taken to prevent recurrence: bed alarm ordered on [DATE]."" An incident report dated 8/1/2010 at 6 AM revealed Resident #1 was ""trying to get up and slid off of the bed. Resident observed sitting on floor with back resting against bed...no injury observed."" ""Steps taken to prevent recurrence: bed alarm ordered on [DATE]."" During an interview on 11/8/2010 at 8:50 AM, the DHS stated that nursing should have implemented an intervention immediately after Resident #1's falls on 7/29, 7/30 and 8/1/2010. The DHS further stated that staff was waiting on her to implement interventions and she stated that she was aware that this practice was not appropriate. The DHS also indicated that the care plan coordinator was to update the care plans with each fall and add new interventions. The DHS stated that the care plans were only updated on the weekdays when the care plan coordinators were working. No other staff members updated the care plans. There was not a system in place to update the care plans on the weekends or off hours.",2014-03-01
10206,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-11-04,323,G,,,GK1G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to provide residents and staff with adequate supervision to ensure it's system for safe transfer of residents was followed by Hospice and facility staff members for 1 of 1 resident reviewed who sustained injury from an inappropriate transfer (Resident #1). Resident #1 was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to [DATE] because of acute renal failure and congestive heart failure exacerbation. Several medications were discontinued on his return to the facility including the Prednisone the resident had taken for years. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to osteoporosis, risk for falls, risk for complications due to CVA with left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the axillary area and left chest on [DATE] were new. The facility's investigation revealed the resident was given care on the morning of [DATE] by his Hospice CNA (CNA #1). After bathing and dressing the resident, CNA #1 requested help to transfer him to the recliner. CNA #1 and a facility CNA (CNA #2) manually transferred the resident to the chair. According to CNA #2's statement, a third CNA (CNA #3) was present in the room and steadied the recliner during the transfer. According to the information in the facility's investigation, the facility CNAs assisted in the inappropriate transfer. There was no evidence to show either of the facility CNAs requested that the mechanical lift be used for the resident.",2014-03-01
10207,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-11-04,282,G,,,GK1G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews the facility failed to ensure that care plans were followed for Resident #1, 1 of 3 sampled residents care planned for a mechanical lift with transfers, was transferred from bed to chair on [DATE] by manual lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to [MEDICAL CONDITION], risk for falls, risk for complications due [MEDICAL CONDITION] left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the axillary area and left chest on [DATE] were new. The facility's investigation revealed the resident was given care on the morning of [DATE] by his Hospice CNA (CNA #1). After bathing and dressing the resident, CNA #1 requested help to transfer him to the recliner. CNA #1 and a facility CNA (CNA #2) manually transferred the resident to the chair. According to CNA #2's statement, a third CNA (CNA #3) was present in the room and steadied the recliner during the transfer. Cross Refers to F323 as it relates to the failure of the facility to follow an established care plan to prevent harm and ensure the safety of Resident #1 when moving the resident in bed or transferring the resident to allow for care.",2014-03-01
10208,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-11-04,225,D,,,GK1G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Resident #1, 1 of 1 sampled resident that sustained an injury during a transfer, was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift, as care planned, by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the axillary area and left chest on [DATE] were new. The facility's investigation revealed the resident was given care on the morning of [DATE] by his Hospice CNA (CNA #1). After bathing and dressing the resident, CNA #1 requested help to transfer him to the recliner. CNA #1 and a facility CNA (CNA #2) manually transferred the resident to the chair. According to CNA #2's statement, a third CNA (CNA #3) was present in the room and steadied the recliner during the transfer. According to the information in the facility's investigation, the facility CNAs assisted in the inappropriate transfer. There was no evidence to show either of the facility CNAs requested that the mechanical lift be used for the resident.",2014-03-01
10209,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2010-11-10,280,D,,,0LRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection, based on observations, interviews and record reviews, the facility failed to ensure that Resident #4's care planned was review and revised regarding one-to-one supervision by the staff (1 of 4 sampled reviewed with behaviors). The findings included: The facility admitted Resident #4 on 10/23/09 with [DIAGNOSES REDACTED]. Review the of Nurse's Progress Notes dated 10/03/10 at 1250 documented at 1145 the staff was paged to the facility's canteen and that Resident #4 was in the canteen area and he threw a chair at a snack machine, hit a visiting family member of another resident and slammed a nurse's finger in a cabinet. The Nurse's Note further indicated that once the resident calmed down he requested to call law enforcement. At 1245 physician's orders [REDACTED].#4 returned to the facility from the hospital; at 1930 Resident #4 was noted running his wheelchair into people and things. The resident later calmed down and went to bed. A Nurse's Note dated 10/04/10 at 2330 indicated the staff was at the bedside with no behaviors noted. A Nurse's Note dated 10/05/10 at 0830 indicated the staff was at the bedside with no behaviors noted; at 2145 the resident became agitated and talked about hitting the vending machine on 10/03/10. Nurse's Note date 10/06/10 indicated that a staff member was at the bedside and in attendance when family and friends visited the resident. A Nurse's Note dated 10/07/10 at 1340 indicated Resident #4 was in the facility lobby with a staff member when he knocked over a table in the front lobby and tried to hit a staff member with a chair. The resident was return to the unit and given 5 mg (milligrams) of [MEDICATION NAME] IM for combativeness. An observation on 11/03/10 at 11:10 AM, 1:30 PM and 2:10 PM revealed staff seated in the room with the resident. There was nothing in the chart to indicate why a staff was seated in the room with the resident. There was no care plan to indicate why staff was present in the room with the resident at all times. An interview on 11/03/10 at 2:45 PM with the SSD (Social Service Director) revealed the care plan did not address one-to-one supervision with the resident as a result of his behaviors. The SSD further stated the resident was put on one-to-one supervision on 10/04/10. The Assistant Administrator confirmed the resident's care plan did not address one-to-one supervision.",2014-03-01
10210,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,241,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation of meal service, the facility failed to provide services that respected resident's dignity during a random observation of a meal. Resident # 5 and 2 other unidentified residents were not served their meal in a timely manner. The findings included: The facility admitted Resident # 5 on 10/30/06 with [DIAGNOSES REDACTED]. On 11/16/10, at 12:20 PM, the lunch trays were delivered to the dining room. Resident # 5 was observed along with two other residents sitting in the dining room facing the other residents. Meal trays were served and the other residents ate or were assisted with their meals. Resident # 5's meal tray was noted to be on the cart. Resident # 5 and the other two residents were not assisted to a table or served the meal until 1:00 PM. This observation was shared with the DON during sharing. The facility admitted Resident # 3 on 6/23/10 with [DIAGNOSES REDACTED]. Prior to observation of wound care on 11-16-10 at 1:35 PM, Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #5 entered the room without knocking. During the course of the treatment from 1:35 PM until 2:55 PM, the LPN left the room two times to obtain needed supplies and reentered without knocking. The nurse entered the shared bathroom to wash her hands four times without knocking to ensure that residents from the adjoining room were not using the commode. At 2:30 PM, when the nurse entered the bathroom for the fifth time (without knocking) to wash her hands, she walked in on a resident who was using the commode. After this incident, the nurse continued to enter the bathroom door three more times without knocking while completing the wound care. The privacy curtain was not closed at the foot of the resident's bed during the entire treatment. During an interview with LPN # 3 on 11-17-10 at 12:40 PM, the nurse verified that she had failed to knock when entering the room and each time she entered the bathroom to wash her hands. On 11-17-10 at 1:05 PM, the Staff Development Coordinator (SDC) provided a document entitled ""Survey Readiness"" which stated: ""Remember Privacy: Knock on each door, close the door, pull the privacy curtain, and close the blinds."" The SDC stated that she goes over this information with new hires and periodically as needed. During a discussion with the Director of Nursing (DON) related to privacy issues identified during treatments on 11-17-10 at 1:00 PM, the DON said she had in-serviced the staff on closing blinds, pulling curtains around the bed, and closing and knocking on doors. She stated she did not recall specifically addressing bathroom doors.",2014-03-01
10211,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,250,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, no medically related social services were provided for Residents #21 and #26 related to behaviors. ( 2 of 6 residents reviewed for specific medically related social services.) The findings included: The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed numerous nurse's notes documenting sexually inappropriate behaviors towards staff and residents and wandering into other resident rooms. This was also confirmed on 11/16/10 at 1:30 PM by 4 of 4 residents who attended group meeting. These residents stated they had been touched on the arms, toe, and asked ""give me some sugar."" Nurse's note on 5/18/10 documents "" CNA (Certified Nursing Assistant) - resident touching and rubbing her leg - won't quit."" On 5/25/10 "" MD (Medical Doctor) in today for touching staff inappropriately. CNA reported resident asked for a kiss."" On 5/26/10 note documents "" CNA makes resident hold to side rails to keep him from reaching for her."" Nurses notes continue: 6/12/10- touches staff inappropriately at times; 6/14/10 - started on Lexapro 10 mg (milligrams) r/t (related to) inappropriate sexual disinhibition; 6/16/10 - continues to enter resident rooms, continues to attempt to touch staff and residents- redirect as necessary; 9/1/10 CNA and PT (Physical Therapist) reported resident made inappropriate gestures and sexual comments. Resident attempted to enter other resident's rooms without permission; 9/4/10 - inappropriate sexual remarks at staff at times; 10/17/10 - staff and residents reported resident has been making inappropriate comments ""give me some sugar and I want a lick."" staff will continue to monitor behavior. On 11/16/10 resident approached a surveyor and asked ""when can we meet"" and made an explicit sexual gesture. Only two physician progress notes [REDACTED]. Review of Social Service Notes revealed a note on 4/22/10 -Resident has been noted wandering into other peoples rooms. He is confused. Easily re-directed. Next note on 6/18/10 - Has periods of wandering t/o (through out) facility, in others rooms. Has inappropriate conduct, tries to touch staff and peers. Does not appear to remember what you tell him. Note of 9/10/10 ""Flirts with staff and visitors."" There was no documentation of any interventions tried by social services. During an interview with Social Services on 10/17/10 at 11:00 AM, she stated ""it was put into the hot box and in the doctors book."" When asked if she did the analysis per the care plan, she stated ""no."" Nursing should have done that. Interview with 100 Unit Manager on 11/17/10 at 12 NOON revealed someone put in hot box charting (to observe and chart every shift for 72 hours ) 10/17/10; however, the Unit Manager stated staff did not do that. They only charted one shift and stopped. It was placed in the doctor's book (nurse did not remember when) but doctor didn't check resident. Did not check with doctor until 11/16/10 after brought to attention by surveyors. On 11/16/10 Nurse Practitioner increased Lexapro to 20 mg and ordered a Psych Consult. No analysis of key times, places, circumstances, triggers, or what de-escalates behavior per care plan had been done by any discipline listed on the care plan. The facility admitted Resident # 27 on 10/20/09 with [DIAGNOSES REDACTED]. Nurses Assistant) responded to the resident's room and intervened d/t (due to) this resident hitting another resident from another station, with a metal/aluminum grabber stick. Yelling at the resident while hitting resident in the back of the resident's head. CN removed the injured resident and checked resident, where she (CNA) found a knot on his head.."" Resident # 27 was encouraged to ask for assistance. Further review of the record revealed no additional follow-up or intervention from Social Services. On 11/16/10 at approximately 11:00 AM, revealed that the DON (Director of Nurses') was unaware of the incident. She stated that the nurse working should have filled out an occurrence report and passed reported this on the twenty-four hour report. She stated that she did not find any incident report related to this incident. The surveyor requested the twenty-four hour report sheet for that date. By the end of the survey no twenty-four hour report was provided to the team. On 11/16/10 at approximately 11:26 during an interview with Social Service Worker # 1, she stated that she was not aware of the incident, however she was not the primary social worker for the unit. When questioned about follow-up by social services, she confirmed that there were no social service notes related to the incident. She confirmed that there should have been an intervention by social services.",2014-03-01
10212,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,281,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide nursing services that met professional standards of practice. The facility nurse failed to transcribe Resident # 7's medication order correctly and multiple nurses administering medications to the resident failed to clarify the entry on the MAR (Medication Administration Record) for [MEDICATION NAME] as needed on Monday, Wednesday and Friday, resulting in a medication errors. The findings included: The facility admitted Resident # 7 on 11/10/10 with [DIAGNOSES REDACTED]. On 11/16/10, review of the resident's medical revealed a physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) revealed that the order had been transcribed incorrectly to the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. On 11/16/10 at approximately 4:00 PM interview with RN (Registered Nurse) # 4 revealed that she had transcribed the order incorrectly. She stated that the computer system being used will not recognize Monday, Wednesday, Friday orders unless entered as a prn order. She stated that she had failed to mark out the PRN as needed when the MAR indicated [REDACTED].",2014-03-01
10213,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,279,D,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a plan of care which addressed the non compliance of Resident # 21 with safety regulations within the facility and failed to address the resident's non compliance with fluid restrictions. (One of one sampled resident known to be noncompliant with smoking regulations and one of one sampled resident reviewed with a fluid restriction reviewed for the development of care plans) The findings included: Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. On 11/14/10, at 6:50PM, the resident was observed to be out of bed sitting near the nurses station and in the dining room. The resident was observed to obtain glass(es) of water from a drinking cooler three times during the observation which lasted approximately one hour. No staff intervened or spoke with the resident about his fluid consumption. During an interview with the unit manager, when asked if the resident was compliant with the fluid restriction, she stated ""no."" The unit manager further verified that the resident's plan of care did not address his non-compliance or the facility plan to address the concern. Further record review revealed the resident had been noncompliant with the facility smoking regulations which had been addressed by the facility Administrator. On August 21, 2009 and on September 10, 2010, the resident had received a letter from the facility addressing his non-compliance. Nursing notes also revealed that on 9/16/10, two cigarette lighters had been removed from the resident's room. When the Administrator was questioned if he was aware of the 9/16/10 occurrence, he did not respond. Further review of the resident's comprehensive plan of care did not reveal any concern/plan related to the residents non-compliance with the facility safety/non-smoking regulations. A copy of the smoking policy (7/06) stated; ""All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person.""",2014-03-01
10214,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,309,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide physician-ordered care and services for one of two residents reviewed with orders for Hospice services and one of one residents reviewed for provision of [MEDICAL TREATMENT]. There was no evidence of implementation of a 10-6-10 hospital transfer order for Hospice for Resident #17. Intake and output was not monitored to ensure compliance with a fluid restriction order for Resident #21. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following a hospitalization from [DATE] to 10-6-10. Record review on 11-15-10 at 12:45 PM revealed a hospital Patient Transfer Form dated 10-6-10 which was noted as faxed to the facility on the same date. Instructions on the cover page of the form included to ""Arrange hospice"". Additionally, the same Discharge Instruction was listed as a line item on an attached Order Confirmation Report. There was no evidence in the medical record that the order had been implemented. During an interview on 11-15-10 at 3:30 PM, the Director of Nurses reviewed the transfer document and confirmed the order for Hospice. She stated she ""did not see"" and had not been aware of the order until 10-26-10, the date of the resident's death. During an interview on 11-16-10 at 11:35 AM, Registered Nurse (RN) #6 also confirmed the Hospice order and stated that she had been unaware of the Hospice order until after the resident's death when she ""found the Hospice note"". The RN stated that the transfer information usually came from the hospital in a packet and that the nurse who received the resident should have written the order for the referral. She stated that, when she became aware of the order, she questioned the nursing staff and they ""said they never saw the order"". The nurse further stated that the admitting nurse ""should have made the referral"". Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. The resident's Comprehensive Plan of Care was updated and stated: ""I & 0 record"" (record intake and output). Further record review revealed consistent missing documentation that the resident's intake and output were monitored. On 11/15/10 at 10:15AM, during an interview with the Unit Manager, she confirmed the resident's intake and output were not consistently/accurately recorded. The Unit Manager stated it was the responsibility of the nurse on each shift to enter the total fluids the resident received per shift and then it was the responsibility of the 11-7 shift to total the amounts for the day.",2014-03-01
10215,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,314,G,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, facility policy on care and assessment of Pressure Ulcers, and interview, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four of seven sampled residents reviewed for pressure ulcers. Resident # 23 was admitted [DATE] with a known pressure ulcer. treatment for [REDACTED]. Resident # 22 with a known red area to the back, receiving treatment, was not assessed weekly for changes in the area and effectiveness of treatment. Resident #1 failed to have ongoing documentation available of a pressure ulcer as it was treated to allow staff to accurately determine response to the treatment and the need for possible changes in treatment. During a pressure ulcer treatment observed on Resident #3 the licensed staff failed to implement infection control techniques to ensure healing. The findings included: The facility admitted Resident # 23 on 3/6/10 with [DIAGNOSES REDACTED]. On the weekly skin documentation form dated 3/6/10 the resident was documented by nursing to have a black area to the right heel with no further description/measurement noted. On 3/15/10 the area was documented as ""soft and black."" There was no physician order for [REDACTED]. ... He has a large decubitus over the right heel. It is covered by skin"" . He previously had a blister and nursing staff reported that this has drained and there is some serosanguineous type drainage....Small area in the plantar surface of the right foot that is measuring approximately .5cm (centimeter) in diameter Wound bed in this area is pink, moist. This again is a very superficial area ..."" The NP at this time ordered vitamin C, Prosource and Vitamin with Minerals, treatments to both areas, continued use of Podus boots, and floating of the heels while in bed. The physician saw the resident on 3/23/10 and made no changes. A care plan for the pressure ulcer to the heel was not developed until 3/18/10 During an interview with the current Unit Manager and the Unit Manager for the unit on which the resident originally resided, revealed that neither nurse could provide evidence the wound(s) noted on admission had been measured or assessed as pressure areas. There was no documentation found that the facility was providing any treatment to the heel wound from 3/6 until 3/18/10. During the interview, the unit manager stated- ""It should have been skin prepped. Anything black we always skin prep to off with."" On 3/22/10 a ""dark area"" to the bottom of the right foot was documented on the weekly assessment form. However, an order was written previously on 3/9/10 to apply skin prep to the ball of the right foot bid until healed (stage I decubitus) . There was no documentation per facility provided policy to include: "" location, measurement, appearance, drainage, odor, color, presence of undermining/tunneling, healing, stage if a pressure ulcer, pain and [MEDICAL CONDITION].The resident's admission care plan noted on 3/8/10 the presence of a stage I - ""ball of RH foot (?right heel) -skin prep ball of rh foot as ordered."" Resident # 22 was admitted to the facility with Arthritis and Bullous Lung Disease. On 6/12/10 a weekly skin assessment noted the resident had a ""pink"" area to the bony prominence of the mid back and sacral area. On 6/27/10 an order was obtained for Optofoam pad, cover with [MEDICATION NAME] every three days for protection to mid back bony prominence area. On 11/15/10 at 11AM, during an interview with the Unit Manager, she stated although weekly skin assessments were completed, they were done by the weekend nurse who would be unable to see thru the Optofoam pad to visualize the area. There was no documentation that the area was measured. On 11/17/10, during an interview with the Director of Nursing, she verified that a red/pink area over a bony prominence would meet the definition of a Stage I pressure area. She stated she would have expected the area to be measured weekly and to have been included in the pressure ulcer reports submitted to her office. After checking the pressure ulcer records on file in her office, the Director of Nursing stated the resident was not and had not been included in the pressure ulcer reports. Further review of the treatment flow sheet for October 2010 revealed there were no signatures present for the application of the treatment to the back from from 10/17 to 10/29/10. On 11/15/10 at 11AM, during an interview, the Unit Manager and the nurse responsible for the application of the treatment verified there was no documentation that the dressing had been applied per the order. Resident #22 was seen by the Nurse Practitioner (NP) on 11/8/10 who commented: ...""The family was somewhat concerned.... The buttocks area and gluteal cleft are inspected. There is some pinkness in the superior aspect of the gluteal cleft. She has a very prominent coccyx, and some pinkness over these and open areas. ...Upper back approximately T8 through T 12 is pink. She has a foam dressing on, which was removed, and there is some mild what appears to be fungal -type changes to the skin, redness and pinkness, which again blanched, while there are no open areas....."" The resident was diagnosed by the NP with a stage I decubitus to the Sacrococcygeal area and started on Vitamin C. The treatment to the mid back was changed at that time. The Facility provided policy for Staging pressure ulcers (Revised 6/08) stated: A stage I pressure ulcer was defined as ""intact skin"" and a Stage II pressure ulcer was a ""partial loss of dermis..."" The policy also stated that wounds will be evaluated/documented to include: "" location, measurement, appearance, drainage, odor, color, presence of undermining/tunneling, healing, stage if a pressure ulcer, pain and [MEDICAL CONDITION].Treatments should be re-evaluated every 2-3 weeks. If no wound progression noted treatment change should be considered. If no change in treatment done documentation should occur as to why current treatment maintained."" The facility admitted Resident #1 on 7/07/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed the resident to be receiving treatments of Santyl ointment to right heel and wrap for a pressure ulcer. The last documentation found in the record was dated 9/03/10 showing a measurement of 4 cm ( centimeters) by 6 cm 1/2 sealed off pink brown lower area- 1/2 dark purple with surrounding skin normal. On 9/17/10 the wound measured .3 by .8 had scant amount of yellow drainage. An interview with RN #1 (Registered Nurse) revealed she did not do the daily dressings but measured all the wounds weekly. She stated, ""I have a sheet I document all the information on and give a copy to the DON (Director of Nursing). I am supposed to transfer the information to each resident's individual Wound Treatment & Progress Record weekly. I goofed. I have not always documented weekly on the individual sheets."" The nurses doing the dressings had nothing to compare with in order to make recommendations about continuing or changing treatments. The nurses assigned to do the treatments were the staff nurses on duty each day and not the same nurse each day. There was no continuity of care in treating the wound. The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During an observation of wound treatment for [REDACTED].#3 failed to wash or sanitize her hands between removal of the soiled dressing from the Stage III wound on the top of the left foot and placement of the clean dressing. LPN #3 stated that the dressing was saturated with ""yellow, bloody drainage"". Prior to placement of the clean dressing, the nurse removed scissors from her pocket and cut a foam dressing for use on the wound without disinfecting or cleaning the scissors prior to use. The dressing was then applied to the Stage III wound. Prior to the wound treatment to the Stage II wound on the left buttock, when the resident was positioned onto her right side, the underpad was noted to be soiled with a red tinged drainage. LPN # 3 stated, ""This could be a vaginal drainage"". After removal of the soiled dressing, the resident was allowed to turn back onto her back on the underpad without a dressing to the open wound on the left buttock. When the resident was turned back for placement of the clean dressing, an area of red tinged drainage the size and shape of the wound was noted on the soiled underpad. On 11-17-10 at 1:05 PM the Staff Development Coordinator (SDC) provided a facility policy entitled, ""Dressing-Absorption Dressing, Application of"". Step #10 stated: ""Disposes of soiled dressings appropriately. Removes gloves and disposes. Washes hands."" The policy then continued with the preparation and application of the clean dressing. An interview was conducted with LPN #3 on 11-17-10 at 12:40 PM. The nurse verified all the above observations and stated, ""I messed up with glove changing and handwashing."" The nurse stated that she cleaned the scissors prior to placing them in her pocket and she was unaware that the scissors should be cleaned prior to each use.",2014-03-01
10216,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,367,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide the diets as ordered by the physician for two of seven sampled residents reviewed for therapeutic diets. Resident #17 was provided solid foods on a mechanically-altered (pureed) diet and an order for [REDACTED]. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following hospitalization from [DATE] to 10-6-10 for Aspiration Pneumonia, Dehydration, and [MEDICAL CONDITION]. Additional/chronic [DIAGNOSES REDACTED]. Record review on 11-15-10 at 12:45 PM revealed that Resident #17 was on a ""Puree diet with nectar thick liquids for pleasure"" prior to hospitalization and received an ""egg salad sandwich c (with) ea(ch) meal"" per a physician's orders [REDACTED]. The hospital Patient Transfer Form dated 10-6-10 noted ""Instructions"" for a Discharge Diet of ""TF (tube feeding)"". The hospital Discharge Summary noted that the resident was to receive ""[MEDICATION NAME] 1.5 at 80 ml (milliliters)/hour for 18 hours, start at 3 PM, off at 9 AM."" physician's orders [REDACTED]. There was no evidence in the record that the sandwiches had been reordered. A copy of a Diet Order & Communication form dated 10-7-10 was found in the medical record. Pureed Texture and Nectar-Like Thickened Liquids were checked to indicate the type of diet to be provided. During an interview on 11-15-10 at 4 PM, the Speech Language Pathologist (SLP) reviewed the Rehabilitation Screen form she had completed on 10-8-10. She stated that the resident had been on caseload prior to the 9-26-10 hospitalization , but had reached a plateau. He had received the sandwich with meals prior to hospitalization and was ""safe"" with it. Upon readmission, she stated that the resident was uncooperative with the screening process for oral motor assessment and noted that the resident was ""WFL (within functional limits) for puree"". She did not request an upgrade in the diet because of her inability to perform an assessment. The SLP was aware that Resident #17 had received the sandwich without an order and thought that dietary had written an order or provided it without a current order or evaluation/recommendation from the SLP. During an interview on 11-15-10 at 4:15 PM, the Certified Dietary Manager (CDM) stated that Resident #17 had been provided a pureed diet with nectar thick liquids and an egg salad sandwich three times daily from the date of his readmission on 10-6-10 to the date of his death. The CDM stated that she had received verbal notification from nursing staff upon readmission to continue the resident's diet as prior to hospitalization . She reviewed and verified receipt of the diet communication form dated 10-7-10 and that the order failed to include the sandwich. When questioned as to the reason the resident had continued to receive the sandwich after receipt of the order on 10-7-10, the CDM stated that there was ""no order to discontinue it"". During an interview on 11-16-10 at 11:05 AM, the Director of Nurses (DON) reviewed and verified the Speech Language Pathologist's documented screen. During interviews with the DON on 11-16-10 at 11:05 AM and Registered Nurse (RN) #6 on 11-16-10 at 11:35 AM, each stated that the sandwich should have been cancelled if not reordered after hospitalization . Interviews with Licensed Practical Nurse (LPN) #4 on 11-15-10 at 3:45 PM, with CNA #2 on 11-16-10 at 12 PM, with CNA #1 on 11-16-10 at 12:05 PM, and with the Unit 4 Manager on 11-16-10 at 11:35 AM revealed that Resident #17 had received egg salad sandwiches with each meal daily prior to his death and had tolerated them well with no choking episodes noted. During an interview on 11-15-10 at 5 PM, the attending physician stated that he would expect physician's orders [REDACTED]. Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. During observation of the breakfast meal on 11/15/10, the resident was observed to receive fluids in excess of what the planned dietary plan had established. When the resident was interviewed as to what the facility had sent in his bagged lunch to eat while at [MEDICAL TREATMENT], it was stated that less fluids were sent than established in his dietary plan. During an interview with the Dietary department on 11/16/10 at 9AM, it was verified that a plan had been developed which established how much dietary would send the resident with each meal and how much nursing would provide. However, it was confirmed that the Dietary Department had not followed the established plan for breakfast nor lunch on the day of the observation.",2014-03-01
10217,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,156,C,,,JNTL11,"On the days of the survey, based on record review and interview, the facility failed to provide Liability Notices to 3 of 3 residents reviewed for notification of Medicare Provider Non- Coverage. The facility did not utilize form or any of the 5 denial letters to inform residents or their responsible party of the items and services expected to be denied under Medicare Part A. The findings included: On 11/17/10 at 10:20 AM, a review of 3 random Medicare Non-Coverage Notices revealed that there were no Liability Notices included in the information given to the resident or responsible party. An interview with the Admission Coordinator revealed that she had not been aware until yesterday that Liability Notices were required. According to information provided by the Admission Coordinator, Resident A had used 50 days and his last covered day was 10/27/10 due to therapy being discontinued. Resident B had used 64 days and no longer required skilled services. His last covered day had been 9/2/10. Resident #8 had used 36 days and her last covered day had been 8/20/10 due to her therapy having been discontinued.",2014-03-01
10218,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,159,D,,,JNTL11,"On the days of the survey, based on record review and interview, the facility co-mingled personal funds with facility funds for 2 of 5 residents reviewed with Resident Trust Fund Accounts. Resident D had personal funds withdrawn from her Trust Fund Account and deposited into the facility account. Resident E had retirement checks deposited into the facility account instead of being deposited into her Trust Fund Account first. In addition, there was no evidence of notification of balances that would jeopardize Medicaid eligibility for Resident D. The findings included: Review of Resident D's Trust Fund Account record on 11/17/10 at 1:42 PM revealed a Care Cost Payment dated 9/17/10 of $3.04, a second Care Cost Payment dated 10/7/10 for $11.28, and a third Care Cost Payment dated 11/5/10 for $30.06. When asked about what these payments were for, the Business Office Manager stated that she withdrew these amounts from the resident's Trust Fund Account and deposited the monies into the facility account since the resident had reached her $1800.00 limit in which she would need to start spending down her account since she was a Medicaid recipient. According to the Business Office Manager, the monies deposited into the facility account would go towards payment of any remaining balances the resident might have. When asked if the resident owed a balance, she stated ""no"". She stated the facility account was not interest bearing. When asked if she had contacted the family of the resident to try to see if they could spend down her account she stated she had never seen the family and hadn't recently tried to get ahold of them, but she would try now. Review of the Resident Fund Management Service reports revealed that these funds had been withdrawn from the resident's Trust Fund Account and had been deposited into the facility account. During the funds interview on 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that when a Medicaid resident's account reached #1800.00, she told the resident or responsible party that they needed to spend down the account. She stated she did not document this notification any where. According to the Administrator, the facility used letters to notify residents that their Trust Fund Account balances were within $200.00 of exceeding what is allowable under Medicaid. However, he was unable to provide a copy of any letters notifying Resident D or her responsible party with this information. Review of Resident E's Trust Fund Account Record on 11/17/10 at 12:25 PM revealed a Care Cost Payment of $31.00 on 6/8/10 and another Care Cost Payment of $1077.33 dated 11/5/10. When asked what these payments were for, the Business Office Manager stated they were payments for balances owed since the resident's room and board were more than her Social Security check. She provided documentation of these balances owed and revealed a Resident Statement dated 5/21/10 which listed a balance of $31.00 on 6/8/10. It also had a ""receipt copy"" included on the statement dated 5/26/10 for a check from the ""State Budget"" for $461.85. The amount of the check received from the State Budget had been handwritten onto the statement and deducted from the resident's balance on 5/26/10. According to the Business Office Manager, the ""State Budget"" check had been deposited into the facility account, and had not been deposited into the Resident's Trust Fund. When asked if the ""State Budget"" checks were made out to the resident, she said that they were. When asked why it had not been deposited into the resident's Trust Fund Account, she did not answer. Review of a letter dated October 23, 2007 from the resident to the Insurance Operations Department revealed the resident had requested her ""WestPoint Stevens"" retirement check to go to the nursing home, and that she only wished to change her check mailing address. Review of the Resident statement dated 5/21/10 revealed an entry for a check from ""West Point Stevens"" for $63.11 that had been deducted from the resident's balance on 6/1/10. According to the Resident Trust Fund Account Statement dated 6/1/10 through 11/16/10, there had not been a deduction of $63.11 from that account on 6/1/10. The Business Office Manager also provided a Resident Statement dated 10/21/10 that listed a balance of $1077.33 on 11/5/10. On the statement were 2 payments that were both dated 10/8/10, one for $461.85 and one for $63.11, both of which had been deducted from the resident's balance and were not included in the Resident Trust Account statement dated 6/1/10 through 11/16/10. This indicated these funds had not been first deposited into the Trust Fund Account for the resident before being used to pay balances owed. Further review of the Trust Fund Account record dated 6/1/10 through 11/16/10 revealed the resident had been receiving ""miscellaneous income"" of $63.11 on 8/4/10, 9/1/10, and 11/8/10. According to the statement, she also had a ""State/Cnty/City CK"" for $461.85 that had been deposited into her Trust Fund Account on 11/8/10. There was no indication of any deposits matching these amounts in October.",2014-03-01
10219,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,160,D,,,JNTL11,"On the days of the survey, based on record review and interview, one of five resident records reviewed for conveyance of funds revealed disbursement of funds without written authorization. The findings included: On 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that Resident #19 had $30.00 in the Resident Trust Fund Account that had been sent to the funeral home at the family's request after her death. According to the Business Office Manager, the family wanted the cash money, however, she told them she could send it to the funeral home or the estate. The family requested the money sent to the funeral home. According to the Business Office Manager, there was no Power of Attorney in effect over the resident's financial matters. Review of the Admission Agreement revealed a ""Beneficiary Designation:"" section that was not filled out and did not designate a person to receive the resident's personal funds.",2014-03-01
10220,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,167,C,,,JNTL11,"On the days of the survey, based on observations, the facility failed to post the most recent survey report within the facility. The facility failed to post the most recent complaint survey with citations from 9/16/10 and failed to post a complaint survey with citations from February 2010. The findings included: Observation on 11/15/10 at approximately 5:00 PM revealed a plastic holder mounted on the wall in the hallway near the front lobby. Observation of the contents of the holder revealed a labeled notebook containing the annual recertification survey report from September 2009. The complaint surveys with citations from 9/16/10 and February 2010 were not posted as required. On 11/17/10 at approximately 4:30 PM, the surveyor reviewed the contents of the notebook with the Administrator. The Administrator confirmed that the complaint surveys were not posted at that time.",2014-03-01
10221,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,282,D,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the care plan was not followed related to pacemaker checks for Resident #9 and analysis of causative factors of behavior for Resident # 26. ( 1 of 2 residents reviewed with pacemakers and 1 of 1 resident reviewed for socially inappropriate behaviors.) The findings included: The facility admitted Resident #9 on 5/13/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 revealed the resident to have a pacemaker. The Physician's History and Physical listed a [DIAGNOSES REDACTED]. Dates of 5/14/09, 9/3/09, 12/17/09 and 3/4/10 were listed on the sheet as to when checks should be done. The only documentation of testing in the medical record was dated 9/03/09. No other documentation could be found. There was no physician order to do pacemaker checks. The care plan for pacemaker also documented pacemaker check as ordered q 3 months ( every 3 months). An interview with RN # 1 (Registered Nurse) and the Unit Manager revealed that the nurse did not know the resident had a pacemaker. She was unable to find any information in the record related to the checks other than the one report of 9/03/09. RN #1 placed a call to the Clinic and found that a check had been done on 9/03/10. There were no other reports sent at this time. The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem which stated, ""Resident exhibits socially inappropriate behaviors IE: wandering into others room, touching peers and staff inappropriately, pulling fire alarm. Under approaches were listed: assess resident's understanding of the situation, monitor resident frequently, analyze key times, places, circumstances, triggers, and what de-escalates behavior, and Psychiatric evaluation as indicated. An interview with the Unit Manager of 100 unit and Social Services on 11/17/10 revealed that no one had done an analysis, and no psychiatric evaluation had been done. The Unit Manager was not even aware of the care plan approach, and although Social Services was listed also, she stated, ""Nursing should do that, not me."" None of the disciplines listed for the approach had done an analysis.",2014-03-01
10222,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,441,E,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to provide evidence that all personal laundry was effectively cleansed/sanitized to destroy microorganisms. Also, based on observations and interviews, the facility failed to follow a procedure whereby expired topical agents, irrigation trays, and wound care supplies were removed from current stock and were available for daily use in two of four medication rooms reviewed. The findings included: During observation of the laundry on [DATE] at 10:15 AM, two home-type washers were noted (in use) not to be connected (via the chemical dispensing system) to any type of sanitizing agent. Bleach was set up to be dispensed on an automatic dispensing system to a third commercial-type washer. A sign was noted on the wall above a dryer indicating ""no bleach"" formula to be used on given wash cycles. When asked at this time, the Laundry Aide confirmed that bleach was not used for some personal laundry. She stated that the water temperature ranged from 120 to 160 degrees and was monitored by maintenance. She was unaware if any type of sanitizer was used and deferred to the Housekeeping Supervisor. During an interview on [DATE] at 2 PM, the Maintenance Supervisor provided laundry water temperature logs for review. Water temperatures ranged from 129 to 141 degrees Fahrenheit over the previous six month period. When informed that personal laundry was being washed without bleach, or water temperatures over 160 degrees, the Housekeeping Supervisor stated that he could provide no information to verify use of any other type of sanitizing agent. During an interview at 2:35 PM on [DATE], a second maintenance employee stated that he had checked the dispensing mechanism on the two home-type washers and that the commercial bleach product had not been connected. At that time, the Housekeeping Supervisor verified that he could provide no information on use of any type of sanitizing agent, other than the bleach product used on one of the three machines in use, to enable the facility to provide hygienically cleansed laundry. On [DATE] at 7:43 AM, observation of the Station 2 Medication Room revealed 2 Medline Piston Irrigation Trays with Sterile Sodium Chloride expired ,[DATE]. During an interview on [DATE] at 8:01 AM, Licensed Practical Nurse (LPN) #4 revealed that the medication nurses and the stock supply person from Central Supply checked the medication room for expired products. Central Supply comes to restock the cabinets about once a week. There is no set schedule for the medication nurses to check the medication room. On [DATE] at 8:04 AM, observation of the Station 3 Medication Room revealed the following: - two one ounce (28.35 gram) White [MEDICATION NAME] USP (United States Pharmacopoeia), expired ,[DATE] - two Piston Irrigation Trays with Sterile Sodium Chloride, expired ,[DATE] - 14 Medline Sterile Bordered Gause, 4 inch by 14 inch dressings, expired [DATE] During an interview on [DATE] at 8:32 AM, Registered Nurse (RN) #5 revealed that the medication nurses checked the medication room for expired products and that it should be checked every day. The Nurse Manager could also check the medication room.",2014-03-01
10223,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,164,D,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility protocol entitled ""Survey Readiness"", the facility failed to provide privacy to 1 of 3 residents observed for wound care and 1 resident randomly observed in the bathroom during the same wound care procedure. Resident # 3 was exposed during wound care to the buttock when a Certified Nursing Assistant (CNA) entered the room without knocking. The Licensed Practical Nurse (LPN) entered an occupied bathroom without knocking during this same treatment. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During observation of wound treatment for [REDACTED].#3 entered the room through the closed bathroom door without knocking, left the bathroom door open while she got the lift and then left the room through the same bathroom door. The wound care treatment was in progress with Resident #3's buttock exposed and the privacy curtain was not pulled at the foot of the bed. During observation of the same wound treatment for [REDACTED].#3 entered the bathroom to wash her hands and did not knock. A resident was using the bathroom at the time when the nurse entered without knocking. During an interview with LPN #3 on 11-17-10 at 12:40 PM, the nurse verified that she did enter the occupied bathroom without knocking. She also verified that CNA #3 entered the room without knocking while Resident #3 was exposed. On 11-17-10 at 1:05 PM, the Staff Development Coordinator (SDC) provided a document entitled ""Survey Readiness"" which stated: ""Remember Privacy: Knock on each door, close the door, pull the privacy curtain, and close the blinds."" The SDC stated that she goes over this information with new hires and periodically as needed. During a discussion with the Director of Nursing (DON) related to privacy issues identified during treatments on 11-17-10 at 1:00 PM, the DON said she had in-serviced the staff on closing blinds, pulling curtains around the bed, and closing and knocking on doors. She stated she did not recall specifically addressing bathroom doors.",2014-03-01
10224,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,315,D,,,JNTL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review, review of the facility policy entitled ""Suprapubic Catheter Care"", and review of the training manual ""Assisting in Long Term Care, Second Edition"", the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infections for 2 of 4 sampled residents reviewed with indwelling catheters. Resident #3 had the catheter anchored inappropriately during catheter care causing a potential for trauma. Resident # 14's catheter tubing was on the floor throughout catheter care observation. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. On 11-17-10 at 10:45 AM during observation of suprapubic catheter care for Resident # 3, Licensed Practical Nurse (LPN) #3 anchored the catheter tubing approximately 4 inches away from the insertion site and cleansed the tubing from the insertion site in an outward motion causing potential trauma. Review of the facility policy entitled ""Suprapubic Catheter Care"" step # 12 stated: 'With the third wipe, clean the catheter tubing about 4 inches, while holding the catheter securely."" The facility admitted Resident # 14 on 6/12/09 with [DIAGNOSES REDACTED]. During observation of suprapubic catheter care by Registered Nurse (RN) # 5 on 11-17-10 at 10:30 AM, the catheter tubing was noted to be lying on the floor upon entering the room and remained there during the entire procedure. After completion of the procedure, RN #5 was questioned about the cloudy character of the urine. The nurse stated that the resident was currently being treated for [REDACTED]. Record review revealed a Physician's Telephone Order dated 11/14/10 which stated: ""Keflex 250 mg. (milligrams) po (by mouth) TID (three times daily) X 10 days for positive urinalysis."" RN # 5 confirmed that the tubing was on the floor during an interview held on 11-17-10 at 12:30 PM. The nurse verified that she was aware that the tubing should be positioned off the floor to prevent infection. Review of ""Assisting in Long Term Care, second edition"", page 390 stated ""The drainage bag or tubing must never touch the floor.""",2014-03-01
10225,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2010-11-18,225,D,,,PITJ11,"On the day of the inspection, based on record review and review of facility files, the facility failed to ensure that all allegations of neglect were reported within twenty-four hours to the State survey and certification agency for 1 of 1 allegation of neglect reported (Resident #1). The findings included: On 10/22/10, after Resident #1 complained of pain in her right ankle, the physician found a dressing dated 9/27/10 on her ankle. The dressing had originally covered a callus. When the physician removed the dressing, he found the resident's ankle red and swollen with an open and infected ulcer. Review of the medical record revealed the resident was to have a DuoDerm dressing to the site, changed every three days. The facility reported this allegation of neglect to the State survey and certification agency on 10/25/10, which exceeded the twenty-four hours allowed.",2014-03-01
10226,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2010-11-18,281,G,,,PITJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, interviews, and review of facility files, the facility failed to ensure that services provided by the facility met professional standards of quality for 1 of 1 resident who developed redness, swelling, pain, and an open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). Facility staff failed to ensure the resident's treatment order was carried forward to the new month, and failed to thoroughly assess and accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician found an occlusive dressing on the right lateral ankle dated 09/27/10. There was pus underlying the dressing and an infected open area measuring 1 X 1 cm (centimeter) surrounded by a 3 by 3 cm area of [MEDICAL CONDITION]. The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. Review of the medical record and the facility's investigative materials revealed none of the staff providing care to the resident (five nurses and thirteen nursing assistants), from 9/27/10 to 10/22/10, noticed the unchanged dressing and the developing decline in the resident's skin condition. CNAs (Certified Nursing Assistants) doing daily skin inspections noted the resident's skin was ""clear."" Licensed staff documented on the weekly body audits that the resident had a callus on her right ankle. The licensed staff failed to update the monthly cumulative orders for October 2010 to show the dressing change order for DuoDerm to the right ankle every three days. This order was initiated on 6/30/10. Licensed staff failed to realize the omission of the order and therefore, failed to provide the resident with the treatment. The staff also failed to provide the appropriate care and ongoing assessment required to manage the resident's skin care. Cross refer to F-314 related to the facility's failure to assess the resident and failure to provide care and services to prevent development of an open area and infection of the site.",2014-03-01
10227,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2010-11-18,314,G,,,PITJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review and interview, the facility failed to ensure that a resident received treatment to promote healing, prevent infection, and prevent new sores from developing for 1 of 1 resident reviewed who developed an infected sore when facility staff left a protective dressing in place from 9/27/10 to 10/22/10 (Resident #1). The resident did not have her dressing changed because the treatment order was omitted from the October 2010 orders and treatment record. Facility staff failed to recognize the omission. As the resident's ankle declined in condition, the staff failed to thoroughly assess and accurately document her condition in the medical record. The daily skin inspection and weekly body audit documentation showed no changes in the condition of the resident's ankle. These failures lead to a lack of appropriate interventions. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician's progress note, dated 10/22/10 and signed on 11/18/10, stated he found an occlusive dressing on the right lateral ankle ""which was dated 09/27 and had pus underlying the dressing."" Under the dressing was ""a 3 X 3 cm (centimeter) stage 2 ulceration and a 1 X 1 cm stage 3 ulceration with surrounding [MEDICAL CONDITION]."" The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. According to the physician's progress note, it was his understanding the Wound Care team was assessing this wound at least weekly. The physician wanted to know why the dressing had ""apparently not been changed for 23 days."" He showed the wound to the Unit Manager and wanted to know why the dressing had not been changed. The facility began an investigation to answer the physician's questions. Review of the medical record revealed the resident had an ulcer on her right lateral ankle in February 2010. The pressure ulcer was treated with antibiotics for two weeks and wet to dry dressings for one month. The ulcer healed. Review of the medical record revealed the resident had [MEDICATION NAME] cream applied to her knees twice a day by the licensed staff. Review of the Nurse's Notes showed the resident complained of pain in the right outer ankle on 5/8/10 while receiving her treatment to her knees. The nurse observed a raw area on the ankle and applied barrier ointment. The resident continued to sporadically complain of pain in her ankle. On 5/23/10, a hard callus was observed on the right outer ankle with no open area or redness. On 6/30/10, the physician ordered ""Duoderm patch applied to (R) lateral ankle every 3 days"" for treatment. He also ordered padded boots. Review of the physician's progress note of 9/25/10 showed no evidence of a pressure ulcer on the resident's right lateral ankle. Review of the C.N.A. (Certified Nursing Assistant) Daily Skin Inspection Record showed ""clear"" results for September 1 - 31, and for 10/1 - 22/10. Review of the Body & Skin Audits done by the licensed staff showed results of ""callus to R ankle "" on 9/1/10, 9/8/10, 9/15/10, and 9/22/10. The body audit on 9/29/10 revealed a checkmark next to ""Red/Broken Areas"" under the heading ANKLES. The word Red was circled and a handwritten note ""(R) ankle Tx (treatment) in progress"" was to the side. The body audit on 10/6/10 showed ""callus to (R) ankle."" On 10/13/10, the audit showed a checkmark by ""normal"" under the heading ANKLES with a noted under ""Abnormal Explanation:"" stating ""callus to (R) ankle - tx in process."" The body audit of 10/20/10 showed ""normal"" ANKLES with ""callus to (R) ankle"" written next to that finding. Review of the Nurse's Notes revealed no documentation of the discovery of the ankle ulcer on 10/22/10. The nurse's entry stated the physician made rounds and ordered new treatment. There was no description of the area or notation of the old dressing found on the resident's ankle. Review of the Skin Condition Report showed documentation beginning on 10/22/10 for a right outer ankle ulcer measuring 1.2 cm by 2 cm with a light amount of serous foul smelling drainage. The surrounding area was red, warm, swollen, and tender to touch. Documentation on 10/27/10 showed the resident was in less pain. The ulcer measured 1 by 0.8 cm. No swelling was noted but a slight amount of serous drainage continued. On 11/5/10, the ulcer measured 1 by 1 cm. Treatment was changed to using Santyl daily. The Skin Condition Report for 11/10/10 showed the resident's ulcer was 1.5 by 1.5 cm with a central area measuring 0.8 by 0.8 cm. Review of the Weekly Wound Tracking Worksheet showed the resident's wound was designated an open callus. The physician's progress note of 10/22/10 designated the wound a pressure ulcer. An interview with LPN #1 on 11/18/10 at 12:15 PM revealed she was on duty but was not the resident's assigned caregiver on 10/22/10 when the physician saw the resident. The physician called her over to the resident and asked what type of dressing was on the ankle and what date was on the dressing. The LPN went to the Documentation Record for treatments and did not see any treatment corresponding to the dressing on the resident's ankle. She observed that the dressing had bubbled. The dressing was dated 9/27 and had initials written on it. The resident's foot was swollen and red. After the physician removed the dressing, she saw an open ulcer measuring approximately 1 cm in diameter. An observation of the resident's pressure ulcer on 11/18/10 revealed a sore measuring approximately 1.5 by 1.5 cm with a central area of approximately 0.8 by 0.8 cm. covered with slough. The surrounding skin was darkened in an area approximately 4 centimeters round. There was no swelling, redness, or drainage noted. The resident briefly complained of pain when her ankle was touched and then lay quietly in between manipulations. The facility's investigation found that the resident's direct caregivers failed to accurately document her skin condition on the nursing assistant daily skin inspection and on the weekly body audits. An LPN had signed for the [MEDICATION NAME] treatment as being done on 9/30/10. During the investigation the LPN revealed the resident had refused it and she failed to circle her initials indicating the treatment was not done. The facility's investigation also showed that the treatment order was not carried forward to the October 2010 cumulative orders. Three nurses did body audits, one nurse checked the monthly orders, one nurse signed for a treatment that was not done, and thirteen nursing assistants provided direct care to the resident in the time span of 9/27/10 to 10/22/10. The nurses were terminated and the nursing assistants were all given final warnings. An interview with the Director of Nurses (DON) on 11/18/10 at 11:45 AM revealed night shift nurses were assigned to do resident body audits. The verification of monthly orders in preparation for a new month was assigned to different nurses for completion. When the DON interviewed her staff for the investigation, the nurses said they did the body audits but ""didn't see"" the dated dressing on the resident's ankle. The nurses also stated they did the treatments listed on the Documentation Record and did not recall the resident had a treatment to her ankle. CNAs told the DON that they ""didn't see it"" when she asked them about the resident's ankle. Some of the CNAs said the resident's foot was red and she complained of pain. They would tell the nurse and assumed the nurse provided medication for the pain. The DON was asked about the Wound Team. She stated the Unit Managers assessed wounds on a weekly basis and then met with the DON to report. When asked how the Unit Manager missed Resident #1's dressing, the DON stated that the resident's area was not a pressure ulcer but a callus, so the Unit Manager would not have assessed it.",2014-03-01
10228,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2010-11-18,514,G,,,PITJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident who developed an infected open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). On 11/18/10, the physician's progress note of 10/22/10 was not on the record. Facility staff failed to ensure monthly cumulative orders were complete related to treatments ordered, and failed to accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 10/22/10, the resident complained to the physician of pain in her ankle. While examining the resident, the physician found a DuoDerm dressing on the ankle 9/27/10. Under the dressing was an open and infected ulcer. Review of the resident's medical record on the morning of 11/18/10 failed to show a physician progress notes [REDACTED]. The physician signed and sent his progress note for 10/22/10 via facsimile on the afternoon of 11/18/10. Review of the Nurse's Notes for 10/22/10 showed no descriptive documentation of the resident's right ankle. The redness, swelling, and open area found by the physician was not included in the nurse's note. The pressure ulcer's characteristics were documented in the Skin Condition Report, but other than the physician's progress note, the medical record did not show that a dressing dated 9/27/10 was found on the resident on 10/22/10. Facility staff failed to note the omission of the DuoDerm treatment order on the printed cumulative orders for October 2010. Therefore, the order was not listed on the Documentation Sheet for treatments and the resident did not receive the DuoDerm treatment 10/1-22/10. Review of the CNA Daily Skin Inspection Record and the Body & Skin Audits done by the nurses on a weekly basis revealed documentation for September 2010 and up to October 22, 2010 showing no changes in the resident's condition although she was developed swelling, redness, pain, and an open area under the [MEDICATION NAME] dressing on her outer right ankle.",2014-03-01
10229,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2010-11-30,225,D,,,5NE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review, interviews, and review of the facility's policy on Abuse and Neglect, the facility failed to provide evidence that an incident involving the care of Resident #1 was thoroughly investigate. The facility failed to interview and obtain witness statements from the Certified Nursing Aide (CNA) assigned to Resident #1 at the time of the incident and the Registered Nurse (RN) on duty at the time of the incident; Resident #2's family's concern about his eye was not investigated and reported to the state agency. (2 of 5 sampled residents reviewed). The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, ""Called to room Resident on floor matt with laceration to right forehead measuring 1.5 cm (centimeters)..."" Review of the facility investigation file revealed a facility accident/incident report dated 11/08/2010 at 11:22 AM Section One: To be completed by person reporting/witnessing the incident. CNA #1 described the incident as follows: ""staff turn back and res (resident) rolled over and hit head on closet. Section Two: To be completed by a licensed nurse dated 11/08/2010 at 1500 under Corrective/preventive measures RN #1 stated, ""Resident receiving AM care staff turned and resident rolled OOB (out of bed) struck head on closet. Orders written to pad closet and nightstand to prevent this type of injury. Matts were on floor..."" The facility investigation included incident witness statements from three staff members who stated they were unaware of the incident; there were no credentials/job titles to identify the three witnesses. The facility failed to obtain interview statements from CNA #1 and RN #1. In an interview on 11/17/2010 at 10:40 AM the Director of Nurses confirmed there were no witness statements completed by CNA #1 and RN #1. The facility admitted Resident #2 on 11/29/2004 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 9/21/2010 that indicated the resident had memory problems and impaired cognitive daily decision making skills. A nurse's note dated 7/03/2010 at 11:50 PM Late entry for 5:15 P (M) stated, ""Summoned to resident ' s room by resident's daughter who stated that her father's (R) (right) eye was stuck in the corner and that it looks as though some one had struck him in the eye. Resident's daughter preceded to say that her aunt, resident's sister had called her and told her that someone had struck resident in the eye..."" A nurses' note dated 7/04/2010 at 1:10 PM stated, ""Resident's wife called this afternoon regarding Resident's (R) eye. She said that her sister-n-law told her that Mr. --- eye appeared to be stuck in the (R) corner and that it appeared red and swollen. She wanted to know if resident had fallen or if he was hit in the eye..."" The facility was unable to show that the family's concern about Resident #2's eye was investigated and reported to the state agency.",2014-03-01
10230,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2010-11-30,282,G,,,5NE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews the facility failed to ensure that care plans were followed for 1 of 5 sampled residents reviewed. Resident #1 care planned as a total assist with two care givers with bathing, dressing and grooming, was injured on 11/08/2010 when Certified Nurse Aide #1 provided care unassisted. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, ""Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..."" Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 ""Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..."" Interventions included, ""1. Requires total assistance of two care givers with bathing, dressing and grooming needs..."" In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around ""to grab things"" while providing care. CNA #1 stated, ""I turned away for a few seconds and the resident rolled out of bed."" CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA providing care for the resident at the time of the incident.",2014-03-01
10231,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2010-11-30,323,G,,,5NE411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews the facility failed to ensure that Resident #1's environment remains as free of accident hazards as possible. Resident #1 injured on 11/08/2010 when a Certified Nurse Aide (CNA) bathed him alone, was care planned to have two people with bathing. The review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. Following the injury the care plan was updated on 11/09/2010 to include padded edges to the nightstand and closet, observation on 11/17/2010 revealed no padded edges. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, ""Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..."" Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 ""Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..."" Interventions included, ""1. Requires total assistance of two care givers with bathing, dressing and grooming needs..."" On 11/09/2010 the care plan was updated with an intervention to include ""Pad night stand and closet."" Review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around ""to grab things"" while providing care. CNA #1 stated, ""I turned away for a few seconds and the resident rolled out of bed. CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/30/2010 CNA #1 stated that she was not aware that two people were needed when providing care. She stated that she used the Nursing Guide to Care sheet, which did not address how many people were needed to provide care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA providing care for the resident at the time of the incident. RN #1 stated he was not aware that the resident was a two-person assist. An observation on 11/17/2010 at 10:00 AM revealed the closet edges were not padded as ordered; at 10:40 AM the Director of Nurses confirmed that the closet edges were not padded appropriately.",2014-03-01
10232,"UNIHEALTH POST ACUTE CARE - AIKEN, LLC",425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2010-11-22,153,G,,,6LCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of requested copies of the medical record. Review of the current medical record indicated that on [DATE] the resident's wife signed a facility provided Authorization for Use & Disclosure of Information form requesting records for her husband (Resident #1) from ""[DATE] - Present for personal purposes"". On [DATE] Resident #1's wife received a letter from a representative of the facility, which stated, ""...regarding your request for the above mentioned patients' medical records. As you are aware, the Health Insurance Portability and Accountability Act and the privacy regulations promulgated there under (collectively, ""HIPPAA"") has imposed strict requirements on health care providers regarding the release of protected health information (""PHI""). Under HIPPAA, a provider may disclose an individual's PHI to a personal representative who under state law has authority to act on behalf of the individual. See 45 CFR 164.502(g)(1), 164.514(h)(1)(i). Further, HIPPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. See 45 CFR... Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living, or the permanent administrator or executor of the state if the individual is deceased . The Advance Directive provided to the facility does not provide the proper authority. The center will not be able to release these records until it receives verification of the applicable representation..."" Information provided by the Ombudsman revealed a letter to Resident #1's wife dated [DATE] in which she was advised of her rights under the Health Care Consent Act (SC Code [DATE] et. esq.). A letter to the facility dated [DATE] from the Ombudsman was also provided, which included the following statement, ""...I will meet with Resident #1's wife in the morning to visually inspect the medical record and from there will assist as needed in identifying the records she wants copied for her personal use."" On [DATE] Resident #1's wife signed another Authorization for Use & Disclosure of Information form requesting records ""from date of admission to present: nurses notes, skin asst. (assessments)/body audits, Soc (social) Services notes, all physical therapy, speech therapy, care plans"" for personal use. Review of the Health Care Consent Act (SC Code [DATE] et. esq.) Section [DATE] states, ""Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. (A) Where a patient is unable to consent, decisions concerning his health care may be made by the following persons in the following order of priority: (1) a guardian appointed by the court pursuant to Article 5, Part 3 of the South Carolina Probate Code, it the decision is within the scope of the guardianship; (2) an attorney-in-fact appointed by the patient in a durable power of attorney executed pursuant to Section [DATE], if the decision is within the scope of his authority; (3) a person given priority to make health care decisions for the patient by another statutory provision; (4) a spouse of the patient..."" Resident #1's spouse is his personal representative and per the Health Care Consent Act is the person who makes health care decisions for him. In a telephone interview with the facility on [DATE] the facility stated that this was a HIPPA concern and they would not release information to Resident #1's wife for ""personal use"" and that the wife would have to complete the request to list specific information and the purpose of the use of the information. In an interview with the surveyor on [DATE] the Ombudsman stated that she met with Resident #1's wife at the facility on [DATE] in order to review Resident #1's medical record during a care plan meeting. A verbal review was conducted of the medical record with the Administrator, Social Worker, Director of Health Services, Senior Care Partner and Speech Therapist present along with Resident #1's wife and the Ombudsman. Following the verbal review Resident #1's wife and the Ombudsman looked at the record page by page to determine what she wanted copied. When asked if the resident's wife filled out the authorization form, the Ombudsman stated that the facility staff completed the Authorization for Use & Disclosure of Information form and the resident's wife initialed and signed where needed. At no time did the facility staff give any instructions to the resident's wife regarding how to fill out the form. At the time of the survey Resident #1's wife had not received the requested copies of her husband's medical record.",2014-03-01
10233,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2010-11-23,225,D,,,FIPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interview, the facility's ""Patient/Resident Incident/Accident Investigation Worksheet"" and review of the facility's policy on Abuse and Neglect, the facility failed to report injuries of unknown origin to the State survey and certification agency related to Resident #1. Resident #1 with injuries of unknown origin; a bruise to her right lower jaw on 10/27/2010 and a bruise to her left knee/leg on 11/04/2010 that were not reported to the state agency. (1 of 3 sampled residents reviewed) The findings included: The facility admitted Resident #1 on 5/09/1907 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that indicated the resident had short and long-term memory problems with severely impaired cognitive skills for daily decision-making. Range of motion showed limitation on both side for neck, arm, hands and leg with partial voluntary movement. Review of a 10/27/2010 ""Patient/Resident Incident/Accident Investigation Worksheet"" indicated ""2 cm (centimeter) bruise noted to RT (right) v (lower) jaw. doesn't flinch when touch. Unable to communicate to tell what happened D/T (due to) mentality."" Review of an 11/04/10 ""Patient/Resident Incident/Accident Investigation Worksheet"" indicated ""8 AM called to Room CNA (Certified Nurse Aide) states every time I move her left leg she hollers. In to exam Resident noted to have light purple bruise appx (approximately) 3x (times) 3 in (inches) area (just above left outer knee)..."" In an interview with the surveyor on 11/23/2010 at 11:50 AM the Director of Nursing (DON) revealed she did not report the 10/27/2010 or the 11/04/2010 incidents to State survey and certification agency. An interview on 11/23/10 at 12: 20 PM with the Interim Administrator revealed the unwitnessed incidents were not reported because he believed the facility had within 24 hours to determine the cause of the incident.",2014-03-01
10234,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2010-11-23,323,D,,,FIPL11,"On the day of the compliant inspection, based on an observations, interviews and record reviews, the facility failed to ensure that Resident A received adequate assistive devices to prevent accidents. Resident A had padded side rails; the pads did not cover the entire length of the side rails and were not securely attached to the side rails. The findings included: An observation and interview on 11/23/10 at 11:15 AM with the DON (Director of Nursing) revealed Resident A had padded side rails, the pads did not cover the entire length of the side rails and were not stable. The DON showed how easily the padded side rails moved back/forth and confirmed the pad would not protect the resident from injury if she rolled against the uncovered side rails.",2014-03-01
10235,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-16,157,D,,,SPEH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to notify the physician, or failed to notify the physician timely, of changes in status for 3 of 11 residents reviewed for notification. The facility failed to notify the physician of a positive stool hemoccult test for Resident #1 and failed to notify the physician timely of complaints of pain for Resident #11. In addition, the facility failed to notify the physician of blood noted in Resident #9's brief and also failed to notify the family of the blood or of an order for [REDACTED]. The findings included: At 5:28 PM on 11/15/10, record review for Resident #9 revealed a physician's orders [REDACTED]."" Review of the Progress Notes revealed a note by the FNP (Family Nurse Practitioner) dated 9/27/10 regarding debridement of eschar from the right heel wound. On 11/16/10 at 9:29 AM review of the Nurse's Notes revealed a note dated 9/27/10 at 2:00 PM that the wound had been debrided per the FNP. No documentation of family notification of the FNP evaluation or debridement was found in the record. On 11/16/10 at 9:29 AM, record review for Resident #9 revealed a Nurse's Note dated 9/22/10 of a late entry for 9/21/10 at 3:40 PM stating ""noted dark red blood on brief + (and) penis size of quarter."" Review of the physician's orders [REDACTED]. No new orders were initiated. The Nurse's Notes also revealed a note dated 9/24/10 at 12:00 noon ""Res(ident) had another episode of small amt (amount) of dark rusty blood p (after) he voided clear urine."" There was no documentation of physician notification of the second episode of blood in the resident's brief and there was no documentation that the family was notified of either episode. During an interview at 1:47 PM on 11/16/10, LPN (Licensed Practical Nurse) #4 confirmed there was no documentation that Resident #9's family was notified of the evaluation and debridement of his wound or of the blood in his brief. She also verified that the physician was not notified of the second episode of blood in the resident's brief. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: ""This nurse (LPN #1) brought to the DON's (Director of Nurses) office by res (ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, ""the CNA was rough with me last night."" Then res stated the CNA offered to use lift to stand resident. Res states, ""I said hell no."" Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated ""ok"" and seemed pleased."" A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated ""Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray."" At 5:00 PM a nurses note documented ""Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle."" Review of the Incident Report dated 9/24/2010 at 9:15 AM revealed ""res stated to this nurse ""the CNA was rough with me last night."" Then resident stated the CNA offered to use lift to stand res. Res states ""I said hell no."" Res c/o left ankle pain."" The physician and the responsible party were not notified until after 3:30 PM. During an interview on 11/16/2010, Resident #11 stated that she reported the pain in her left ankle to CNA #1 after a transfer on 9/23/2010. During interviews at 10:50 AM and 1:15 PM, LPN #1 stated that Resident #11 reported an allegation of abuse to her on 9/24/2010 at approximately 9:15 AM. LPN #1 stated that Resident #11 reported that CNA #1 was rough with her last night and reported left ankle pain. LPN #1 stated that she assessed the resident's ankle and did not notice anything abnormal. She also stated that Resident #11 had received pain medications that morning for the pain. LPN #1 stated that the Administrator and DON were not in the building. She stated that she did not contact either one until after 3:00 PM. LPN #1 confirmed that the Physician and the family were not contacted after 3:00 PM either. LPN #1 confirmed that she was aware of the allegation of abuse at 9:15 AM and waited 6 hours before contacting anyone regarding the allegation. She stated that she ""did not think (the doctor) needed to know about the allegation."" She stated that she ""waited to call the doctor until the family member requested an x-ray."" During an interview on 11/16/2010 the Administrator and Director of Nursing confirmed that CNA #1 did not report the ankle pain to the nurse. Both stated that she should have reported the incident immediately to the nurse or the charge nurse. Both the Administrator and the DON confirmed that LPN #1 did not report the allegation of abuse timely to administration, the physician or the family. The Administrator stated she expected changes in condition to be reported immediately to the nurse and the nurse should immediately notify the physician and the family. The Administrator stated that LPN #1 should not have waited 6 hours to notify the physician of the allegation of abuse or the pain. During an interview on 11/16/2010 at 11:15 AM, CNA #1 stated that she routinely took care of Resident #11 until 9/23/2010. CNA #1 stated that she wheeled Resident #11 into the bathroom where the resident pulled up and turned around and sat on the toilet. She stated that Resident #11 complained of pain in her ankle during the transfer. CNA #1 stated that she did not report the pain to the nurse. The facility admitted Resident #1 on 11/12/09 and readmitted the resident on 12/25/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 at approximately 2:55 PM revealed a Physician's Telephone Order dated 9/3/10 for ""...Stool for Occult Blood x 3"". Record review on 11/16/10 at 9:15 AM revealed Nurse's Notes dated 9/3/10 through 11/16/10. An entry dated 9/3/10 revealed that orders were received for ""...Stool for occult blood x 3"" and an entry dated 9/6/10 documented a negative stool for occult blood. There was no mention of a positive hemoccult result on 9/12/10 or that the Physician had been notified of the positive result. During an interview on 11/16/10 at 12:40 PM, the Director of Nursing (DON) provided the Treatment Flowsheet for Resident #1 dated 9/1/10 through 9/30/10. It revealed an entry ""Stool for Occult Blood x 3"". Recorded on 9/6/10 was a ""-"", recorded on 9/12/10 was a ""+"" result. During the interview the DON stated that she thought the Physician had discontinued the [MEDICATION NAME] on 9/16/10 due to the positive hemoccult. Review of Physician/Nurse Practitioner Progress Notes for 9/7/10, 9/16/10, and 10/7/10 revealed no mention of a positive hemoccult. According to the Nurse Practitioner's Progress Note dated 9/16/10, the resident's prn (As needed) [MEDICATION NAME] was discontinued ""...as she really should not require that as she has [MEDICATION NAME] available"". There was no mention that the Nurse Practitioner had been made aware of the positive hemoccult or that the [MEDICATION NAME] had been discontinued as a result of the positive result. During an interview on 11/16/10 at 3:30 PM, Licensed Practical Nurse #4 verified she had documented the positive stool for occult blood on the treatment sheet on 9/12/10. She stated she had not notified the Physician of the positive result because the third hemoccult had not been completed. During an interview on 11/16/10 at 3:38 PM, LPN #1 was told that LPN #4 stated she did not notify the Physician relative to the positive hemoccult. LPN #1 stated that she thought the Physician had responded to the positive result by discontinuing the resident's [MEDICATION NAME]. However, upon review of the Nurse Practitioner's note dated 9/16/10 which indicated that the [MEDICATION NAME] had been discontinued due to the resident having [MEDICATION NAME] available with no mention of a positive hemoccult, LPN #1 stated that she would have notified the Physician of the positive result.",2014-03-01
10236,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-16,225,D,,,SPEH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interviews and review of the facility's Abuse policy, the facility staff failed to immediately report an allegation of abuse to the administrator of the facility. Resident #11 reported an injury to her ankle on 9/23/2010 to her Certified Nursing Assistant (CNA). The CNA failed to report the injury to the nurse. An allegation of abuse was made to the Licensed Practical Nurse (LPN) the next morning. The LPN waited 6 hours before contacting the administration of the allegation. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: ""This nurse (LPN (Licensed Practical Nurse #1) brought to the DON (Director of Nurses) office by res(ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, ""the CNA was rough with me last night."" Then res stated the CNA offered to use lift to stand resident. Res states, ""I said hell no."" Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated ""ok"" and seemed pleased."" A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated ""Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray."" At 5:00 PM a nurses note documented ""Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle."" Review of the Incident Report dated 9/24/2010 at 9:15 AM revealed ""res stated to this nurse ""the CNA was rough with me last night."" Then resident stated the CNA offered to use lift to stand res. Res states ""I said hell no."" Res c/o left ankle pain."" The physician was not notified until 3:30 PM and the responsible party was not notified until 3:00 PM. The facility failed to report the allegation of abuse within the regulatory 24 hours. The initial report was sent to Certification on 9/25/2010, 2 days after the incident. During an interview on 10:50 AM and 1:15 PM, LPN #1 stated that Resident #11 reported an allegation of abuse to her on 9/24/2010 at approximately 9:15 AM. LPN #1 stated that Resident #11 reported that CNA #1 was rough with her last night and reported left ankle pain. LPN #1 stated that she assessed the resident's ankle and did not notice anything abnormal. LPN #1 stated that the Administrator and DON were not in the building. She stated that she did not contact either one until after 3:00 PM. LPN #1 confirmed that she was aware of the allegation of abuse at 9:15 AM and waited 6 hours before contacting anyone regarding the allegation. She stated that she ""did not think (the doctor) needed to know about the allegation."" During an interview on 11/16/2010 at 11:15 AM, CNA #1 that Resident #11 complained of pain in her ankle during the transfer. CNA #1 stated that she did not report the pain to the nurse. During an interview on 11/16/2010 the Administrator and Director of Nursing confirmed that CNA #1 did not report the ankle pain to the nurse. Both stated that she/he should have reported the incident immediately to the nurse or the charge nurse. Both the Administrator and the DON confirmed that LPN #1 did not report the allegation of abuse timely to administration. The Administrator stated she expected allegations of abuse to be reported immediately. The Administrator stated that LPN #1 should not have waited 6 hours to notify the physician of the allegation of abuse or the pain. The Administrator confirmed that she did not send in the initial 24 hour report until 9/25/2010, 2 days after the alleged incident.",2014-03-01
10237,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-16,280,D,,,SPEH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to assure that 1 of 11 residents reviewed had their care plans reviewed and revised to reflect the care needs of each resident. Resident #11's care plan did not reflect the specific transfer devices needed. Resident #11 was recommended to use a sliding board, rolling walker and gait belt for safe transfers. The care plan did not reflect the recommendations. The findings include: Review of the medical record revealed Resident #11's was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 10/1/2010 indicated that the Nurse Practitioner and the Physical Therapist assessed Resident #11's decreased Range of Motion and functional ability of the left ankle and recommended it was ""safest for res. to use slide board to transfer and use BSC (bedside commode) after standing from w/c."" Review of the Physical Therapy notes revealed on 10/1/2010 ""...sliding board transfer to w/c and standing pivot transfer with walker for w/c recliner transfer. No more toilet transfer and used bedside commode..."" A Physical Therapy inservice was conducted with 4 CNA's related to safe transfers for Resident #11. The inservice indicated the staff was to use a gait belt and rolling walker for transfers. Another Physical Therapy inservice was conducted with the Ambustar staff related to safe transfers for Resident #11. The education provided indicated the resident was to be transferred using a gait belt and rolling walker with ""no ankle lock on floor."" Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included ""bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive."" There were no approaches related to the type of transfer devices needed or what was the safest way to transfer the resident. The CNAs used the same care plan as the nurses. The care plan was located in the resident's chart at the nurse ' s station. There was no documentation on the resident's care plan that indicated what the specific care needs of Resident #11 were (i.e. slide boards, rolling walker, gait belt ect.) During an interview on 11/16/2010 the DON confirmed the care plan did not reflect the transfer needs of Resident #11. The DON stated that the care plan should reflect what the resident needed (i.e. sliding boards, lifts, gait belt, walkers etc).",2014-03-01
10238,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-16,323,D,,,SPEH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview, the facility failed to assure Resident #11's range of motion was appropriately assessed and the appropriate interventions were put in place related to safe transfers. Resident #11 did not have a current range of motion assessment in place, did not have documented the safe handling devices that were recommended by the nurse practitioner and the physical therapist and staff were not consistent/aware of the recommendations for safe transfers. The findings included: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #11 as needing extensive one person assist with bed mobility, transfers, walking in and out of the room and locomotion on the unit. Resident #11 also needed extensive one person assist with toileting, hygiene, bathing and dressing. Resident #11's functional range of motion was coded as one sided partial loss of the leg. Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included ""bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive."" There were no approaches related to the type of transfer devices needed or what was the safest way to transfer the resident. The CNAs used the same care plan as the nurses. The care plan was located in the resident's chart at the nurse ' s station. There was no documentation on the resident's care plan that indicated what the specific care needs of Resident #11's were (i.e. slide boards, rolling walker, gait belt etc) Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: ""This nurse (LPN (Licensed Practical Nurse #1) brought to the DON (Director of Nurses) office by res(ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, ""the CNA was rough with me last night."" Then res stated the CNA offered to use lift to stand resident. Res states, ""I said hell no."" Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated ""ok"" and seemed pleased."" A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated ""Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray."" At 5:00 PM a nurses note documented ""Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle."" A Nurses' Note dated 10/1/2010 indicated that the Nurse Practitioner and the Physical Therapist assessed Resident 11's decreased Range of Motion and functional ability of the left ankle and recommended it was ""safest for res. to use slide board to transfer and use BSC (bedside commode) after standing from w/c."" Review of the monthly nursing summaries from September and October revealed no indication of how to transfer the resident and what the safest method was to use. Review of the Joint Mobility Screens revealed Resident #11 did not have her joint mobility assessed since 5/27/2010. That assessment indicated the decreased range of motion interfered with hygiene, dressing, bed mobility, transfers, sitting, standing and walking. No interventions were listed. There were no other assessments located related to safe transfers or the use of safety devices (gait belts, lifts, slide boards etc.) Review of the Physician's Progress Notes dated 9/30/2010 indicated that Resident #11's left ankle was assessed with [REDACTED]. The left ankle was also noted to be slightly more swollen than the right and had marked decreased dorsiflexion and plantarflexion in both ankles. The Nurse Practitioner and Therapy staff concluded that the safest transfer was with a slide board and gait belt and to use a bed side commode. Review of the radiology report dated 9/24/2010 indicated Resident _____""left ankle is without fracture."" Review of the MRI report dated 10/8/2010 documented the left ""tibialis anterior tendon is torn and retracted proximally with hypertrophy of the tendon appreciated at the level of the tibiotalar joint. The distal aspect of the torn tendon resides just superficial to the talar neck. There is no significant surrounding subcutaneous edema or inflammatory change suggesting this may be chronic."" Review of the Physical Therapy notes revealed on 10/1/2010 ""...sliding board transfer to w/c and standing pivot transfer with walker for w/c recliner transfer. No more toilet transfer and used bedside commode..."" On 10/4/2010 ""...perform toilet transfer with RW (rolling walker) using bedside commode moved up behind pt (patient) while standing to avoid SPT (standing pivot transfer). On 10/25/2010 the Physical Therapy Assistant documented Resident #11 ""continues to be limited with transfers/safety awareness. Due to stand pivot transfers being limited, a stretcher is needed when being transferred to/from dialysis. PT/OT will continue with skilled services to address above issues."" A Physical Therapy inservice was conducted with 4 CNA's related to safe transfers for Resident #11. The inservice indicated the staff was to use a gait belt and rolling walker for transfers. Another Physical Therapy inservice was conducted with the Ambustar staff related to safe transfers for Resident #11. The education provided indicated the resident was to be transferred using a gait belt and rolling walker with ""no ankle lock on floor."" During an interview, Resident #11 repeatedly stated when staff members transfer her they do not always use a gait belt. She also stated that the staff do not use the sliding board and sometimes would have her use the rolling walker for transfers. Resident #11 then stated she does not use the bedside commode and that the staff does not offer it to her. In a telephone interview with the surveyor on 11/16/2010 at approximately 11:20 AM, CNA #3 stated that she ""always used a gait belt during transfers with any resident."" CNA #3 further stated that during transfers with Resident #11 she would put on the ""gait belt and let her use her walker to pull herself up."" Resident #11 ""was able to walk well."" CNA #3 stated that she was aware that the resident was not to pivot on her ankle. During a telephone interview on 11/16/2010 at 11:35 AM, CNA #4 stated that she transferred Resident #11 using ""a gait belt and rolling walker."" She stated that she ""does not use a sliding board."" CNA #4 stated that the resident refused to use the bedside commode so she wheeled her to the bathroom and transfers her to the toilet. During a telephone interview on 11/16/2010 at 12:15 PM, CNA #2 stated that she was to use a gait belt during transfers. She further stated that Physical Therapy told her to ""use a gait belt and rolling walker."" She stated that the therapist told her to ""pivot on good leg with walker."" CNA #2 stated that she was ""never told to use a slide board with a bedside commode."" During an interview on 11/16/2010 at 10:15 AM, LPN #3 stated that she routinely cared for Resident #11. She stated that Resident #11 required a ""two person assist"" with transfers and needed a ""gait belt or used a stand up lift."" During an interview on 11/16/2010 at 10:20 AM, CNA #5 (Lead CNA) stated that to transfer Resident #11 she always used a sliding board and a gait belt. She further stated that she used the bedside commode when the resident was feeling weak. During an interview on 11/16/2010 at 10:45 AM, CNA #6 stated that she routinely cared for Resident #11. She stated that to transfer the resident she would use a sliding board and gait belt. She also stated that she did not have the resident stand to pivot. During an interview on 11/16/2010, the Physical Therapist and Physical Therapist Assistant stated that the safest mode of transfer for the resident was to use a gait belt and a rolling walker to stand up and then turn slowly picking up her feet and placing them down. Both stated that she was not to pivot on either foot. Both confirmed that the staff had been educated on the safest way to transfer the resident. The inservice with 4 CNA's attending on 9/29/2010 was provided for review. During an interview on 11/16/2010 at 12 PM, the Nurse Practitioner, stated that she assessed the resident's ankle and did not see an acute injury. She stated that Resident #11 had decreased ROM in both ankles and that had been present for since she first started seeing the resident. She confirmed that a slide board and gait belt was the safest transfer. The NP stated that she expected communication and collaboration to determine what interventions should be in place or discontinued related to transfers. She further stated that she expected a ""consistent manner to transfer for all staff."" ""If inconsistent then you open it up for injury.""",2014-03-01
10239,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2010-11-15,280,D,,,RSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review and interviews, the facility failed to review and revise one of four resident's care plans. Resident #1 had a significant weight loss that was not identified or updated on the care plan. The care plan also did not reflect the resident's diarrhea. The findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded the resident's weight as 157 pounds with no weight changes. The Medicare 14 day MDS dated [DATE] coded the resident weight was 152 pounds with no weight changes. Review of the daily weights revealed her admission weight of 151.6 pounds on 7/13/2010. On 7/17/2010 Resident #1 weighed 148.4 pounds. On 7/25/2010 she weighed 140.2 pounds. Resident #1 had a steady rapid weight loss during that week of 8.2 pounds in 8 days. On 8/2/2010 she weighed 135.6 pounds. On 8/5/2010 she weighed 134.8 pounds. A total weight loss of 15.4 pounds or an 11.4% weight loss in 3 weeks. Review of the Physicians Orders revealed an order to ""Notify MD (medical doctor) of weight change > (greater than) 5 pounds."" Review of the care plan revealed expected weight loss related to diuretic therapy was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included ""dietician to evaluate nutritional status, weigh per order..."" The care plan had not been updated with the actual significant weight loss, or the supplements that had been added. During an interview on 11/15/2010 at 1 PM, the Care Plan Coordinator confirmed that Resident #1's care plan was not updated to reflect the resident's significant weight loss. She also confirmed that interventions should have been put in place to address the weight loss. She stated that she routinely updated care plans, however anyone can update them.",2014-03-01
10123,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2010-12-07,463,J,,,R87Z11,"On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to ensure that all components of the nurse call system were operational. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light to room 712 was blinking on and off with no sounds. The call light to room 715 was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights to rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room 715 to turn off the call light for room 701. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms 718 and 719, located in a corner, not readily visible to the staff from the halls. When asked how long problems existed on the unit with the call lights CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room 701 called for a CNA to go to room 717 due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room 717 was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:25 PM Licensed Practical Nurse (LPN) #1 revealed she was aware of the problems with the call lights a few weeks ago and so was the Maintenance Manager. LPN #1 stated the call lights for rooms 701 and 715 would just ""come on"". In an interview with the surveyor on 12/06/2010 at 8:30 PM the Director of Nursing (DON) and LPN#1 revealed the call light system used by the facility was both audible and visual. When a resident pushed the call light button in the room a sound was heard and the light came on over the resident's doorway and at the panel at the nurse's station. In an interview with the surveyor on 12/06/2010 at approximately 8:45 PM the Administrator confirmed she was aware the call lights were not working and that the Maintenance Manager received a report regarding call lights not functioning properly on 11/25/2010. The Administrator showed the surveyor a maintenance log dated 11/25/2010 that documented the concern that the call light system on Unit 700 was not working. In an interview with the surveyor on 12/06/2010 at approximately 9:05 PM the Maintenance Manager stated that some work was performed on the call lights 2 months ago. He stated he was not aware of the recent concerns but showed the survey a log dated 11/25/2010 that addressed concerns that the call light was not working on Unit 700. The Maintenance Manager stated that because the concerns were documented in the log did not mean anyone knew about the problems. Cross Refer to F-490, as it relates to the facilities administrator being aware of the call lights no working prior to the survey. No interventions were in place to prevent further concerns with the call lights. On 12/06/2010 at approximately 9:15 PM, Immediate Jeopardy was identified related to F463 at a scope and severity level of J. An acceptable plan of correction was submitted at 2:03 PM on 12/07/2010; at 2:30 PM, the Immediate Jeopardy was removed. However, the citations remained at a lower scope and severity level of D.",2014-04-01
10124,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2010-12-07,490,J,,,R87Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on observations, interviews and record reviews the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The nurse call panel at the Unit 700 nursing station was not operational during the first day of the survey and the facility administrative staff was aware of problems with the call lights. The findings included: An observation on 12/06/2010 at approximately 7:30 PM revealed call lights lit over resident rooms 701, 712 and 715 with Certified Nurse Aide (CNA) #1 attempting, without success, to turn off the call lights after providing care. The call light for room [ROOM NUMBER] was blinking on and off with no sounds. The call light for room [ROOM NUMBER] was lit with no sounds. In an interview with the surveyor, at the time of the observation, CNA #1 confirmed that the call lights for rooms 701, 712 and 715 were not working appropriately. CNA #1 stated that he went to room [ROOM NUMBER] to turn off the call light for room [ROOM NUMBER]. The 700 Unit comprised of four halls not in full view of the nurse's station and rooms [ROOM NUMBERS], located in a corner, not readily visible to the staff from the halls. When asked how long problems with the call lights had existed on the unit CNA #1 stated that the call lights had not been working since last week when he informed a nurse. When asked how the staff determined a resident needed assistance CNA #1 stated that they looked to see if a light was on over the resident's door to determine if the resident needed assistance. An observation by the surveyor on 12/06/2010 at approximately 8 PM revealed the lights were on over the doors to rooms 710, 712 and 715; the call light panel was not functioning at the nurse's station. There was no staff member at the nurse's station. A nurse observed near room [ROOM NUMBER] called for a CNA to go to room [ROOM NUMBER] due to the call light being on over the door, in the hallway. Observation of the call light panel at the nurse's station revealed the light for room [ROOM NUMBER] was not lit. In an interview with the surveyor on 12/06/2010 at approximately 8:45 PM the Administrator confirmed she was aware the call lights were not working and that the Maintenance Manager received a report regarding call lights not functioning properly on 11/25/2010. The Administrator showed the surveyor a maintenance log dated 11/25/2010 that documented the concern that the call light system on Unit 700 was not working. In an interview with the surveyor on 12/06/2010 at approximately 9:05 PM the Maintenance Manager stated that some work was performed on the call lights 2 months ago. He stated he was not aware of the recent concerns but showed the survey a log dated 11/25/2010 that addressed concerns that the call light was not working on Unit 700. The Maintenance Manager stated that because the concerns were documented in the log did not mean anyone knew about the problems. Cross Refer to F-463, as it relates to a nonfunctioning nurse call panel at the Unit 700 nursing station during the first day of the survey On 12/06/2010 at approximately 9:15 PM, Immediate Jeopardy was identified related to F463 at a scope and severity level of J. An acceptable plan of correction was submitted at 2:03 PM on 12/07/2010; at 2:30 PM, the Immediate Jeopardy was removed. However, the citations remained at a lower scope and severity level of D.",2014-04-01
10125,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2010-12-07,280,D,,,R87Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review the facility failed to assure a resident's care plan was reviewed and revised to reflect the current status of one of one resident reviewed with socially inappropriate behaviors. Resident #1 alleged that a new Certified Nurse Aide (CNA) hit him in the eye. Resident #1's care plan was not updated to reflect the allegation and no new interventions were initiated to attempt to address the behaviors. The findings included: The facility admitted Resident #1 on 11/14/2007 and readmitted him on 11/14/2008 with [DIAGNOSES REDACTED]. During record review for Resident #1 on 12/06/2010 the Nurse's Notes dated 11/11/2010 stated, ""Resident called nurse to room and states, 'look what the new CNA did to me'. Nurse asked what did CNA do resident states 'CNA punched me in the face'. SA (screening assessment) done noted bluish injury to (R) (right) eye..."" Review of the resident's care plan dated 08/17/2010 identified Socially inappropriate/disruptive behavior and Resistance to care, restlessness, crawling on the floor, history of combative behavior...w (with) potential for self-inflicted injury as problems. The care plan had not been updated following the 11/11/2010 incident related to the allegation that the CNA punched him in the face. No new interventions were initiated to address the resident's behavior or the alleged response of a staff member to the continuing behaviors. The care plan included a statement under the problem area dated 11/12/2010 ""continue problem x 3 months"".",2014-04-01
10126,"FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC",425016,208 JAMES STREET,ANDERSON,SC,29625,2011-01-26,281,D,,,ZGHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review, observations and interviews, the facility failed to assure that licensed staff appropriately handled narcotics. Two licensed practical nurses (LPN) failed to appropriately count narcotics at the change of shift. Liquid [MEDICATION NAME] was left unattended on a resident's bedside table for an unknown period of time. That resident (Resident #2) was sent to the emergency room with a change in condition. The findings included: The facility readmitted Resident #2 on 3/10/2010 with [DIAGNOSES REDACTED]. Record review revealed the resident was receiving [MEDICATION NAME] 7.5/500 milligrams 1-2 tablets every 6 hours for pain. The resident was also receiving [MEDICATION NAME] for anxiety nightly. Residents #2 and #3 sampled as a result of a facility reported incident dated 1/9/2011 related to an allegation against Licensed Practical Nurses (LPN) #2 and #3. The initial 24 hours report stated, ""medication left at bedside on Saturday 1/8/2011. A thorough investigation was implemented immediately. The incident was reported to the administration at 2:08 PM."" Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nurses was notified on 1/8/2011 at 2:08 PM. The report indicated that the resident (#2) was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were ""nurse in attending to resident and found liquid [MEDICATION NAME] at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident was ""narcotics are counted and reconciled at shift change."" Immediate corrective action taken was that LPN #1 was ""suspended immediately and will not return to employment and license will be reported to LLR per protocol. 100% audit of narcotics in 4 of 4 medication carts was conducted. 100% of licensed staff was re-inserviced regarding securing and accounting for narcotics. Hazardous material re-inservice was done with 100% of staff."" The Summary of Incident was ""Nurse violated standard of practice related to securing medication."" Review of the Timeline related to the incident provided by the facility revealed the resident was found lethargic and unintelligible at 1 PM per the nurse's notes. At 1:21 PM, the ambulance was called. At 1:27 PM the ambulance arrived at the facility (per the ambulance record). Per the nurses notes the resident left at 1:30 PM. According to the ambulance record the resident did not leave the facility until 1:58 PM and arrived at the hospital at 2:03 PM. LPN #1 notified the Director of Nursing (DON) at 2:08 PM of the [MEDICATION NAME] and incorrect narcotic count. LPN #1 also reported to the DON that Resident #2 was sent to the emergency room in respiratory distress. LPN #1 reported that 13.5 milliliters of liquid [MEDICATION NAME] were unaccounted for. The DON arrived at the facility at 2:30 PM. Drug tests were performed on all staff with potential contact with Resident #2 including LPN #1 and 2 and on two Certified Nursing Assistants. LPN #1 and #2's drug tests were negative. CNAs #1and #2 drug tests were positive; they were suspended. Review of the nurse's notes dated 1/8/2010 at 5:30 AM stated, ""Resident coughing up thick green tinged sputum. Breathing trt (treatment) given. Congestion noted in upper lobes bilaterally. Will continue to monitor."" On 1/8/2010 at 6:30 AM it was documented that ""Breathing trt helped resident loosen mucous and has productive cough with green sputum."" At 1PM, ""Resident lethargic, unintelligible sounds noted, resp(iratory) distress noted. Spitting up green mucous. Talked with RP (responsible party) and she would like res(ident) sent to ER. (Doctor) notified and order received to send to ER for eval and treatment."" At 1:30 PM the resident was sent to the ER via ambulance. Further review revealed no documentation of the resident's status between 6:30 AM and 1 PM, however review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Count sheets on 01/26/2011, for Resident #3 (roommate of Resident #2) revealed [MEDICATION NAME] 20 mg/ml, 30 ml (milliliter) bottle. Line 48 indicated that LPN #1 signed out the [MEDICATION NAME] on 1/8/2011 at 2 PM. It was documented that 23.5 ml should have been left in the bottle. Review of the facility obtained statement for LPN #1 revealed that she and LPN #2 ""counted narcotics this am (1/8/2011). I saw three bottles of [MEDICATION NAME] and glanced at them for content. I did not read labels with names. At 1:30 PM, I went to get Resident #3's [MEDICATION NAME] and could not find the bottle on the cart. I checked each drawer, narcotic box, and refrigerator and (the nurse) checked her cart. I(t) occurred to me that some nurses administer [MEDICATION NAME] with the dropper so. I immediately check res(ident) room and found bottle on bedside table of roommate (Resident #2). I had been in room several times this AM and did not see bottle (or notice bottle). Bottle of [MEDICATION NAME] had 10 ml when I found it. When we counted meds this AM, I looked at the meds and LPN #2 looked at the sheets."" During an interview on 1/26/2011 at 12 PM, LPN #1 stated that during the narcotic count at shift change it was routine practice not to count the liquid medications because they were ""always off."" LPN #1 stated that she was giving [MEDICATION NAME] to another resident around 11:30 AM or 12 PM and noticed only three bottles of [MEDICATION NAME] were in the cart. She stated that she searched for the missing [MEDICATION NAME] in other drawers, medication room, refrigerator and the other med carts. She stated that it ""occurred to her that nurses would use the medication dropper."" She stated that she then went into Residents #2 and #3's room and found the [MEDICATION NAME] on Resident #2's bedside table. She stated that she immediately counted the medication and noticed it was off. She stated that the CNAs then reported to her that Resident #2 was unarousable. LPN #1 performed a sternal rub and notified the family and then the doctor. She stated that she assumed the resident consumed the medication. LPN #1 then stated that it was between 12 and 12:30 PM that she noticed the missing [MEDICATION NAME] and about 15-20 minutes later noticed Resident #2 was unarousable. LPN #1 stated that she did not obtain any vital signs and had administered the resident's breathing treatment. LPN #1 stated that she notified the family and then the doctor because that was the normal protocol. LPN #1 stated that she instructed the CNAs to ""clean the resident up"" before she was sent out. LPN #1 stated that during the narcotic counts at shift change, one nurse would look at the medication and one nurse would look at the sheets. She stated that both nurses did not visualize the medications. LPN #1 stated that it ""was not an absolute necessity"" for both nurses to reconcile the narcotics. LPN #1 stated that no other nurse had access to her cart that day. LPN #1 also stated that there was only one set of keys per cart. LPN #1 verified her facility obtained statement was correct as well as the statement reported to the surveyor. LPN #1 could not account for the discrepancies in the statement nor in the times of the events accounted. Review of LPN #2's facility obtained statement dated 1/8/2011 revealed that LPN #2 ""counted off with first shift nurse. I stated amounts left in [MEDICATION NAME] bottles and she stated ok. I was looking at each narcotic sheet and did not visualize the narcotics as we were counting. I gave (Resident #3) her meds then her [MEDICATION NAME] set the [MEDICATION NAME] on (Resident) nightstand, started her breathing treatment. When (sic) to (Resident #2) to check on her, she asked for pain medicine. I went back to med cart to get (Resident's #2's) two [MEDICATION NAME] and breathing treatment. At the end of my shift I counted off with first shift nurse called amounts left in [MEDICATION NAME] bottles and she stated ok for each."" During an interview on 1/26/2011 at 4:35 PM, LPN #2 stated that she was positive she replaced Resident #3's [MEDICATION NAME] back into the medication cart after she administered the [MEDICATION NAME] to her at 6 AM. LPN #2 stated that during the Narcotic count at shift change she was calling off the medications from the narcotic sheets and LPN #1 was counting the medications. LPN #2 stated that she visualized all 4 [MEDICATION NAME] bottles but didn't measure the contents. LPN #2 stated that LPN #1 didn't pick up any [MEDICATION NAME] bottles but both visualized all 4 bottles were present at shift change. LPN #2 stated that she normally reads the narcotic sheets and counts the medications. She stated that the other nurse picks up the liquid medications and would hold them up so both could visualize the amounts. LPN #2 stated that she ""always counted liquid narcotics."" LPN #2 verified the accuracy of her facility obtained statement and stated that both the statement given to the facility and the statement given to the surveyor were the same and accurate. LPN #2 again stated that she visualized the [MEDICATION NAME] bottles at shift change. LPN #2 could not account for the discrepancy in the statements. During an interview on 1/25/2011 CNA #1 stated that she was assigned to Residents #2 and #3 on 1/8/2011. She stated that she did not see the [MEDICATION NAME] bottle in the residents' room. CNA #1 stated that she was informed that [MEDICATION NAME] was missing by the DON and was drug tested . CNA #1 stated that her drug test was positive. CNA #1 stated that she had not been back to work since 1/8/2011 and stated that she had not been contacted by the facility since her suspension. During an interview on 1/25/2011, CNA #2 stated that she was working on 1/8/2011 but was not assigned to either Resident #2 or #3. CNA #2 stated that she was not aware of the missing [MEDICATION NAME] nor was she questioned regarding the incident. CNA #2 stated that she was drug tested and the test was positive. During an interview on 1/24/2011 at 12 PM, the DON stated that LPN #1 and #2 were suspended pending the conclusion of the investigation. The Director of Nursing (DON) stated that the facility was ""still in the investigation process."" During a follow up interview with the DON and the Administrator, the Administrator stated that the hospital was notified of the potential ingestion of [MEDICATION NAME]. The emergency room (ER) doctor stated that a Toxicology Screen was not performed because the resident was already prescribed narcotics. The ER doctor did state that [MEDICATION NAME] was given and the resident did ""perk up a bit."" The DON stated that both LPN #1 and #2 admitted to counting the narcotics incorrectly, the DON stated that both nurses should have visualized the narcotic as well as the narcotic sheet. The DON stated that LPN #1 reported that only 3 [MEDICATION NAME] bottles were in the cart at shift change even though 4 were recorded as present. The DON stated that she did not know what happened to the missing 13.5 ml of [MEDICATION NAME]. A Narcotic Count of liquid [MEDICATION NAME] was conducted on 1/24/2011 with the DON and the surveyor. Some of the [MEDICATION NAME] bottles were noted to have more than the recorded amount. The Narcotic sheets would record a number then a + sign to indicate the excess. The DON stated that the pharmacy was aware. The Pharmacy stated that the amount in the bottles was correct, however the curvature of the [MEDICATION NAME] bottles made it appear that there was more in the bottles. Review of the Controlled Medication Policy stated, ""...there must be complete accountability of all controlled substances being stored at the facility. The nurse going off duty and the nurse coming on duty must count all controlled substances at the end of each shift.""",2014-04-01
10127,"FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC",425016,208 JAMES STREET,ANDERSON,SC,29625,2011-01-26,431,D,,,ZGHV11,"On the days of the complaint inspection based on interviews, review of the facility's investigation and review of the facility's policy on Drug Storage, the facility failed to assure narcotics were securely and safely stored. A bottle of Roxanol was found at a resident's bedside with 13.5 milliliters (ml) missing. The findings included: Review of the 24 Hour Report dated 1/9/2011 revealed neglect was alleged against Licensed Practical Nurse (LPN) #2. The description of the incident was ""medication left at bedside on Saturday 1/8/2011. An investigation was implemented immediately. The incident was reported to the administration at 2:08 PM. Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nursing (DON) was notified on 1/8/2011 at 2:08 PM. The report indicated that Resident #2 was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were ""nurse in attending to resident and found liquid Morphine at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident were 'narcotics are counted and reconciled at shift change.' Immediate corrective action that was taken was LPN #1 was ""suspended immediately and will not return to employment and license will be reported to LLR per protocol. 100% audit of narcotics in 4 of 4 medication carts was conducted. 100% of licensed staff was re-inserviced regarding securing and accounting for narcotics. Hazardous material re-inservice was done with 100% of staff."" The Summary of Incident was ""Nurse violated standard of practice related to securing medication."" Review of the Timeline related to the incident provided by the facility revealed the resident was found lethargic and unintelligible at 1 PM per the nurse's notes. At 1:21 PM, the ambulance was called. At 1:27 PM the ambulance arrived at the facility (per the ambulance record). Per the nurse's notes the resident left at 1:30 PM. According to the ambulance record the resident did not leave the facility until 1:58 PM and arrived at the hospital at 2:03 PM. LPN #1 notified the Director of Nursing (DON) at 2:08 PM of the Morphine and incorrect narcotic count. LPN #1 also reported to the DON that Resident #2 was sent to the emergency room in respiratory distress. LPN #1 reported that 13.5 milliliters of liquid Morphine were unaccounted for. The DON arrived at the facility at 2:30 PM. Drug tests were performed on all staff with potential contact with Resident #2 including LPN #1 and 2 and on two Certified Nursing Assistants. LPN #1 and #2's drug tests were negative. CNAs #1 and #2 tested positive for drugs and were suspended. Review of the Narcotic Count sheets for Resident #3 revealed Roxanol 20 mg/ml, 30 ml bottle. Line 48 indicated that LPN #1 signed out the Roxanol on 1/8/2011 at 2 PM. It was documented that 23.5 ml should have been left in the bottle. Review of the facility obtained statement for LPN #1 revealed that she and LPN #2 ""counted narcotics this am (1/8/2011). I saw three bottles of Roxanol and glanced at them for content. I did not read labels with names. At 1:30 PM, I went to get Resident #3's Roxanol and could not find the bottle on the cart. I checked each drawer, narcotic box, refrigerator and (the nurse) checked her cart. It occurred to me that some nurses administer Roxanol with the dropper so I immediately check resident room and found bottle on bedside table of roommate (Resident #2). I had been in room several times this AM and did not see bottle (or notice bottle). Bottle of Roxanol had 10 ml when I found it. When we counted meds this am, I looked at the meds and LPN #2 looked at the sheets. During an interview on 1/26/2011 at 12 PM, LPN #1 stated that during the Narcotic Count at shift change it was routine practice not to count the liquid medications because they were ""always off."" LPN #1 stated that she was giving Roxanol to another resident around 11:30 AM or 12 PM and noticed only three bottles of Roxanol were in the cart. She stated that she searched for the missing Roxanol in other drawers, medication room, refrigerator and the other med carts. She/he stated that it ""occurred to her that nurses would use the medication dropper."" She stated that she then went into Residents #2 and #3's room and found the Roxanol on Resident #2's bedside table. She stated that she immediately counted the medication and noticed it was off. She stated that the CNAs then reported to her that Resident #2 was unarousable. LPN #1 performed a sternal rub and notified the family and then the doctor. She stated that she assumed the resident consumed the medication. LPN #1 then stated that it was between 12 and 12:30 PM that she noticed the missing Roxanol and about 15-20 minutes later noticed Resident #2 was unarousable. LPN #1 stated that she did not obtain any vital signs and had administered the resident's breathing treatment. LPN #1 stated that she notified the family and then the doctor because that was the normal protocol. LPN #1 stated that she instructed the CNAs to ""clean the resident up"" before she was sent out. LPN #1 stated that during the narcotic counts at shift change, one nurse would look at the medication and one nurse would look at the sheets. She stated that both nurses did not visualize the medications. LPN #1 stated that it ""was not an absolute necessity"" for both nurses to reconcile the narcotics. LPN #1 stated that no other nurse had access to her cart that day. LPN #1 also stated that there was only one set of keys per cart. LPN #1 verified her facility obtained statement was correct as well as the statement reported to the surveyor. LPN #1 could not account for the discrepancies in the statement nor in the times of the events accounted. Review of LPN #2's facility obtained statement dated 1/8/2011 revealed that LPN #2 ""counted off with first shift nurse. I stated amounts left in Roxanol bottles and she stated ok. I was looking at each narcotic sheet and did not visualize the narcotics as we were counting. I gave (Resident #3) her meds then her Roxanol, set the Roxanol on nightstand, started her breathing treatment. Went to (Resident #2) to check on her, she asked for pain medicine. I went back to med cart to get (Resident #2's) Lortab and breathing treatment. At the end of my shift I counted off with first shift nurse called amounts left in Roxanol bottles and she stated ok for each."" During an interview on 1/26/2011 at 4:35 PM, LPN #2 stated that she was positive she replaced Resident #3's Roxanol back into the medication cart after she administered the Roxanol to her at 6 AM. LPN #2 stated that during the narcotic count at shift change she was calling off the medications from the narcotic sheets and LPN #1 was counting the medications. LPN #2 stated that she visualized all 4 Roxanol bottles but didn't measure the contents. LPN #2 stated that LPN #1 didn't pick up any Roxanol bottles but both visualized all 4 bottles were present at shift change. LPN #2 stated that she normally reads the narcotic sheets and counts the medications. She stated that the other nurse picks up the liquid medications and would hold them up so both could visualize the amounts. LPN #2 stated that she ""always counted liquid narcotics."" LPN #2 verified the accuracy of her facility obtained statement and stated that both the statement given to the facility and the statement given to the surveyor were the same and accurate. LPN #2 again stated that she visualized the Roxanol bottles at shift change. LPN #2 could not account for the discrepancy in the statements. During an interview on 1/24/2011 at 12 PM, the DON stated that both LPN #1 and #2 admitted to counting the narcotics incorrectly, the DON stated that both nurses should have visualized the narcotic as well as the narcotic sheet. The DON stated that LPN #1 reported only 3 Roxanol bottles were in the cart at shift change even though 4 were recorded as present. The DON stated that she did not know what happened to the missing 13.5 ml of Roxanol. A Narcotic Count of liquid Morphine was conducted on 1/24/2011 with the DON and the surveyor. Some of the Roxanol bottles were noted to have more than the recorded amount. The Narcotic sheets would record a number then a + sign to indicate the excess. The DON stated that the pharmacy was aware. The Pharmacy stated that the amount in the bottles was correct, however the curvature of the Roxanol bottles made it appear that there was more in the bottles. Review of the Controlled Medication Policy revealed, ""there must be complete accountability of all controlled substances being stored at the facility. The nurse going off duty and the nurse coming on duty must count all controlled substances at the end of each shift. Review of the ""Medication Storage in the Facility"" policy revealed, ""medications and biologicals are stored safely, securely and properly...."" ""The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications."" Cross refers to F-281 as it relates to two nurses inappropriately accounting for narcotics.",2014-04-01
10128,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,250,D,,,8F5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 14 residents reviewed for social services. Resident #16 failed to receive medically related social services for discharge planning and lost personal items. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. The resident was noted in the Resident Assessment Profile as being a short term rehabilitation resident, planning to return to home. The social service note dated 6/7/10 (admitted ) stated that the resident was living in an apartment alone at Pickens County disability prior to hospitalization and that"" the goal is to d/c (discharge) home on 31st day. "" Social service notes stated, ""will visit on reg. 1:1 basis to observe moods and adjustment to placement."" The social service notes contained 5 more entries -6/14/10, 6/21/10, 6/24/10, 7/6/10, and 8/3/10. None of the entries addressed discharge planning or assessment for the resident's plan to return home. There was no indication in the documentation that the social services director had talked with the resident regarding the plans to return home and no documentation that he/she had helped the resident with planning for the discharge to home. The information in the social services notes addressed areas,such as; the resident's mood, appetite, weight, and activities. There was no mention of the arrangements to prepare for a move back home, although the 31st day had passed on July 1, 2010. There was no documentation as to why the resident's discharge date had been extended. In review of the resident's current Care Plan dated 6/24/10, there was no mention of the resident's upcoming discharge under social services or nursing sections of the plan. In an interview with the Social Services Director (SSD) on 8/25/10 at 9:00 AM he/she was unsure of the agencies involved with the resident and stated there was a man and a nurse who visited him/ her (the resident) , but was unsure of who they were, the agency they represented, or the role they played in the resident's discharge plan. The SSD did indicate he/she thought the delayed discharge was related to the resident's inability to bear weight. The SSD was unable to provide any additional evidence of social services involvement related to discharge planning with the resident and stated that his/her careplan for the resident was included on the overall careplan in the patient's record. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. Resident #16 continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. When questioned about the plan to return to his/her apartment, he/she stated that he/she knew he/she needed a ""rail put up in the bathroom"" before he/she could return to the apartment, but did not know how it would be paid for. Resident #16 also informed this surveyor that he/she had been employed in the local Disability Board's Day Program(workshop) and was unsure if he/she could ever return to this work. The resident expressed he/she wanted to return to the apartment provided by the Disability Board and was upset that his/her purse was missing because his/her only keys for the apartment were in that purse. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director and he/she was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse. In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. There was no documentation in the social service notes related to the resident's lost items and concerns the resident expressed about the missing keys in relation to his/her return to the apartment.",2014-04-01
10129,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,514,D,,,8F5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews the facility failed to maintain accurately documented records for 3 of 18 records reviewed for accuracy of records. Resident #7 had inaccurate documentation related to the application of a sling, Resident #13 had inaccurate documentation related to the application of ted hose, and Resident #16 had inaccurate documentation of a Grievance/Complaint Report. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. He/she continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director (SSD) and the SSD was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. The Social Services Director informed that the form should had been dated 8/16/10 and offered to date the form for the surveyor. This Surveyor requested a copy of the original document as received with no date. When the copy was provided at 12 noon, the copy was dated 8/16/10 and signed by the Social Services Director. Resident #7 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. There were multiple observations on all days of the survey of the resident without a sling, however, the Treatment Record documented the resident had worn the sling on all 3 days of the survey. Record Review on 8/23/10 at 3:48 PM revealed cumulative physician's orders [REDACTED].D. (Medical Doctor). O.K. to remove orthopedic device to left arm for ADL (Activities of Daily Living) Care"". The following observations were made in which Resident #7 was not wearing the ordered sling. - On 8/23/10 at 1:52 PM. Resident sitting in the doorway of the therapy office. at 2:59 PM. Resident sitting in wheelchair in her room. at 6:22 PM. Resident sitting in wheelchair in her room eating dinner. - On 8/24/10 at 8:55 AM. Resident lying in bed. at 10:00 AM. Resident lying in bed. at 12:32 PM. Resident eating lunch in her room. -On 8/25/10 at 9:12 AM. Resident sitting in wheelchair in room. During an interview on 8/24/10 at 10:00 AM, Resident #7 was asked about the sling and why it wasn't being worn. The resident stated that at her/his last appointment, the orthopedic doctor told her/him that she/he could take it off. She/He stated that if the doctor wanted her to wear it, she/he would. When asked if staff encourage her/him to wear the sling, the resident stated that staff members haven't instructed her/him to wear it. Review of the consult section of the chart on 8/24/10 revealed no orthopedic notes. Review of the Nurses Notes on 8/25/10 revealed no mention of the use of a sling for 8/23/10 through 8/25/10. During an interview on 8/25/10 at 10:30 AM, Licensed Practical Nurse #3 was asked about Resident #7's last orthopedic visit. The nurse checked the appointment calendar and stated the last orthopedic visit for Resident #7 was in July. When asked about any orthopedic progress notes, the nurse stated the physician only sent a note if there were any changes and verified there were no orthopedic notes in the chart. LPN #4 joined the interview and both nurses were told that Resident #7 had been observed on all days of the survey without her/his sling having been worn. The cumulative physician's orders [REDACTED]. Upon review of the Treatment Record for Resident #7 for August 2010, documentation for the dates of the survey were brought to the nurses attention. For August 23rd and 24th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7, 7-3, and 3-11 shifts. For August 25th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7 and 7-3 shifts. LPN #4 verified she/he was the nurse that documented on the Treatment Record regarding the use of the sling. When asked about the discrepancy between the surveyor observations and documentation on the Treatment Record, LPN #4 stated that she/he had been asking Physical Therapy (PT) if Resident #7 had been wearing her/his sling. LPN #4 stated she/he thought that PT had supplied the sling for the resident. The surveyor and LPN #4 then went to see Resident #7, who was not wearing the ordered sling. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. There were multiple observations on 8/24/10 of the resident without her/his ordered TED Hose, however, the Treatment Record documented the resident had worn the TED Hose that day. Record review on 8/24/10 at 9:05 AM revealed cumulative physician's orders [REDACTED].M. OFF IN P.M. R/T (Related To) [MEDICAL CONDITION]"". Review of the Care Plan on 8/24/10 at 11:24 AM revealed ""TED hose as ordered"" as an approach for resident being ""At risk for complications r/t (related to) [MEDICAL CONDITION]"". Review of the 8/9/10 ""Easley Living Center"" progress note (signed by the Nurse Practitioner) on 8/24/10 at 9:30 AM revealed ""Her/His [MEDICATION NAME] was recently increased to 40 mg (milligrams) because she/he was having [MEDICAL CONDITION]"". Review of the 8/6/10 ""Easley Living Center"" progress note signed by the Physician revealed ""She does complain of some increased [MEDICAL CONDITION] in her left lower extremity, however. Nursing staff reports no major issues with this patient including any skin breakdown...Extremities: She does have 1+ [MEDICAL CONDITION] in that left lower extremity primarily in the dorsum of her left foot. Trace lower extremity [MEDICAL CONDITION] on the right...Regarding the lower extremity [MEDICAL CONDITION], we will increase her [MEDICATION NAME] up to 40 mg a day"". Review of the August 2010 Treatment Record on 8/24/10 at 10:20 AM revealed an entry for ""Ted Hose: On in A.M. Off in P.M. R/T [MEDICAL CONDITION], 7-3 On, 3-11 Off"" that had been initialed for the 7-3 shift for August 24th. Observations on 8/24/10 at 10:25 AM, 11:48 AM, 12:27 PM, 1:52 PM, 4:00 PM, and 4:38 PM revealed Resident #13 sitting in her/his wheelchair wearing socks, but no TED hose. During an interview on 8/25/10 at approximately 10:20 AM, Licensed Practical Nurse (LPN) # 3 was told that there were observations made of Resident #13 without her/his TED hose on. LPN #3 reviewed and verified the cumulative Physician""s Orders for August 2010 and the resident's Care Plan which indicated the resident was to wear the Ted Hose. She/He also verified the Physician's progress notes that indicated the resident had [MEDICAL CONDITION]. LPN #4 joined the interview and was told that the resident had been observed without the ordered TED Hose. LPN #4 verified that she/he was the nurse that documented on the Treatment Record regarding the application of the TED Hose. The surveyor, LPN #3 and LPN #4 reviewed the Treatment Record documentation for August 2010 in which the TED hose had been initialed as having been worn on 8/24/10 and 8/25/10 for the 7-3 shift. When asked about the discrepancy between the Treatment Record documentation and the observations of the resident without her/his TED Hose, the nurse stated that she/he reminded the Certified Nursing Assistants (CNAs) to apply the TED Hose. When asked to go to check and see if the resident was currently wearing the TED Hose, LPN #4 stated that she/he was new and didn't know the residents well, and if the resident was not in her/his room then LPN #3 would have to point the resident out to her/him. Upon entry to the room, Resident #13 was lying on her/his bed. The nurse stated the resident would not be wearing TED Hose in bed, and staff usually kept the TED Hose on her/his wheelchair. There were no TED Hose on the wheelchair, and, while checking the bedside table and closet, the nurse stated the TED Hose was probably in the laundry being washed. When asked if the resident only had one pair of TED Hose, the nurse answered ""yes"".",2014-04-01
10130,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,164,D,,,8F5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies entitled ""Competency Catheter Care- Female"" (undated) and ""Competency Catheter Care-Male"" ([DATE]), the facility failed to provide adequate personal privacy for 2 of 2 sampled residents observed for catheter care. Appropriate clothing/draping was not provided for Residents #6 and #8 to prevent unnecessary exposure of body parts during catheter care. Also, based on random observation and interviews, the facility failed to provide privacy/confidentiality during medical/financial communication with Resident #13 in a common area of the facility. The findings included: The facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Prior to beginning catheter care on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 closed the corridor door and pulled the privacy curtain around the resident's bed. Observation revealed the resident lying in bed with a house dress pulled up to the epigastric area. A towel was positioned across the abdomen and perineal area. The resident's legs were bare to her/his ankles except for the disposable brief which was pulled down to the knees. Prior to the treatment, the CNA removed the towel drape and placed it below the resident's feet on the bed, exposing the resident from the epigastric area to the ankles. Resident #6 remained thusly exposed throughout the catheter care, perineal care, positioning on her/his left side, and cleansing of the buttocks and anal areas. The resident was then instructed to ""lie back"" which she/he did without assistance. Both staff then left the bedside with the resident exposed to wash their hands. They returned to the bedside and assisted the resident to replace the brief and pull down and snap the housedress in readiness to get out of bed. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 had not been draped appropriately during catheter care. During observation of catheter care on [DATE] at 3:32 PM, Licensed Practical Nurse (LPN) #1 removed the towel covering Resident #8's perineum leaving him exposed while she/he raised the bed to a workable height. Certified Nursing Assistant (CNA) #3 then performed catheter care. After removing her/his gloves and discarding them in the trash bag, CNA #3 left the bedside to wash her/his hands leaving the resident's perineum exposed. LPN #1 followed and observed while CNA #3 washed her/his hands. Upon returning to the bedside, CNA #3 said ""I am going to place the towel back over you"" and redraped the resident. During an interview on [DATE] at 9:18 AM, LPN #1 and CNA #3 verified Resident #8 had been left exposed while the bed was being raised and during handwashing. LPN #1 stated that she/he thought privacy had been afforded since the privacy curtain had been closed. Review of the policy provided by the facility entitled ""Competency, Catheter Care- Male"" on [DATE] at 3:42 PM revealed that once catheter care was completed, the procedure would be to ""...Remove gloves. Reposition residents clothing and cover. Wash hands"". Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 had been asked by a staff member to sign paper work allowing the facility to collect funds for room and board in a common area. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, ""I'm not going to sign any papers!"" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, ""Don't touch me!"" The staff member continued to ask her/him to sign the paper work with the resident tearfully yelling out ""No!"" Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A Certified Nursing Assistant (CNA) identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM, the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today the resident was not in a good mood. The OT stated that the resident would not sign the paper so, ""We thought it best to stop"". During an interview on [DATE] at 3:35 PM, the Social Services Director (SSD) and the Director of Nursing (DON) were present. The SSD stated that Resident #13 had exhausted her/his Medicare benefits and the facility needed funds in order for the resident to stay there. She/He stated that the resident's son needed a letter signed by the resident in order to have the bank release her/his funds. She/He stated that the resident had refused to sign the paper work for her/him, so therapy was asked to get the paper work signed since the resident was more comfortable with the therapy staff. The SSD stated that Resident #13 had ""Sundowners in the afternoon"" and that she/he discussed the funds matter with the resident this morning. They did not have the resident sign any papers. Instead, she/he stated they had the resident call the bank herself/himself in order to get the funds released. The SSD and DON were informed of concerns that the OT attempted to get Resident #13 to sign paper work related to her/his financial affairs in the dining room and did not provide privacy. The SSD verified that she/he had brought the resident to her/his office that morning to discuss the resident's financial matters and stated this was the usual practice.",2014-04-01
10131,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,241,D,,,8F5E11,"**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 promote care in a manner that maintained or enhanced dignity and respect. Staff failed to respect Resident #13's wishes to refuse to sign paperwork and terminate a conversation in a common area which resulted in increased agitation. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, ""I'm not going to sign any papers!"" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, ""Don't touch me!"" The staff member continued to ask her/him to sign the paperwork with the resident tearfully yelling out ""No!"" After the staff member left, Certified Nursing Assistant (CNA) #2 came and sat down next to the resident to talk to her/him. Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A CNA identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today she/he was not in a good mood. The OT stated that the resident would not sign the paper so, ""We thought it best to stop"". During an interview on [DATE] at 3:35 PM, the Social Services Director (SSD) and the Director of Nursing (DON) were present. The SSD stated that Resident #13 had exhausted her Medicare benefits and the facility needed funds in order for the resident to stay there. She/He stated that the resident's son needed a letter signed by the resident in order to have the bank release her/his funds. She/He stated that the resident had refused to sign the paper work for her/him, so therapy was asked to get the paper work signed since the resident was more comfortable with the therapy staff. The SSD stated that Resident #13 had ""Sundowners in the afternoon"" and that she/he discussed the funds matter with the resident this morning. They did not have the resident sign any papers. Instead, she/he stated they had the resident call the bank herself/himself in order to get the funds released. The SSD and DON were informed of concerns about the OT's continued attempts to get Resident #13 to sign the paper work after the resident clearly indicated she/he was not going to sign them and became increasingly agitated and upset. During an interview on [DATE] at 4:02 PM, the surveyor asked CNA #2 what she/he knew about the incident since she/he had been observed going in and out of the dining room the day before while the therapist was speaking with Resident #13. CNA #2 stated she/he had heard Resident #13 fussing with the therapist about signing papers. The CNA stated that the resident had been thinking that people are trying to steal her/his money. The CNA stated the resident's demeanor is usually pretty quiet during the day, but in the afternoon the resident gets upset and cries when approached. When asked about how long this had lasted yesterday afternoon, CNA #2 stated that the resident had been agitated for about ,[DATE] minutes before she/he calmed down. Cross Refer to F164 as it relates to failure of the facility to address personal issues with",2014-04-01
10132,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,157,D,,,8F5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to notify the responsible party (RP) of changes. For one of five residents reviewed for falls, Resident #3 had a family member who was not notified of a fall with injury. The findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/23/10 at 1:45 PM revealed Resident #3 sitting on her/his bed. She/He had a dark swollen area on her/his forehead along with yellow/black discolorations under her/his eyes. Record Review on 8/24/10 at 11:52 AM revealed Nurse's Notes dated ""8/11/10 5P(M) Resident asleep in high back chair + rolled onto floor. Has aprox(imately) 9 cm (centimeter) bruise to forehead. BP (Blood Pressure) 158/84, P(ulse)- 76, R(espirations)- 20, T(emperature)- 97.8. ROM (Range of Motion) (without) difficulty. Assisted to chair. Neuro (checks) WNL (within normal limits). No distress noted"". ""8/11/10 6 P(M) (Family member) called + notified of fall + injury."" ""8/11/10 6:15 P(M) Dr.__ notified on voice mail of fall + injury."" Review of the Incident/Accident Report on 8/24/10 revealed the following: ""Date of Incident/Accident: 8-11-10, Time of Incident/Accident: 5 PM, ...Name of Physician Notified: Dr. __, Date: 8/11/10, Time of Notification: 6:15 PM, Name and Relationship of Family Member/Resident Representative Notified: (Family Member), Date: 8/11/10, Time of Notification: 6 PM"". During a phone interview on 8/25/10 at 9:00 AM, Resident #3's family member stated that she/he would be the person who would be notified if the resident's condition changed. The family member went on to state that she/he came in to visit her/his family member one afternoon and found bruises on Resident #3's face. She/He had asked the staff what had happened, but they didn't know. She/He stated that there was a big fuss made because nothing had been documented about it, but that she/he was told that Resident #3 had fallen the night before. The family member stated she/he later received a call from the nurse who had been taking care of Resident #3 at the time of the incident, and was told that Resident #3 went to sleep in a chair without arms and had fallen out of the chair. She/He was unable to recall the date she/he had visited and found her/his family member with the injury. During an interview on 8/25/10 at 10:10 AM, Licensed Practical Nurse (LPN) # 3 stated she/he was aware of the incident and that the Assistant Director of Nursing (ADON) had been called to talk to the family member and had handled the situation. During an interview on 8/25/10 at 10:48 AM, the ADON stated she/he had spoken with the family member regarding the incident and verified that the family member had not been notified of the fall with injury. The ADON could not recall the date she/he had spoken with the family member about the incident. The ADON stated that she/he had called the nurse who had been on duty the evening of the incident and the nurse had stated she/he had been so busy that she/he didn't notify the family.",2014-04-01
10133,"MAJESTY HEALTH & REHAB OF EASLEY, LLC",425018,200 ANNE DRIVE,EASLEY,SC,29640,2010-08-25,309,D,,,8F5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide care and services as ordered by the Physician for 2 of 18 sampled residents reviewed. The facility failed to ensure that Resident #13, on anticoagulant therapy, did not receive [MEDICATION NAME] after the Physician ordered the medication held due to an elevated PT/INR ([MEDICATION NAME]/International Normalization Ratio). In addition, Resident #13 did not have Ted Hose applied as ordered. Resident #7 did not have a sling applied as ordered by the physician. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 8/24/10 at 9:36 AM revealed a laboratory (lab) report dated 5/17/10. The PT was 37.2 H(igh). The reference range was listed as 9.4-10.8 sec(onds). The INR was 3.9 H(igh). The reference range was listed as .9-1.2 with the suggested therapeutic INR range for venous [MEDICAL CONDITION] and [MEDICAL CONDITION] listed as 2.0-3.0. A handwritten note to the right of the page stated ""Dr. __: Hold [MEDICATION NAME]. Redraw PT/INR Thursday 5/20/10 and call to Dr. __during business hrs (hours) Thursday"". Review of the Physician's Telephone Orders on 8/24/10 at 12:42 revealed an order to ""Hold [MEDICATION NAME], Check PT/INR Thursday 5/20/10, Call results to Dr. __ during business hours Thursday"". The Physician's Telephone Order had been dated 5/17/10 and the time next to ""Signature of Nurse Receiving Order"" was 6:45 PM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] 5 mg (milligrams) (1) PO (By Mouth) (at) HS (Bedtime) 9P(M)"". The [MEDICATION NAME] had been initialed as having been given on 5/15/10, 5/16/10, and 5/17/10. The [MEDICATION NAME] had been held from 5/18/10 through 5/22/10 and had been discontinued on 5/23/10 according to the MAR indicated [REDACTED] During an interview on 8/24/10 at 3:45 PM, the Director of Nursing (DON) reviewed and verified the 5/17/10 PT/INR results, the Physician's Telephone Order dated 5/17/10 at 6:45 PM, and the MAR indicated [REDACTED]. Review of the laboratory reports and additional physician orders [REDACTED]. At that time the physician ordered Vitamin K to be given and a follow-up PT/INR to be drawn on 5/22/10, continue to ""hold [MEDICATION NAME], d/c (discontinue [MEDICATION NAME])"". The lab work on 5/22/10 was INR 3.19. Record review on 8/24/10 at 9:05 AM revealed cumulative physician's orders [REDACTED].M. OFF IN P.M. R/T (Related To) [MEDICAL CONDITION]"". Review of the Care Plan on 8/24/10 at 11:24 AM revealed ""TED hose as ordered"" as an approach for resident being ""At risk for complications r/t (related to) [MEDICAL CONDITION]"". Review of the 8/9/10 ""Easley Living Center"" progress note (signed by the Nurse Practitioner) on 8/24/10 at 9:30 AM revealed ""Her/His [MEDICATION NAME] was recently increased to 40 mg (milligrams) because she/he was having [MEDICAL CONDITION]"". Review of the 8/6/10 ""Easley Living Center"" progress note signed by the Physician revealed ""She does complain of some increased [MEDICAL CONDITION] in her left lower extremity, however. Nursing staff reports no major issues with this patient including any skin breakdown...Extremities: She does have 1+ [MEDICAL CONDITION] in that left lower extremity primarily in the dorsum of her left foot. Trace lower extremity [MEDICAL CONDITION] on the right...Regarding the lower extremity [MEDICAL CONDITION], we will increase her [MEDICATION NAME] up to 40 mg a day"". Observations on 8/24/10 at 10:25 AM, 11:48 AM, 12:27 PM, 1:52 PM, 4:00 PM, and 4:38 PM revealed Resident #13 sitting in her/his wheelchair wearing socks, but no TED hose. During an interview on 8/25/10 at approximately 10:20 AM, Licensed Practical Nurse (LPN) # 3 was told that there were observations made of Resident #13 without her/his TED hose on. LPN #3 reviewed and verified the cumulative Physician""s Orders for August 2010 and the resident's Care Plan which indicated the resident was to wear the Ted Hose. She/He also verified the Physician's progress notes that indicated the resident had [MEDICAL CONDITION]. LPN #4 joined the interview and was told that the resident had been observed without the ordered TED Hose. LPN #4 verified that she/he was the nurse that documented on the Treatment Record regarding the application of the TED Hose. The surveyor, LPN #3, and LPN #4 then reviewed the Treatment Record documentation for August 2010 in which the TED Hose had been initialed as having been worn on 8/24/10 and 8/25/10 for the 7-3 shift. When asked about the discrepancy between the Treatment Record documentation and the observations of the resident without her/his TED Hose, the nurse stated that she/he reminded the Certified Nursing Assistants (CNAs) to apply the TED Hose. When asked to go to check and see if the resident was currently wearing the TED Hose, LPN #4 stated that she/he was new and didn't know the residents well. She/He went on to say that if the resident was not in her/his room, then LPN #3 would have to point the resident out to her/him. Upon entry to the room, Resident #13 was lying on her/his bed. The nurse stated the resident would not be wearing TED Hose in bed, and staff usually kept the TED Hose on her/his wheelchair. There were no TED Hose on the wheelchair, and, while checking the bedside table and closet, the nurse stated the TED Hose was probably in the laundry being washed. When asked if the resident only had one pair of TED Hose, the nurse answered ""yes"". Resident #7 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7 had not worn a sling as ordered for all the days of the survey. Record Review on 8/23/10 at 3:48 PM revealed cumulative physician's orders [REDACTED].D. (Medical Doctor). O.K. to remove orthopedic device to left arm for ADL (Activities of Daily Living) Care"". Review of the Care Plan on 8/23/10 at 4:33 PM revealed ""Orthopedic device as ordered 7/13/10"" as an approach to impaired mobility. The following observations were made in which Resident #7 was not wearing the ordered sling. - On 8/23/10 at 1:52 PM. Resident sitting in the doorway of the therapy office. at 2:59 PM. Resident sitting in wheelchair in her room. at 6:22 PM. Resident sitting in wheelchair in her room eating dinner. - On 8/24/10 at 8:55 AM. Resident lying in bed. at 10:00 AM. Resident lying in bed participating in interview with surveyor. at 12:32 PM. Resident eating lunch in her room. -On 8/25/10 at 9:12 AM. Resident sitting in wheelchair in room. During an interview on 8/24/10 at 10:00 AM, Resident #7 was asked about the sling and why it wasn't being worn. The resident stated that at her/his last appointment, the orthopedic doctor told her/him that she/he could take it off. She/He stated that if the doctor wanted her to wear it, she/he would. When asked if staff encourage her/him to wear the sling, the resident stated that staff members haven't instructed her/him to wear it. Review of the consult section of the chart on 8/24/10 revealed no orthopedic notes. During an interview on 8/25/10 at 10:30 AM, Licensed Practical Nurse (LPN) #3 was asked about Resident #7's last orthopedic visit. The nurse checked the appointment calendar and stated the last orthopedic visit for Resident #7 was in July. When asked about any orthopedic progress notes, the nurse stated the physician only sent a note if there were any changes and verified there were no orthopedic notes in the chart. LPN #4 joined the interview and both nurses were told that Resident #7 had been observed on all days of the survey without her/his sling having been worn. The cumulative physician's orders [REDACTED]. Upon review of the Treatment Record for Resident #7 for August 2010, documentation for the dates of the survey were brought to the nurses attention. For August 23rd and 24th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7, 7-3, and 3-11 shifts. For August 25th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7 and 7-3 shifts. LPN #4 verified she/he was the nurse that documented on the Treatment Record regarding the use of the sling. When asked about the discrepancy between the surveyor observations and documentation on the Treatment Record, LPN #4 stated that she/he had been asking Physical Therapy (PT) if Resident #7 had been wearing her/his sling. LPN #4 stated she/he thought that PT had supplied the sling for the resident. The surveyor and LPN #4 then went to see Resident #7, who was not wearing the ordered sling.",2014-04-01
10134,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2010-12-20,224,G,,,5SHE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record reviews, interviews and review of the facility's Abuse and Neglect policy, the facility failed to assure 3 of 5 sampled residents were free from neglect. Resident #1 and #3's dressings were not changed per the physician's orders [REDACTED]. Resident #2's wound was observed to have a yellow center with dried blood. The findings included: Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. The Annual MDS coded Resident #1 as totally dependent for hygiene, bathing and toileting. Resident #1 was coded as needing extensive assistance with transfers, dressing and eating. No behaviors were coded as occurring during the assessment period. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. The interventions that were in place prior to the incident were ""abuse and neglect addressed 10/1/2010 by staff development coordinator."" The interventions taken by the facility to prevent future abuse were ""facility continues to stress no tolerance for abuse or neglect. Reeducation of staff on abuse/neglect."" LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she ""had done all of my treatments. I done (sic) some extra tx (treatment) on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse."" LPN #3's facility obtained statement dated 11/22/2010 stated, ""On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10."" Review of the care plan revealed ""Altered Skin Integrity"" as a problem area. Interventions and approaches included ""Tx (treatments)/dressings as ordered, Routine body audits, observe skin with care."" Review of the Nurses' Progress Notes dated 11/19/2010 indicated a ""tx to right foot continued, odor to right foot."" On 11/20/2010 at 1:10 AM, ""tx cont(inued) to R foot. Strong odor noted. Black areas noted on R foot."" The next nurse's note dated 11/23/2010 documented [MEDICATION NAME] sprinkles were ordered for the wound bed. Review of the Weekly Skin Evaluations revealed the resident's skin was assessed on 11/13/2010 with Right Foot and Sacrum receiving treatments. On 11/20/2010, the resident was assessed as having ""right foot dark toes and underneath. Draining with odor...treatment continued."" On 11/27/2010 the right foot with toes were ""black with odor."" Review of the physician's orders [REDACTED]."" The coccyx wound was to be cleaned with normal saline and ""apply santyl and cover with foam dressing everyday and as needed."" Review of the MAR from November 2010 revealed on 11/20/2010 and 11/21/2010, LPN #1 initialed the MAR indicated [REDACTED]. The facility admitted Resident #2 on 11/17/2010 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 12/20/2010 revealed the resident laying in bed. The resident had a [MEDICATION NAME] dressing on her lower right leg dated 12/06/2010. The wound bed was observed to be yellow with dried blood observed under the [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the medical record revealed no documentation related to the wound. The Unit Manager confirmed the presence of the yellow wound bed and dried blood. She assessed the wound after the surveyor brought the wound to the facility's attention and then provided appropriate treatment for [REDACTED]. The facility admitted Resident #3 on 03/05/2010 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 12/20/2010 revealed the resident lying in bed. The Resident had a Medi-honey strip on the lateral aspect of her lower leg. The Medi-honey was not covered with a [MEDICATION NAME] pad nor was the strip dated. The resident had a dressing on her left foot dated 12/17/2010. Review of the MAR indicated [REDACTED]. Another order for Medi-Honey to the top of the left foot and to cover with a [MEDICATION NAME] pad and to change daily. The treatments were last initialed as done on 12/17/2010. The Unit Manager confirmed that the dressings had not been changed since 12/17/2010. She assessed the wounds and performed the prescribed treatments. During a telephone interview on 12/20/2010, LPN #2 stated that she worked weekends from 7 PM to 7 AM. She stated that she was working the weekend of 12/18 and 12/19/2010. LPN #2 confirmed that she was assigned to Resident's #2 and #3. She stated that she did not change the dressing on Resident #3's foot on either 12/18 or 12/19. She stated that she ""just didn't do it."" LPN #2 stated that she was aware of the orders to change the dressings daily. LPN #2 also stated that if she noticed the dressings were not changed per the physician's orders [REDACTED]. She stated that she would not notify the unit manager or the Director of Nurses. LPN #2 stated she was aware that Resident #2 had a dressing on her right leg but did not notice that it was dated 12/06/2010. LPN #2 stated that she was unaware of any dressing changes for Resident #2's right leg. Three other LPN's were asked if they checked orders daily. All answered ""yes."" All 3 LPN's stated that during their daily assessments of the residents they check the dressings. All 3 stated that if the dressing was not changed per the physician's orders [REDACTED]. Three CNA's were interviewed; all three stated that they would notify the nurse immediately if a dressing was not in place or if there were any skin concerns. During an interview on 12/20/2010, the Director of Nurses (DON) stated that LPN #1 failed to change Resident #1's dressing as ordered. The DON stated that the LPN signed the treatment record. LPN #3 on 11/22/2010 reported to the unit manager that the dressings had not been changed. LPN #1 was suspended and an investigation was completed. Upon completion of the investigation it was determined that LPN #1 neglected Resident #1 and she was immediately terminated. Resident #1's dressings were immediately changed and her wounds assessed. The DON stated that all residents with dressings were assessed on 11/22/2010 with no other abnormal findings. The DON stated that weekly wound rounds were conducted with the DON as the lead and the unit managers. She stated that wound team evaluated the wounds including measurements and assured the treatments were appropriate. She stated that the floor nurses were responsible for changing the dressings on a daily basis. If there were any changes in the wounds, then the physician would be notified as well as a member of the wound team (a unit manager of the DON). The DON also confirmed the dressings on Resident #3's left leg and foot had not been changed since 12/17/2010. The DON confirmed the physician's orders [REDACTED]. The DON also confirmed that the dressing on Resident #2's right leg was dated 12/06/2010. She confirmed that the wound bed was yellow with dried blood. She stated that the dressing should have been changed on 12/11/2010 and 12/18/2010. The DON stated that anytime an allegation of abuse or neglect is made an inservice would be conducted that was mandatory for all staff. An inservice was conducted on Abuse and Neglect on 11/23/2010 regarding the allegation on 11/22/2010. Review of the inservice conducted on 11/23/2010 revealed that 13 nurses signed the attendance log and 20 CNA's signed the log. Review of the facility's employment record indicated that 41 nurses were employed and 72 CNA's were employed. The DON confirmed that not all licensed staff members attended the inservice. Review of the facility's policy on ""Abuse and Neglect"" revealed that ""it is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse... Abuse also includes those practices and omissions, neglect and misappropriation of resident property that left unchecked, lead to abuse. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.""",2014-04-01
10135,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2010-12-20,315,D,,,5SHE12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the follow up inspection based on observations, interviews and review of the facility policy on Peri (perineal)-care, Certified Nursing Assistant #1 failed to provide for the dignity of Resident #6 and failed to appropriately provide peri-care for Resident #6. One of two residents observed for peri-care. The findings include: The facility admitted Resident #6 on 12/18/2008 with [DIAGNOSES REDACTED]. During peri-care observation on 2/7/2011, CNA #1 was observed in Resident #6's room removing the resident's pants. The blinds were left open. The curtains were observed to be open as well. The resident's roommate was in bed awake. A grabber was observed in the bed lying along side the resident's left leg. The CNA exposed the resident and wiped the resident's groin and then wiped once down the middle. CNA #2 then closed the blinds and pulled the curtain. CNA #1 then retrieved a clean brief from the resident's closet using the soiled gloves. CNA #1 rolled the resident over onto the metal grabber and placed the clean brief under the resident. CNA #1 still using soiled gloves fastened the brief and dressed the resident. During an interview on 2/7/2011, CNA #1 stated that she did not close the blinds or pull the curtain to provide for the resident's dignity. She also stated that she ""forgot"" to clean the resident's bottom. CNA #1 confirmed that she did not change her gloves prior to placing a new brief on the resident. CNA #1 stated that she did not recall the last time she was checked off on peri-care competency. Review of the facility's plan of correction revealed that CNA#1 was checked off on competency on peri-care on 1/6/2011. No concerns were noted at that time. Review of the facility's policy on Peri-Care revealed the following:...""3. Provides for privacy. 17. Asks resident to lower legs and assume side lying position. Assists as necessary.""",2014-04-01
10136,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2010-12-20,314,G,,,5SHE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to 3 of 5 sampled resident's wounds. Resident #1 and #3 did not have their dressings changed as ordered. Resident #2 had a dressing on her right lower leg dated 12/6/2010; the dressing was observation on 12/20/2010. The findings included: The facility admitted Resident #1 on 5/5/2006 with [DIAGNOSES REDACTED]. Resident #1 sampled as a result of an incident reported by the facility on 11/24/2010 that indicated the facility substantiated neglect against Licensed Practical Nurse (LPN) #1 for failure to change Resident #1's dressings as ordered. Review of the facility's Five-Day Follow-Up Report dated 11/24/2010 indicated the facility substantiated neglect against LPN #1 for failure to change Resident #1's dressings as ordered. On 11/22/2010 LPN #3 removed dressings from Resident #1's coccyx and right inner ankle dated 11/19/2010; daily dressing changes were ordered. LPN #1's facility obtained statement dated 11/23/2010 indicated that she worked 7 AM to 7 PM the weekend of 11/20/2010 and 11/21/2010. LPN #1 documented that she ""had done all of my treatments. I done (sic) some extra tx on the opposite hall, and stayed over on Sunday night to make sure I had all of my tx done. I remember gathering the notes I wrote and the tx cart and going down the hall. I do recall doing the skin prep and the applying of the [MEDICATION NAME] to the resident's right foot and toes. I unintentionally must have looked over the inner ankle. I could have been thinking about the regular dressing I normally do on 7 p-7 a. I do understand that's no excuse."" LPN #3's facility obtained statement dated 11/22/2010 stated, ""On 11-22-10, I removed a foam drsg (dressing) and a bordered guaze from Res. (resident) coccyx and Rt (right) inner ankle. Both drsgs were dated 11-19-10."" Review of the physician's orders [REDACTED]."" The coccyx wound was to be cleaned with normal saline and ""apply santyl and cover with foam dressing everyday and as needed."" Review of the MAR from November 2010 revealed on 11/20/2010 and 11/21/2010, LPN #1 initialed the MAR indicated [REDACTED]. The facility admitted Resident #2 on 11/17/2010 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 12/20/2010 revealed the resident laying in bed. The resident had a [MEDICATION NAME] dressing on her lower right leg dated 12/6/2010. The wound bed was observed to be yellow with dried blood observed under the [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the medical record revealed no documentation related to the wound. The Unit Manager confirmed the presence of the yellow wound bed and dried blood. She assessed the wound after the surveyor brought the wound to the facility's attention and then provided an appropriate treatment for [REDACTED]. The facility admitted Resident #3 on 3/5/2010 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 12/20/2010 revealed the resident lying in bed. The Resident had a Medi-honey strip on the lateral aspect of her/his lower leg. The Medi-honey was not covered with a [MEDICATION NAME] pad nor was the strip dated. The resident had a dressing on her left foot dated 12/17/2010. Review of the MAR indicated [REDACTED]. Another order for Medi-Honey to the top of the left foot and to cover with a [MEDICATION NAME] pad and to change daily. The treatments were last initialed as done on 12/17/2010. The Unit Manager confirmed that the dressings had not been changed since 12/17/2010. She assessed the wounds and performed the ordered treatments. During a telephone interview on 12/20/2010, LPN #2 stated that she worked weekends from 7 PM to 7 AM. She stated that she was working the weekend of 12/18/2010 and 12/19/2010. LPN #2 confirmed that she was assigned to Resident's #2 and #3. She stated that she did not change the dressing on Resident #3's foot on either 12/18 or 12/19. She stated that she ""just didn't do it."" LPN #2 stated that she was aware of the orders to change the dressings daily. LPN #2 also stated that if she noticed the dressings were not changed per the physician's orders [REDACTED]. She stated that she would not notify the unit manager or the Director of Nurses. LPN #2 stated she was aware that Resident #2 had a dressing on her right leg but did not notice that it was dated 12/06/2010. LPN #2 stated that she was unaware of any dressing changes for Resident #2's right leg. During an interview on 12/20/2010, the Director of Nurses stated that LPN #1 failed to change Resident #1's dressing as ordered. The DON stated that the LPN signed the treatment record. The nurse on 11/22/2010 reported to the unit manager that the dressings had not been changed. She stated that the floor nurses were responsible for changing the dressings on a daily basis. If there were any changes in the wounds, then the physician would be notified as well as a member of the wound team (a unit manager of the DON). The DON also confirmed the dressings on Resident #3's left leg and foot had not been changed since 12/17/2010. The DON confirmed the physician's orders [REDACTED]. The DON also confirmed that the dressing on Resident #2's right leg was dated 12/06/2010. She confirmed that the wound bed was yellow with dried blood. She stated that the dressing should have been changed on 12/11/2010 and 12/18/2010.",2014-04-01
10137,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2010-12-15,502,D,,,OVIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on limited record review, and interview the facility failed to provide laboratory services to meet the needs of its residents in a timely manner for 1 of 3 residents reviewed for laboratory services. Resident #1 with documented [MEDICAL CONDITION] of the external genitalia; waist and legs had a physician's orders [REDACTED]. The CMP and BMP were not drawn. The findings included: Resident #1 admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed nurses' notes dated 10/06/2010 at 11:00 AM which stated, ""...increased [MEDICAL CONDITION] notified Dr. ... N.O. (new order) 40 mg (milligrams) [MEDICATION NAME] IM (intramuscularly) now then 80 mg [MEDICATION NAME] PO (by mouth) BID (twice a day) x 1 week then resume 80 mg [MEDICATION NAME] PO QD (daily), CMP BMP on 10-13-10..."" In a telephone interview with the Director of Nurses on 12/15/2010 at approximately 10:00 AM she stated that the CMP and BMP were not drawn, that she thinks the nurse who took the order failed to transfer it to a lab requisition.",2014-04-01
10138,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2010-12-15,157,G,,,OVIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on limited record review and interview the facility failed to consult the resident's physician regarding persistent pain and swelling following an injury to Resident #2 left arm/hand/wrist. The resident fell on [DATE], the facility notified the physician and an order was obtained for an x-ray of the hand/wrist. Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The findings included: Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: ""11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to ER (emergency room ) for evaluation... 12/03/2010 6 pm Resident readmitted with Dx (diagnosis) of Fx (fracture) to (L) wrist and UTI (urinary tract infection)..."" In an interview with the Director of Nurses on 12/13/2010 at approximately 4:10 PM she was unable to provide information as to why the physician was not notified about the persistent pain and swelling of the resident's left arm/wrist. She stated that the resident was treated for [REDACTED].",2014-04-01
10139,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2010-12-15,309,G,,,OVIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, interview and record review, the facility failed to provide care and services to maintain the highest practicable physical well being for 1 of 3 residents reviewed for a change in condition. Resident #2 injured her left arm/hand/wrist on 11/24/2010, and was not treated for [REDACTED]. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current medical record revealed Nurses' Notes with the following documentation: ""11/24/2010 3:02 PM Nurse called to Res. (resident) room. Res slided (sic) to floor by CNA. CNA was transferring Res. from w/c (wheelchair) to bed. CNA notes was slipping and gently placed res on floor with pillow under Res head.... Res assessed... 3:30 PM Redness and swelling noted to (R) (right) arm and wrist. Old Ecchymotic area noted on Extremity. Arm put on free floating pillows to decrease swelling and order obtained for mobile x-ray of (R) arm... 3:45 PM Mobile x-ray obtained x-ray... 2210 Mobile x-ray obtained r/t (related to) fall resulting to injury to (L) (left) arm waiting for results. (L) arm elevated on billow (sic). c/o (complaining of) pain medicated as ordered... 11/25/2010 3 P (M) Resident has swelling (L) forearm and bruising x-ray neg (negative) Fx (fracture) or dislocation mild [MEDICAL CONDITION] No return call. resident continues to c/o pain (L) forearm recs (receives) [MEDICATION NAME] for pain... 11/26/2010 7 P to 7 A (M) Arm bruised/swollen as well as hand R/T previous fall... 11/27/2010 3 p continues to c/o pain (L) arm. (L) arm elevated on pillow bruising to (L) forearm noted... 7 P - 7 A (L) arm/hand elevated on a pillow. Bruise and slight swelling remains the same due to last fall...Receives scheduled pain medication. 11/28/2010 11 A Resident continues to c/o pain (L) arm bruising and swelling to (L) arm. (L) arm elevated on pillow. Notified Dr. ... N.O. (new order) transport to ER (emergency room ) for evaluation... 12/03/2010 6 pm Resident readmitted with Dx (diagnosis) of Fx (fracture) to (L) wrist and UTI (urinary tract infection)..."" Review of the physician's orders [REDACTED]. Review of the Mobliex Radiology Report dated11/24/2010 at 5:01 pm stated, ""...Examination: Exam: Hand 2 views, Left - Results: ...No fracture or dislocation is seen. [MEDICAL CONDITION] is present...Conclusion: Moderate [MEDICAL CONDITION] of the left hand, but no fracture or dislocation seen..."" Review of the Beaufort Memorial Hospital Discharge Summary dated 12/03/2010 stated, ""...Reason for admission: ...The patient presented with left upper extremity cellulites and fracture... Hospital course: The patient was admitted and placed on IV [MEDICATION NAME] for cellulites..."" Review of the x-ray report revealed that only the hand was x-rayed and reported as negative for fracture. On 11/25/2010 a call was placed to the physician to notify him of the x-ray results, the physician did not return the call. The resident continued to complain of pain in the left arm/wrist and swelling/bruising was noted; on 11/28/2010 the physician was notified and the resident was sent to the hospital for evaluation. Resident #2 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. In an interview with the Director of Nurses on 12/13/2010 at approximately 4:10 PM she was unable to provide information as to why only the hand was x-rayed on 11/24/2010. She could not explain why the physician had not seen Resident #2 following the injury or why the physician was not notified about the persistent pain and swelling of the left arm/wrist.",2014-04-01
10140,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-01-14,250,E,,,JSXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection based on record review and interviews the facility failed to assure medically related social services were provided for one of five sampled residents. Resident #1 did not have his hearing aides replaced after the facility misplaced them. The social worker also had Resident #1 sign legal documents even though the resident was deemed incapacitated by two physicians. The findings included: The facility admitted Resident #1 on 4/16/2010 and readmitted him on 7/23/2010 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Review Date of 8/22/2010 indicated the resident had short-term memory problems and modified independence in decision making. No behaviors were documented as occurring within the assessment period. Review of the monthly summary dated 12/18/2010 revealed the resident had short-term memory problems. He was also noted to have disorganized thinking with moderately impaired abilities for decision making. The resident was noted to be verbally abusive and had delusions. Review of the resident's care plan revealed ""Cognitive Impairment as evidenced by short-term memory loss and confusion at times."" Review of the medical record revealed two Decisional Capacity forms. The first was signed by the Vascular Surgeon on 5/19/2010 and by the Attending Physician on 5/27/2010. The second form was signed by the Vascular Surgeon on 7/23/2010 and by the Attending Physician on 8/6/2010. Review of the record revealed that Resident #1's first hearing aide was lost in May and the second one was lost in early June 2010. A Certified Letter was sent to the Resident's first responsible party and to the resident's son on August 10, 2010. The letter included the ""Medicare Determination Notice, Community Long Term Care and a form regarding Resident #1's hearing aide replacement. On August 10, 2010 the Social Worker documented that she spoke with the resident's son and he stated, ""He was not signing anything."" Review of the Advance Notice Beneficiary Form, dated August 9, 2010 revealed the resident signed the form on August 12, 2010. Review of the Medicare Non Coverage Letter dated 8/9/2010 revealed the resident signed the form on 8/12/2010. Review of the form regarding the resident's hearing aide replacement revealed the resident signed the form on 8/12/2010. During an interview on 1/12/2011 at 4:15 PM, the Social Worker confirmed that Resident #1 was incapacitated and was unable to sign legal documents. She confirmed that the resident signed the Medicare Non-coverage Letter, the Advanced Notice to Beneficiary form and the hearing aide form. The Social Worker stated that she sent the forms to the son to sign. She stated that the son refused to sign and that he stated the Resident could sign for himself. The Social Worker stated that she informed the son that the resident was unable to sign legal papers because he was declared incapacitated by two physicians. The Social Worker stated that Resident #1 did not have a legal Power of Attorney and could not get one at the time because of his lack of capacity. The Social Worker stated that she informed the son he had to go through the probate court to obtain guardianship. The Social Worker stated that on August 12, 2010 the Social Worker and the Resident's son were in the resident's room. The son stated to the social worker that the resident could sign all the paperwork. The social worker then allowed the resident to sign the paperwork. She stated that she knew the resident was not supposed to sign but stated that she needed a signature on the paperwork. The court appointed Guardian Ad Litem on 11/12/2010 signed the legal form for the hearing aides again. As of 1/12/2011 the resident did not have hearing aides.",2014-04-01
10141,SUNNY ACRES,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2010-12-01,225,D,,,07P711,"On the day of the inspection, based on review of facility concern forms and interview, the facility failed to ensure that all allegations of misappropriation of resident property were reported to the State survey and certification agency for 2 of 2 allegations reviewed (Resident A). The findings included: Review of the concerns filed with facility administration since the last recertification survey revealed two allegations of misappropriation from Resident A. On 8/12/10, the resident reported $12.00 missing. Facility staff searched for the money but it was not found. The facility reimbursed the resident. On 9/1/10, Resident A reported $50.00 missing, two twenty dollar bills and other money totaling fifty dollars. A search revealed some one dollar bills in the resident's coat, but she stated this was not part of the $50.00 she had put in her purse. The facility reimbursed the resident by depositing the money in her fund account. The Administrator and Director of Nurses were asked at 4 PM on 12/1/10 if these allegations had been reported to the State survey and certification agency. After researching their files, no evidence was discovered to show the allegations of misappropriation of resident property were reported.",2014-04-01
10142,"GLORIFIED HEALTH AND REHAB OF GREENVILLE, LLC",425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2010-07-07,309,D,,,KOJZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide care and services as ordered by the physician. One of fourteen residents reviewed for care and services, Resident # 8, did not receive a follow-up with the oncologist to get biopsy results as ordered. The findings included: The facility admitted Resident # 8 on 6/14/10 with [DIAGNOSES REDACTED]. Record review on 7/6/10 at 2:30 PM of the accumulative physician's orders [REDACTED]. ___ (1) wk (week) for biopsy results"". Review of the Physician Discharge Summary dated 6/14/10 on 7/6/10 at 2:37 PM revealed under ""Hospital Course"", that Resident # 8 was admitted with AMS (Altered Mental Status) s/p (status [REDACTED]. [MEDICATION NAME] on 6/10 with ROSE (Rapid On-Site cytopathologic Examinations) revealing malignancy...Heme/Onc (Hematology/Oncology) was consulted and recommended breast mass biopsy. This was performed on 6/14 by general surgery and final pathology/results pending. (Resident #8) is scheduled to follow up with Dr. ___ in 1 week for these results and to initiate plan of care... (She/He)does need quick follow up for biopsy results with Heme/Onc as this looks like [MEDICAL CONDITION] from preliminary results. (She/He) may be a possible Hospice candidate given her PMH (Primary Medical History) of dementia and other co-morbid conditions"". Review of the Physician's Progress Notes, Nurses Notes, and Laboratory results on 7/6/10 revealed no mention of the breast mass biopsy results or an office visit. During an interview on 7/7/10 at 9:15 AM, RN (Registered Nurse) #1 reviewed the June 2010 accumulative physician's orders [REDACTED]. During an interview on 7/7/10 at 11:20 AM, Unit Clerk #1 was asked if they used an appointment calendar to keep track of residents' appointments. She/He stated that Resident #8's appointment was not on her calendar. When asked about how Resident #8 would have been transported to the appointment, she/he stated that EMS (Emergency Medical Systems) would transport Resident #8 to her/his appointment. She/He could not provide documentation that an ambulance was requested and stated that sometimes the ambulance service doesn't leave documentation. During an interview on 7/7/10 at 11:25 AM, RN #1 stated that Unit Clerk #1 had called the physician's office and that Resident #8 was in the system, but did not have an appointment. When asked about the process of how appointments are made for residents when they return from the hospital, RN #1 stated that the nurse takes off the orders and leaves a posting for the secretary to make an appointment for the resident. RN #1 stated that sometimes the secretary reads the notes from the hospital and goes ahead and makes the appointment. On 7/7/10 at 11:45 AM, when asked how the facility prevents appointments from being missed, RN #1 stated that the night nurse checks to make sure all orders are carried out. On 7/7/10 at 11:56 AM, RN #1 verified the breast mass biopsy results were not in the chart.",2014-04-01
10143,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2010-12-08,365,D,,,R42P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observations, the facility failed to provide food prepared in a form designed to meet individual needs for 1 of 3 sampled residents with an order for [REDACTED]. The findings included: The facility admitted Resident #14 on 4/28/08 with [DIAGNOSES REDACTED]. Review of the medical record on 12/07/10 revealed a current physician's orders [REDACTED]."" Review of the physician's telephone orders dated 11/19/10 indicated, ""D/C prev. diet. Mech (mechanical) soft, gr (ground) meats...for better tolerance."" Review of the Nurses Notes dated 11/19/10 at 1:00 PM indicated, ""Difficulty chewing pork chop at lunch - given gr mts (meats) (with) better tolerance."" Review of the Dietary Progress Notes dated 11/23/10 revealed, ""The resident's diet consistency was downgraded to mech soft (11/19/10)..."" Observation on 12/07/10 at approximately 12:30 PM revealed Resident #14 sitting at a table in the dining room in the process of eating lunch. Observation of the resident's plate revealed fish which was cut into pieces. Observation of the diet card on the lunch tray indicated, ""Diet regular Texture regular."" Observation on 12/07/10 at approximately 5:45 PM revealed Resident #14 resting in bed, and staff was observed to deliver the dinner tray to Resident #14's room. Observation revealed the dinner plate contained sliced roast beef with gravy, and observation of the tray card again revealed ""Diet regular Texture regular."" The surveyor asked Licensed Practical Nurse (LPN) #3 to review the current orders related to diet, and LPN #3 confirmed that the order was for ground meat. LPN #3 observed the dinner plate at that time and confirmed that Resident #14's meat was not ground. LPN #3 informed staff to hold the dinner plate and stated that another meal with ground meat would be obtained for Resident #14. On 12/08/10 at approximately 10:30 AM, LPN #3 was asked about the process of communicating diet orders to the dietary department. LPN #3 stated that staff complete a Diet Order Form upon receiving a dietary order. LPN #3 stated that the top copy of the Diet Order Form is filed on the medical record, the yellow copy of the form is sent to the Dietary Department, and the pink copy of the order form is sent to the pharmacy. LPN #3 stated that review of the medical record revealed staff failed to complete a Diet Order Form upon receipt of the diet change on 11/19/10; and therefore, the Dietary Department did not receive the diet change.",2014-04-01
10144,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2011-03-02,514,D,,,HLEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews and interviews, the facility failed to maintain accurate, complete, and organized clinical information about each resident that was readily accessible for resident care for 3 of 15 records reviewed for clinical records. For Resident #5 the documentation of allergies [REDACTED]. For Resident # 11 the MDS and Care Plan were not readily accessible and for Resident #7 the Care Plan was not readily accessible. The findings included: The facility admitted Resident #5 on 12/30/10 with the following [DIAGNOSES REDACTED]. The record review on 2/28/11 at 1:45 PM revealed that there were no current Physician order [REDACTED]. The only orders found on the resident's record were dated 12/2010. In an interview with Licensed Practical Nurse(LPN) #1 at that time, she was unable to state where the orders might be or to locate the current orders. The Admissions Director and Facility Consultant #1 attempted to locate the orders for January and February 2011, but were unable to locate the orders. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. While in the process of reviewing the record the MDS and Care Plan were also not found for this resident. LPN #1 was interviewed and did not know where the documentation could be found. The Admissions Director, Director of Nurses, and Consultant #1 all pursued locating the information within the facility. After 3 hours the MDS was not located and a copy had to be printed for the surveyor. At that time the Care Plan was located and provided. The record review on 2/28/11 also revealed a sticker on the front of the chart which stated ""allergies [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""No Known allergies [REDACTED]. The facility admitted Resident #7 on 3/13/07 with the following [DIAGNOSES REDACTED]. Record review on 3/1/11 at 9:10 AM revealed that the Care Plan could not be located and when LPN #1 was questioned she stated she thought the Care Plan was located with the MDS in the file cabinet. The Care Plans were in a separate area and the Admissions Director had to locate the Care Plan for the surveyor and provided it about 2 hours later. The facility admitted Resident # 11 on 12/17/10 with the following [DIAGNOSES REDACTED]. During the record review on 3/1/11 at 8:35 AM the MDS was not in the file and the Care Plan was not available. The Admissions Director had to assist the surveyor in locating the MDS and Care Plan for this resident and it was an hour before it could be located for review.",2014-04-01
10145,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2011-03-02,250,E,,,HLEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interview, the facility failed to provide documented evidence that sufficient medically-related social services were provided to meet the needs of 3 of 12 sampled residents reviewed for social services. Resident # 6 experienced a significant personal loss and expressed suicidal thoughts, which were addressed by the physician in 2/2011. The last documented social service intervention was November 2010. Resident # 8 had a planned discharge which was to occur on 3/1/11. The resident left unexpectedly on 2/28/11. There was no evidence of the anticipated discharge plans/interventions documented by social services. Resident # 24's social service noted did not include an accurate description of the resident's behaviors, the room change with subsequent change in social work providers, or behavior interventions. The findings included: The facility admitted Resident #6 on 3/24/10 with [DIAGNOSES REDACTED]. A review of the medical record revealed a Physician's progress note dated 2/24/11 that the resident had lost her husband of [AGE] years recently. A follow-up note dated 2/25/11 documented the resident was seen and that grief and tearfulness was normal as a reaction to loss of her husband. A nursing note dated 2/24/11 documented indicated that the resident had stated ""I just want to die"" during the morning medication pass. Medicine for increased anxiety was given and the resident seemed to be calmer after the nurse talked to her for a while. The Responsible party was notified and she was going to visit. Follow-up monitoring dated 2/27 revealed no signs or symptoms of depression. Documentation by the Facility psychiatrist dated 3/1/11 revealed that the resident was seen. Group therapy and receiving activity out of the facility was discussed. The resident felt very positive about the opportunity to get out and about the opportunity to socialize with new people. The psychiatrist also addressed the vaguely suicidal comments and concluded there was no suicidal ideation and certainly no intent. A review of the Social Service notes revealed no entries since November 2010. In an interview with Social Worker (SW) #2 on 3/1/11 at 1:55 PM, she stated she had made a referral to Senior Renewal for outpatient counseling and that group therapy had been done. She also stated she did room rounds every morning to check on her residents, but these interventions were not documented in her notes on this resident. The Social Service notes did not mention the resident's spouse dying. An entry by Social Worker #2 dated 3/1/11 documented that she had spoken to nursing about the statement ""I just want to die. It was not reported to her due to the fact that the resident was calmer after receiving the medicine for anxiety. A 3/2/11 note documented that the resident was out of the facility from 9:30-1:30 at Senior Renewal. The facility admitted Resident #8 on 12/22/10 with [DIAGNOSES REDACTED]. Resident #8 was admitted for short term rehabilitation. During the Initial Tour it was mentioned the resident was due to be discharged on [DATE] but left on 2/28/11. Review of the Social Worker notes revealed her last note was dated 12/22/10 with no further documentation related to discharge planning. In an interview with SW (Social Worker) #2 on 3/1/11 at 1:55 PM, she stated that the resident went home with his sister-in-law instead of living by himself. Home Health was contacted to do an evaluation. The prescriptions were given to his sister-in-law, but the Social Worker had not documented the discharge planning interventions in the Social Services notes . A final nursing note dated 2/28/11 documented the ""res(ident) d/c (discharged at 2:15 P with all meds (medications) and order for referral to home health. MD notified of d/c. All meds explained. BA (body audit) complete. No new areas noted."" The facility admitted Resident #24 on 1/28/10 with [DIAGNOSES REDACTED]. During initial tour of the facility on 2/28/11, the ADON (Assistant Director of Nursing) stated that the resident was diagnosed with [REDACTED]. Record review revealed a Social Services note dated 10/21/10 which stated that the resident has been referred to Senior Renewal Program to address behaviors and will be able to attend ""when the foot heals from sprain."" Further notations in the Social Services notes for 11/3/10 states ""Annual Assessment....... Referral has been made to ""Senior Renewal"", which is an out patient counseling service provided by.....She is eligible for this service but had to be able to make transfers from W/C ( wheel chair) to toilet appropriately before she can attend the program."" Another note from Social Services dated 11/15/10 stated ""Resident returned to facility on 11/13/10, returned medicare...."" Additional notes were written on 11/16 related to a medication change; 11/22 related to diet changes and behavior; 11/23/10 related to a room change. The additional November documentation did not address follow up participation of the Senior Renewal program. There was no social service progress notes from 11/23 to 2/4/11 which addressed the resident's participation eligibility in the program. An interview with Social Worker #1 on 3/1/11 at 4:15 PM revealed that the resident had been referred to the above mentioned program. The consent from the family was not obtained in a timely manner. The resident then had been admitted to the hospital and returned to the facility under Medicare and could not attend the program while on Medicare. She further stated that they once again are waiting for the family to sign the consent forms. This surveyor then obtained the medical record for Resident #24 from the nurses station on 3/1/11 at 5:00 PM and noted that there was an additional notation in the Social Services notes dated 2/25/11 which had not been there prior to the 4:15 PM interview with Social Worker #1. An interview was done at 5:15 PM with Social Worker #1, the Administrator and several Corporate Consultants. Social Worker #1 confirmed that she had just written the note and asked if she should have put todays date for the note. The note addressed sending the family a consent form and waiting for a response. Resident #25 was admitted by the facility on 10/08/09 with the following [DIAGNOSES REDACTED]. On 3/1/11 at 4:45 PM Resident #25 stopped a fell ow surveyor in the hall and reported that Resident #24 exhibited behaviors in the dining room and used profanity. In an interview with Resident #25 on 3/2/11 at 9:05 AM she further explained that Resident #24 ""scares me to death"" when she ""takes over"" in the dining room and it takes ""four to handle (her) sometimes... she (Resident #24) tries to fight and I have to leave."" She stated that Resident #24 has ""never hurt me"". During an interview with Social Worker #1 on 3/2/11 at 11:30 AM, she stated that the facility had tried some behavior modification programs with Resident # 24 but they were not effective. When questioned about the resident's behaviors, she stated that the ADON (Assistant Director of Nursing) had very good communication skills with the resident and could deal with her behaviors. She further stated that Social Worker #2 was working with this resident up until her room change on 11/23/10. Social Worker #1 shared that the resident had been seen by the Psychiatrist on 2/8, 2/15, 2/17 and 2/22/11. An accurate description of the resident's behaviors, the room change with subsequent change in social work providers, nor any of the above mentioned interventions were noted by Social Worker #1 or #2 in the documentation. She stated that it should have been documented in the notes what was being done for the resident.",2014-04-01
10146,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2010-12-01,225,D,,,DFSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, interview, review of the facility's grievance log and review of the facility's policy on Abuse and Neglect, the facility failed to report an injury of unknown origin. On 10/14/2010 a large, dark purple bruise was noted on Resident #5's back and left side of his chest; he was unable to state how the injury happened. There was no documentation to indicate the facility reported the incident as an injury of unknown origin. (1 of 5 sampled residents reviewed) The findings included: The facility admitted Resident #5 on 2/07/2009 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS (Minimum Data Set) dated 7/12/2010 indicated the resident had no memory problems with moderately impaired cognitive skills for daily decision-making. Review of the Nurses' Note dated 10/14/10 at 1:30 PM stated, ""large dark purple bruise note L (left) side of chest and back. Res (resident) stated, I don't know it happened..."" Review of the ""Incident/Accident Report"" form signed 10/18/2010 revealed a date of 10/15/2010 as the date a large, dark purple bruise was noted on the left side of the chest and back of Resident #5. The incident report included the statement, ""I don't know what happened."" There was no documentation that a referral was made to the State Survey Agency. An interview on 12/01/2010 at approximately 10:38 PM with the Administrator and Director of Nursing (DON) confirmed the findings. The Administrator stated they did not feel the bruises were significant enough to make a report. The Administrator further stated it was the facility practice to determine the cause of the bruise instead of reporting.",2014-04-01
10147,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2011-01-26,279,D,,,M3RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review, the facility failed to ensure that comprehensive care plans were developed to describe the safety services to be furnished to residents for 2 of 3 residents reviewed who had repeated falls (Residents #1 and #2). The findings included: Resident #1, with [DIAGNOSES REDACTED]. Review of the resident assessments of 11/2/10 and 11/26/10 showed the resident needed total care from the staff with his activities of daily living. The resident did not ambulate. The resident was discharged home with his daughter on 12/20/10 as planned. Review of the medical record revealed the resident fell on [DATE] at 11:30 AM. He was found on the day room floor, sitting in front of the wheelchair. It appeared that he slipped out of the chair. A non slip product was added to the wheelchair seat to prevent further similar occurrences. At 12 noon on 10/30/10, staff coming from the day room heard a noise and they found the resident lying on his right side on the floor. No injuries were assessed. A tab safety alarm was added to his safety precautions. Documentation in the nurses' notes revealed the resident made multiple attempts to get up unassisted on two days. The nurse's note on 11/2/10 at 11:35 AM noted frequent attempts by the resident to get out of his chair. The tab alarm was in place. The 11/20/10 nurse's note at 3:20 PM stated the resident made multiple attempts to get out of his chair and so was assisted back to bed with no further attempts to get up unassisted. The resident's last fall, on 12/12/10 at 6:40 AM, occurred in the day room. Review of the facility's documentation revealed the resident was up early that morning and placed in the day room. The nurse heard a loud noise coming from the day room and found the resident face down on the floor with the wheelchair tipped over, bleeding from a laceration above his right eye. The resident received emergency treatment and returned to the facility. Review of the Certified Nursing Assistant (CNA) Cardex, which was undated, completed in pencil, and not part of the resident's permanent medical record showed the resident needed: padded L shaped calf support; Roho (anti-thrust) cushion with Dycem (non-slip material) underneath; tab alarm to the wheelchair; and a bed sensor alarm. On 12/13/10 the following note was added: ""Don't leave unattended while up and OOB (out of bed)."" The CNA Cardex showed the resident transferred with assist of two or mechanical lift. Review of the physical therapy note of 11/1/10 showed ""(change) transfer status from Hoyer (mechanical) to (A) X 2 (assist with two people)."" Review of the Cardex computerized printout, also not a permanent part of the medical record, showed the resident's tab alarm on the 11/3/10, 11/10/10, and 11/17/10 weekly printout. On 12/1/10, the form listed the resident's tab alarm and included an anti-thrust cushion, calf pad, and sensor alarm to the bed. The 12/8/10 printout showed the tab alarm, the calf pad, a gel cushion with Dycem, and the sensor alarm. Review of the resident's care plan dated 11/3/10 showed a problem of ""At risk for falls related to: Dependency on staff for transfers"" and ""Hx (history) of fall."" The facility's planned approaches to assist the resident with this problem were: ""1. Give needed assist with transfers. ""2. Encourage resident to call for assistance as needed. ""3. Monitor for changes needed in transfer techniques and update therapy for recommendations. ""4. Review any falls for patterns. ""5. Safety devices as indicated."" The care plan did not specify which safety measures were needed or how the resident was to transfer. An update to the care plan on 12/12/10, after the resident's fall, did show the tab alarm to the wheelchair, cushion change, and to keep the resident in sight of staff by nurses' station. Resident #2 with [DIAGNOSES REDACTED]. The resident was also noted to be able to turn off her safety alarm. A nurse's note on 10/10/10 stated the bed alarm was moved out of the resident's reach because of this. The resident's last fall was on 1/10/11 at 7:10 AM. She yelled for help from the bathroom. Staff found her sitting on the floor. The resident's alarm was not on at the time. Review of the CNA Cardex showed interventions of hipsters as tolerated, chair alarm, sensor alarm to the bed, anti-roll back brakes, and gel cushion with Dycem. The plan of care for the resident dated 1/11/11 showed she was at risk for falls due to poor safety awareness and dementia. Approaches listed were: 1. Monitor attempts to stand or ambulate without assistance 2. Review falls for needed changes in care plan No #3 listed 4. Inform therapy of falls for assessment 5. Safe, well lit, clutter free environment 6. Call light and belongings in reach 7. Encourage non-skid footwear 8. Monitor gait and assist with transfer and ambulation 9. Monitor medications for side effects related to unsteady gait 10. Encourage participation in ADLs (activities of daily living) 11. Anti-roll back brakes 12. Cushion armrest to wheelchair 13. Alarm to bed as indicated.",2014-04-01
10148,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2011-01-26,323,D,,,M3RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review, interviews, and review of the facility's investigative materials related to a fall with serious injury, the facility failed to ensure residents received adequate supervision and assistance devices for 1 of 3 residents reviewed for falls (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. Review of the resident assessments of 11/2/10 and 11/26/10 showed the resident needed total care from the staff with his activities of daily living. The resident did not ambulate. The resident was discharged home with his daughter on 12/20/10 as planned. Review of the resident's interim care plan dated 10/26/10 showed the resident at risk for falls related to weakness, poor endurance, and a new environment. Review of the medical record revealed the resident fell on [DATE] at 11:30 AM. He was found on the day room floor, sitting in front of the wheelchair. It appeared that he slipped out of the chair. A non slip product was added to the wheelchair seat to prevent further similar occurrences per the nurse's note. At 12 noon on 10/30/10, staff coming from the day room heard a noise and the staff found the resident lying on his right side on the floor. No injuries were assessed. The post fall assessment by physical therapy recommended a tab safety alarm on the wheelchair. A nurse's note on 11/2/10 stated ""... Tab alarm in place."" Sporadic nurses' notes after that date stated the alarm was in place. The care plan dated 11/3/10 showed a problem of ""At risk for falls related to: Dependency on staff for transfers"" and ""Hx (history) of fall."" The facility's planned approaches to assist the resident with this problem were: ""1. Give needed assist with transfers. ""2. Encourage resident to call for assistance as needed. ""3. Monitor for changes needed in transfer techniques and update therapy for recommendations. ""4. Review any falls for patterns. ""5. Safety devices as indicated."" Documentation in the nurses' notes revealed the resident made multiple attempts to get up unassisted on two days. The nurse's note on 11/2/10 at 11:35 AM noted frequent attempts by the resident to get out of his chair. The tab alarm was in place. The 11/20/10 nurse's note at 3:20 PM stated the resident made multiple attempts to get out of his chair and was assisted back to bed with no further attempts to get up unassisted. The resident's last fall, on 12/12/10 at 6:40 AM, occurred in the day room. Review of the facility's documentation revealed the resident was up early that morning and placed in the day room. The nurse heard a loud noise coming from the day room and found the resident face down on the floor with the wheelchair tipped over. The resident was bleeding from a laceration above his right eye. He received emergency treatment and returned to the facility. The care plan was updated on 12/12/10 to show the fall, the tab alarm, wheelchair cushion, and to keep the resident in a supervised location when up in the wheelchair. Review of the Physical Therapy notes showed a post fall assessment on 12/13/10 recommending all alarms be on and active. Another recommendation was that the resident be supervised when in the wheelchair. The 12/15/10 note said the resident had improved in strength and ability to assist in his activities of daily living and this may have made him feel he could try to get up unassisted. The facility's investigation, and an interview with the 11-7 Certified Nursing Assistant (CNA) who got the resident up that morning, revealed the tab alarm was not in place on the morning of 12/12/10. Although the tab alarm was not ordered by the physician or part of the resident's care plan, the facility assessed that it was needed for the resident's safety. Review of the medical record showed occasional nurse's notes stating the resident's alarm was in place. There was no other documentation, by nurses or CNAs, to show the alarms were used on a consistent basis.",2014-04-01
10149,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2011-01-19,279,E,,,988C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a Comprehensive Plan of Care which reflected the residents' current status of 3 of 7 sampled residents reviewed for Comprehensive Plan of Care. Resident #4 and Resident #6 did not have an Initial Plan of Care to address [MEDICAL TREATMENT]. Resident #1 did not have an Initial Plan of Care to address a Foley Catheter. The findings included: The facility admitted Resident #1 on 01-08-11 with [DIAGNOSES REDACTED]. Record review on 01-18-11 at 5:15 PM of the Daily Physician order [REDACTED]. Additional record review on 01-19-11 at 3:30 PM of the Initial Plan of Care dated 01-08-11 revealed an Initial Plan of Care for a Foley Catheter had not been developed. During an interview on 01-19-11 at 5:17 PM with Registered Nurse (RN) #1, she, after record review, verified an Initial Plan of Care for a Foley Catheter had not been developed. The facility admitted Resident #06 on 12-29-10 with [DIAGNOSES REDACTED]. Record review on 01-19-11 at 4:00 PM of the Daily Physician order [REDACTED].d.)"". Additional record review on 01-19-11 at approximately 4:00 PM of the Initial Plan of Care dated 12-29-10 and updated on 01-11-11 revealed a Plan of Care for [MEDICAL TREATMENT] had not been developed. During an interview on 01-19-11 at 6:00 PM with RN #1, she, after record review, verified a Plan of Care for [MEDICAL TREATMENT] hd not been developed. The facility admitted Resident #4 on 12/24/10 with [DIAGNOSES REDACTED]. Review of the medical record on 1/18/11 revealed Resident #4 received [MEDICAL TREATMENT] treatment three times weekly. Further record review revealed the care plan for Resident #4 did not include [MEDICAL TREATMENT] treatment as a problem area and did not include any treatment objectives or medical care areas related to [MEDICAL TREATMENT] treatment that reflect the standards of current professional practice. This information was shared with the Minimum Data Set (MDS) Coordinator on 1/19/11 at approximately 4:30 PM at which time the MDS Coordinator confirmed the care plan did not address [MEDICAL TREATMENT] treatment for [REDACTED].",2014-04-01
10150,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2011-01-19,280,D,,,988C11,"**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 a plan of care to ensure care needs were met for 2 of 7 resident care plans reviewed. The care plans for Resident #3 and Resident #4 were not revised and updated after both residents were placed on contact precautions. The findings included: The facility admitted Resident #4 on 12/24/10 with [DIAGNOSES REDACTED]. Review of the medical record on 1/18/11 revealed a physician's orders [REDACTED]."" Further record review revealed a positive culture screen for [MEDICATION NAME] Resistant [MEDICATION NAME] reported on 1/08/11. Review of the care plan indicated the care plan was last updated on 1/06/11. The care plan was not reviewed and revised to include Contact Precautions as a problem area after the positive culture and physician's orders [REDACTED]. This information was shared with the Minimum Data Set (MDS) Coordinator on 1/19/11 at approximately 4:30 PM at which time the MDS Coordinator confirmed the care plan was not revised to include Contact Precautions following the 1/08/11 culture screen. The facility admitted Resident #3 on 12/31/10 with [DIAGNOSES REDACTED]. Record review on 1/18/11 revealed that the resident had been placed on Contact Isolation on 1/3/11 and that a care plan for infection/isolation had not been developed. An interview with Licensed Practical Nurse #2 on 1/18/11 at 6:05 PM revealed that if the [DIAGNOSES REDACTED]. An interview with the Care Plan Coordinator on 1/19/11 at 6:30 PM confirmed that a care plan had not been developed to reflect that Resident #3 had been placed on Contact Precautions.",2014-04-01
10151,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2011-01-19,502,E,,,988C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to follow a procedure to ensure that expired laboratory testing supplies were not stored with other laboratory testing supplies available for resident testing in 1 of 1 nursing station. The findings included: On [DATE] at 4:10 PM, observation of a cabinet located behind the nursing station revealed 59 - 6.0 ml BD pink top Vacutainer which expired ,[DATE]. During the observation, Licensed Practical Nurse(LPN) #3 verified that the Vacutainer had expired. During an interview with LPN #1 on [DATE] at 4:55 PM, she stated that nurses were responsible for maintaining in- date Vacutainer and that the cabinet was checked weekly. LPN #1 could not provide documentation which confirmed the weekly checks. During the interview, LPN #1 also confirmed that staff does draw blood samples for testing.",2014-04-01
10152,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,371,F,,,4V0311,"**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 discard 28 cartons of milk which were expired in the resident's refrigerator in the day room. There was an additional observation of the resident's refrigerator not functioning for six (6) hours on the last day of the survey. In addition, the facility failed to discard nine (9) cans of nutritional supplements that had expired in a cabinet in the nurses station. The findings included: On 2/6/12 at approximately 5:30 PM during observation of the residents refrigerator, three Tru Moo one percent low fat chocolate milk and seven Pet skim milk were found with the expiration date of February 3, 2012. Nine (9) Pet whole milk and nine (9) Pet skim milk were found with the expiration date of February 5, 2012. On 2/7/12 at approximately 9:30 AM, the surveyor observed that the expired milk remained in the residents refrigerator in the day area. Review of the refrigerator cleaning schedule states: ""All items are dated and labeled properly, free of all expired items, and temperatures grafted daily. Further review of the schedule revealed the Month of February 2012 was checked off daily. On 2/7/12 at approximately 10:20 AM, Food Service Director verified that the milk was expired. Through interview the Food Service Director stated, "" Dietary Aides do the in and outs in the resident's refrigerator. The in and out policy is to put old to front and new to the back."" On 2/8/12 at approximately 9:25 AM, the surveyor observed the Speech Language Pathologist Director opening the residents refrigerator to get milk for a resident and the interior light did not come on. Following the observation the surveyor checked the temperature of the refrigerator which read 46 degrees Farenheit and freezer which read 38 degrees Farenheit. Noting the temperature of the freezer, the surveyor checked the ice cream cup which was soft and runny. On 2/8/12 at approximately 2:15 PM, there was an observation of two Certified Nursing Assistants getting ice cream cups for residents, following the observation the surveyor checked the temperatures of the the freezer which read 42 degrees Farenheit and the refrigerator which read 49 degrees Farenheit. On 2/8/12 at approximate 2:30 PM, review of the Daily Temperature log did not indicate the actual temperature taken in the Month of February. On 2/8/12 at approximately 3:30 PM, the Director of Nursing and Administrator verified that the residents refrigerator was not functioning. Through interview the Administrator stated ""we will get maintenance to look at the refrigerator."" On 2/7/12 at 7:50 AM, during inspection of the storage cabinets in the nursing station, 7- 237 milliliters cans of [MEDICATION NAME] 1.2 High Protein Nutrition with an expiration of 2/1/12 were found. In addition, 2 cans [MEDICATION NAME] Specialized Nutrition containing 237 milliliters each were found with an expiration date of 2/1/12. During an interview on 2/7/12 at 8:07 AM, the Director of Nursing (DON) confirmed the presence of the expired nutritional supplements. The DON stated that Dietary Services was responsible for checking the expiration dates, usually once a week. She further stated that the nurses do not check expiration dates. At 10:24 AM on 2/7/12, the Director of Dietary Services stated that Dietary Services does not stock the nutritional supplements or check expiration dates of the supplements. He further stated that he thought that the Purchasing Department was responsible for stocking and checking expiration dates of the nutritional supplements and stated he would have the Director of Purchasing from the main hospital contact the surveyor. At the time of the exit, the Director of Purchasing had not contacted the surveyor.",2014-04-01
10153,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,463,E,,,4V0311,"On the days of the survey, based on observation and interview, the facility failed to ensure the safety of residents by not having resident call systems equipped in two of four common area restrooms which were accessible to residents. The findings included: During a general observation of the environment on 2/6/12 and throughout the days of the survey, observations were made of two restrooms that were unlocked and with no call system in place for residents use. The restrooms were located on the opening of the hallway across from the Physical Therapy and Activity area. Residents who were able to ambulate and propel themselves independently resided at the facility. During an interview on 2/8/12 at approximately 3:35 PM, the Administrator verified the restrooms were accessible to the residents and that there were no call systems in place.",2014-04-01
10154,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,323,D,,,4V0311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observation of Room 910 revealed hazardous objects stored on opening shelving in the resident's room. The findings included: The facility admitted Resident #7 on 2/03/12 with [DIAGNOSES REDACTED]. During a tour of resident rooms on 2/07/12 at approximately 10:30 AM, Resident #7 was observed in his/her wheelchair in the hallway. After Resident #7 entered his/her room, the surveyor entered the room and talked briefly with the resident. While in the room, observation of the open shelves on the wall near the resident's bathroom revealed two clear boxes containing multiple bronze/gold-colored small objects. Observation of the end of one of the boxes revealed the word ""Ammunition"" among the wording on the box. At that point, the resident informed the surveyor that the boxes were his ammunition and that they were a birthday gift. After informing the Director of Nursing (DON) and Administrator of these findings, the surveyor accompanied the DON to the resident's room, and the DON observed the boxes of ammunition. After talking with the resident, the DON informed the resident that the ammunition would need to be removed from the room for safety reasons. After removing the boxes of ammunition from the room, it was determined that the two boxes contained a total of 100 bullets. The DON and Administrator confirmed that the ammunition was given to the resident as a gift while the resident was in the hospital for surgery. Further investigation was necessary to assure that the resident was not in possession of a firearm. Review of the medical record revealed no Inventory of Personal Items list was completed upon admission to the facility. In addition, the hazardous objects stored on the open shelving were not observed/identified until brought to the staff's attention by the surveyor.",2014-04-01
10155,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,309,E,,,4V0311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, review of the policy entitled [MEDICAL TREATMENT] and interview, the facility failed to consistently document checking for thrill and bruit of the arteriovenous (AV) graft for Resident #1 used for his [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #1 on 12/26/11 with [DIAGNOSES REDACTED]. Record review of the nurses notes on 2/8/12 revealed the nurses had not consistently documented checking for thrill and bruit of the resident's AV graft. The record review revealed that the thrill and bruit had not been documented for a total of 22 days since the resident's admission to the facility. On 20 days there was documentation of a positive thrill and bruit and there was one day for which no documentation could be found. After sharing this information with the Director of Nursing, the facility did not dispute the findings or provide any additional documentation that the thrill and bruit had been checked. On 2/8/12 review of the facility's policy entitled [MEDICAL TREATMENT] in the section designated as ""Post-[MEDICAL TREATMENT] Nursing Responsibilities"" revealed...""Assess and document status of access site every four hours and prn (as needed)."" At that time the Director of Nursing verified that the policy did not specifically address checking for thrill and bruit of an AV graft for residents receiving [MEDICAL TREATMENT].",2014-04-01
10156,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,314,D,,,4V0311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and review of the facility's policy entitled Dressing Changes, the facility failed to provide necessary treatment and services to promote healing and prevent infection for Resident # 1, 1 of 1 residents reviewed for wound care. The findings included: The facility admitted Resident #1 on 12/26/11 with [DIAGNOSES REDACTED]. On 2/8/12 at 9:49 AM, Licensed Practical Nurse (LPN) #2 was observed performing wound care to 5 wounds for Resident #1. After explaining the procedure to the resident, setting up her supplies and clean field, the LPN cut and removed the soiled dressing from the left knee wound. She removed her gloves, washed her hands and donned clean gloves. She then obtained a non-adherent dressing from a shelf on the wall and opened it. She sprayed the periwound with wound cleanser and rubbed around the periwound several times. She then sprayed the wound bed with wound cleanser and dabbed the bed several times right to left then back from left to right. She applied the clean dressing and applied tape. The LPN then removed the dressing from a posterior lower leg wound and discarded the soiled dressing. She removed her gloves, washed her hands and donned clean gloves. She then removed the soiled outer dressing from the anterior foot and heel of the left foot and discarded them. LPN # 2 sprayed wound cleanser on the periwound and cleaned the medial, lateral and distal periwound areas with several wipes without turning the gauze. Wound cleanser was then sprayed on the wound bed, and the LPN dabbed the wound bed with gauze 3 times, went beyond the wound margin into the periwound area then back into the wound bed. A clean gauze was moistened with Normal Saline and applied to the wound bed and a dry gauze was placed over the moist gauze. She removed her gloves washed her hands and donned clean gloves. The soiled inner dressing from the left heel was removed and discarded. LPN # 2 removed her gloves, washed her hands and donned gloves. The LPN sprayed the periwound with wound cleanser and wiped the medial periwound twice, sprayed wound cleanser onto the same area of the gauze and wiped the lateral periwound 3 times. She sprayed the wound bed with the cleanser and wiped 5 times with the same gauze without turning it, left to right and top to bottom, then place a normal saline moist gauze in the wound bed, covered it with the clean dressing and wrapped the foot with Kerlix gauze. She removed her gloves, washed her hands, and donned clean gloves. The LPN then sprayed the posterior lower leg periwound with wound cleanser, wiped the medial periwound and around to the proximal wound twice then 3 times on the lateral periwound and around to the distal area. With a clean gauze she cleaned the periwound a second time wiping the lateral area twice and around the bottom and then back and forth on the medial periwound. She sprayed the wound bed with cleanser and with a clean gauze wiped back and forth 4 times. A normal saline moist gauze was placed in the wound bed, covered with a dry gauze and secured it with tape. The LPN did not change gloves at this time but opened the resident's brief, removed the soiled dressing from the penis and discarded it. She then removed her gloves, washed her hands and donned clean gloves. She obtained an additional package of gauze from the shelf on the wall and opened it. She moistened a gauze with normal saline and wiped the periwound and shaft of the penis 10 times then wiped the periwound 2 more times. The wound bed was cleaned with a normal saline moist gauze with 2 wipes. LPN # 2 then turned the gauze and wiped 6 more times in the wound bed. The LPN then applied Saf Gel to a clean gauze, applied it to the wound bed, placed a dry gauze over that and wrapped with a second dry gauze and secured with tape. The LPN did not change gloves after cleaning any of the wounds before applying the clean dressings. Review of the facility's policy, Dressing Changes, revealed, in the section labeled ""Procedure"", ...5. Don Clean gloves. 6. Place water proof pad under affected area. 7. Clean wound thoroughly. Pat dry with guaze sponge. 8. Remove gloves and don a clean pair. 9. Apply topical medication ointment as ordered to wound bed and/or periwound area. 10. Apply dressing per physician order [REDACTED]. During an interview at 2:29 PM on 2/8/12, the LPN stated she had ""tried to be extra careful"" since she was being observed. She stated she thought ""some gentle scrubbing would be required"" to clean the wound bed. She further stated that she did not think she needed to change gloves between cleaning the wound and applying the clean dressing. The LPN stated that it had not been intentional to go out side the wound bed and into the periwound area when she had cleaned the wound bed. In addition, she confirmed that she had left the posterior lower extremity wound open while she did the dressing changes to the top of the left foot and the left heel. During an interview on 2/8/12 at 3:03 PM, the the Director of Nursing confirmed that the LPN should have changed her gloves after cleaning the wound prior to applying the clean dressing. She also confirmed it was inappropriate to go over the same area of the wound bed with the same gauze and verified the standard of practice is to clean a wound bed in a circular motion from the center outward in one continuous motion. In addition, the DON also confirmed the posterior wound should not have been left open while the dressings were being changed to the foot.",2014-04-01
10157,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2012-02-08,332,D,,,4V0311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record reviews, the facility failed to maintain a medication error rate less that 5 per cent. The facility had 2 errors out of 40 opportunities for error resulting in an error rate of 5.0 per cent. The findings included: Error #1: On 2/6/12 at 4:49 PM, Registered Nurse (RN) #1 was observed during the Medication Pass. RN #1 removed 2 [MEDICATION NAME] ([MEDICATION NAME]) 40 milligram (mg) tablets in single dose packs from the Pyxis machine and the dose of the tablets was confirmed by the surveyor. She verified that the dose to be administered was 40 mg. in the Medication Administration Record (MAR) and in the electronic record in the Pyxis. This was confirmed by the surveyor at that time. She continued to Resident #2's room and opened both single dose unit packs and placed the tablets into the souffle cup. She informed the resident that she was giving him 40 mg. of [MEDICATION NAME] and handed him the souffle cup. The surveyor stopped RN #1 at that time from administering the medication. Review of the Discharge Medication Reconciliation Orders Form from the hospital, signed by the physician, revealed the order was for [MEDICATION NAME] 40 mg. 1 tablet by mouth every AM and every PM. During an interview at that time, RN #1 confirmed that she had two 40 mg tablets in the souffle cup for administration and that it was double the amount ordered to be administered. During an interview on 2/7/12 at 8:15 AM, the Director of Nursing confirmed the order was written for [MEDICATION NAME] 40 mg. 1 tablet every AM and every PM. She stated she would have expected the nurse to check the dose of the medication when it was removed from the Pyxis drawer, check it against the MAR and again in the resident's room. Error #2: During observation of the medication pass on 2/7/12 at 9:04 AM, Licensed Practical Nurse (LPN) # 1 withdrew 0.11 milliliters (ml) of [MEDICATION NAME] 20,000 units per 1 ml. into a syringe and administered it into Resident A's right upper arm. Review of the Daily Physician order [REDACTED]."" At 9:55 AM, the LPN confirmed that she gave the incorrect dose of [MEDICATION NAME]. She stated she ""was having difficulty seeing the markings"" on the syringe but required cues from the surveyor to calculate the appropriate amount that needed to be administered. During an interview on 2/7/12, the Director of Nursing stated that if the nurse was having difficulty reading the markings on the syringe, she would have expected the nurse to have one of the other nurses check behind her to ensure the correct dose was administered.",2014-04-01
10158,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2013-03-07,371,F,,,375T11,"On the days of the survey, based on random observations and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Multiple concerns were identified related to cleanliness, food storage, and the lack of appropriate hair restraints. The findings included: During initial tour of the kitchen area on 3/5/13 at 9:30 AM with the Manager of Dining and Kitchen, the following items were observed: the main oven had dark brown dried substances inside the ovens; cabinets, carts, and ovens had a grease-like film on the outside; carts had debre' inside the carts; multiple pans were stored wet on the dry rack; a small cooler by the tray line had multiple racks of food that were unlabeled or undated; the reach in cooler had multiple pans of food unlabeled and undated; the walk-in cooler had 4 pans of jello undated; 1 container of food labeled with date 2/27/13 was outdated; salad items in containers that were uncovered and undated on a cart in the walk-in cooler; trash and debre' noted under racks near the walls of the walk-in cooler and freezer. It was also noted the kitchen floor had a heavy grease build-up; there was no trash can with a pedal by the handwashing sink; a large uncovered trash barrel near the tray line and a deep fryer with very dark oil and crumbs floating on top of the oil. The Manager verified the deep fryer could not have been cleaned on Sunday as per the cleaning schedule. There were bags of grapes stored in the walk-in cooler not sealed. One kitchen employee had hair not completely covered by a hairnet, and two male employees had beards not covered. The Manager confirmed each of the items noted above.",2014-04-01
10159,CAROLINAS HOSP SYS TRANS CARE,425177,121 EAST CEDAR STREET,FLORENCE,SC,29501,2013-03-07,520,F,,,375T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility's Quality Assessment and Assurance Program failed to develop and implement appropriate steps to correct identified quality deficiencies concerning ongoing issues related to the dietary department. The findings included: On 3/6/13 at approximately 1:30 PM Registered Nurse (RN) #1, who was identified as the Quality Assessment and Assurance Program (QAA) contact by the Administrator, was asked by the surveyor if there were any ongoing QAA that identified issues related to the kitchen. His/her response was ""Yes"" and stated he/she would get the information. On 3/6/13 at 4 PM the Manager of Dining and Kitchen Services gave the surveyor a 2012 Quality Improvement Plan for Food & Nutrition Services 4th Quarter Report. The report identified: Indicator, Goal, Results, and Outcome / Plan. On 3/7/13 at 9:41 AM the Administrator gave the surveyor Carolinas Hospital System Food & Nutrition 2012 4th Quarter for ""Monitor: Patients will receive meals that are accurate and served at the correct temperature"", ""Food & Nutrition will maintain a clean and safe environment at all"", and ""Patients receiving [MEDICATION NAME] nutrition will meet ASPEN Guidelines for appropriateness"". The Goal and Results for both 2012 Quality Improvement Plan for Food & Nutrition Services 4th Quarter Report and Carolinas Hospital System Food & Nutrition 2012 4th Quarter were written in percentages and had a completion date of ""Ongoing monitor, ""Ongoing weekly monitor"", or ""Ongoing monthly monitor"". On 3/7/13 at 9:35 AM RN #1 provided the facility policy on QAA. The QAA for the Transitional Care Unit (TCU) states ""The Transitional Care Unit Participates with the Quality Improvement Program of Carolinas Hospital System (CHS). TCU adheres to the policies of CHS in regard to Program Improvement and Quality Assurance and Assessment. RN #1 delivered the Plan for Organizational Improvement for Department Generating Policy ""Quality Improvement"" and stated that it was the hospitals QAA policy. The CHS Quality Improvement (QI) policy section XII defines the procedural steps for the QAA process as ""Plan, Design, Measure, Assess, Improve"". The facility was unable to produce a QAA in progress, for ongoing kitchen deficiencies, that fulfilled their policy requirements. Neither the The Goal and Results for both 2012 Quality Improvement Plan for Food & Nutrition Services 4th Quarter Report nor Carolinas Hospital System Food & Nutrition 2012 4th Quarter identified the deficiencies and their root cause, developed nor described a plan of action, defined how they would monitor that plan of action, included a goal date for review for monitoring the effectiveness of the plan of action, or define how revisions would be implemented when the plan of action was found ineffective.",2014-04-01
10160,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-01-13,281,E,,,EE4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interviews and review of the facility's policy on ""Venous Access Devices,"" the facility failed to assure the nursing staff provided the appropriate interventions for Resident #1's peripherally inserted central catheter (PICC) line (one of two residents sampled with a PICC line.) The facility also failed to assure a newly admitted resident had a written plan of care to meet the needs of that resident. Resident #1's interim care plan did not include his PICC line, his leg wounds or his extensive activities of daily living (ADL) requirements. The findings included: The facility admitted Resident #1 on 2/28/2010 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 3/7/2010 revealed the resident had no short term or long-term memory problems and was independent in decision-making. The MDS documented the resident as having repetitive verbal complaints and was verbally abusive 1-3 days within the assessment period. The MDS also coded the resident as needing extensive assistance with transfers, toileting and bathing. The resident was coded as totally dependent for ambulation on and off the units and was totally dependent for toileting. The resident was coded as frequently incontinent of bowel and bladder. The resident was also coded as have a Stage III ulcer. Review of the Interim Care Plan revealed no problem areas related to his PICC his wound or his need for extensive assistance related to his activities of daily living. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation that the PICC line was flushed every 12 hours. However the resident was receiving antibiotics once daily through the PICC line. Review of the facility's policy on ""Venous Access Devices"" revealed PICC lines should be flushed a minimum of every 12 hours. The dressing should be changed every 7 days if an occlusive dressing was used, the dressing should be changed every 48 hours if gauze was used. During an interview on 11/9/2010, Resident #1's spouse stated that she saw the dressing change to the PICC line once. She stated that she observed blood under the dressing but was unsure how long the blood had been there. Two staff Registered Nurses were interviewed, both stated that PICC lines were to be flushed with normal saline twice a day and the dressings were to be changed once a week. During an interview on 1/13/2011, the Administrator confirmed the interim care plan did not include the resident's PICC line, the lower extremity ulcer or the need for extensive assistance with ADL's. The Administrator stated that the interim care plan should have included the above. The Administrator also confirmed that there was no documentation related to the PICC line flushes. The Administrator stated that the PICC line dressing should be changed every 7 days. He confirmed that the resident's PICC line dressing was not changed timely. The Administrator confirmed the policy was not followed related to the resident's PICC line.",2014-04-01
10161,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-01-13,314,D,,,EE4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on observations, interviews, record review and review of the facility's policy on ""Treatment Changes,"" the facility failed to provide the necessary care and services to 2 of 5 sampled residents. Resident #1 did not have the dressing changed per the physician's orders [REDACTED]. Resident #4 also did not receive appropriate wound care to her bilateral lower extremities. The findings included: The facility admitted Resident #1 on 2/28/2010 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date of 3/7/2010 revealed the resident had no short term or long-term memory problems and was independent in decision making. The MDS documented the resident as having repetitive verbal complaints and was verbally abusive 1-3 days within the assessment period. The MDS also coded the resident as needing extensive assistance with transfers, toileting and bathing. The resident was coded as totally dependent for ambulation on and off the units and was totally dependent for toileting. The resident was coded as frequently incontinent of bowel and bladder. The resident was also coded as have a Stage III ulcer. Review of the Physician order [REDACTED]. To the right leg, clean with wound cleanser, apply Mesalt to wound and then wrap leg with ace bandage, change every day and as needed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the wound care notes revealed a ""Skin Alteration"" record for the Right leg first dated 2/28/2010. The wound was noted to be 10 cm by 10 cm by 3 cm deep, with a moderate amount of serous drainage and [MEDICAL CONDITION]. No odor was noted. The next note was dated 3/8/2010, the wound was noted to be 2.3 cm by 2.3 cm by 0.1 cm deep, a scant amount of slough was noted, a scant amount of serous drainage was documented and no foul odor. Review of the Physician's Progress Notes revealed an entry dated 3/5/2010 that documented the resident had a ""small open wound on the pretibial region of his right lower leg. It measures approximately 0.5 to 0.2 cm. The wound bed is pale pink. It is moist and stippled with nonviable slough. There was no odor."" Review of the nurses notes dated 3/5/2010 at 10:45 AM revealed the following entry: ""writer in to change dressing to bilat (eral) lower legs. Res (ident) had visitors and explained to writer that the figure eight wrappings were too tight. Stated that he has a family member that was a nurse practitioner that wrapped his legs last pm...Requested that wraps be left in place because the family nurse practitioner would be back to re-wrap his legs tomorrow. Writer paged attending for building to discuss concerns...Discussed need for some pressure to lower extremities...bilateral lower extremities weeping clear fluid, writer cleansed wound to right lower ext with wound cleanser wound bed noted to be 40% slough and 60 % pink. No complaints of pain or discomfort...pulses checked in lower ext, present and strong bilaterally."" During an interview on 11/9/2010, Resident #1's spouse stated that family member's changed Resident #1's dressings frequently because of his weeping legs. The spouse stated that there was a foul odor when she changed the dressings. During an interview on 1/13/2011 the Administrator confirmed the dressing was not changed on 3/6/2010. The facility admitted Resident #4 on 12/31/2010 with [DIAGNOSES REDACTED]. Observation of wound care on 1/13/2011 revealed the following: Registered Nurse #1 removed the left leg dressing and then the right leg dressing without cleaning the scissors or cleansing his hands in between the removal of the dressings. No dressings were noted under the Kerlix gauze wraps. The left leg was noted to have deep crevices and nodules from the knee down to the ankle. The foot was also noted to have deep crevices. A non draining, dark red/black pressure ulcer was noted to the left heel. The left big toe bony prominence was noted to be red with an approximately 1 cm scabbed area in the center. RN #1 was observed to use saline wipes and wipe up and down the leg and foot repeatedly with the same wipe. RN #1, without cleansing his hands, proceeded to clean the right leg the same way (repeatedly wiping with the same cloth). RN #1 used skin prep to the heel area. Then he proceeded to put [MEDICATION NAME] onto his gloved hands and rub it into both legs. RN #1 sanitized his hands and donned new gloves; he then put [MEDICATION NAME] cream onto his fingertips and rubbed the medicine onto the resident's legs, using the same finger for multiple areas and on both legs without cleansing his hands. RN #1 was asked what the treatment to the bony prominence of the left toe was; he stated, ""skin prep."" However RN #1 failed to apply any treatment to the bony prominence. RN #1 cleansed his hands and applied new gloves. He wrapped the right leg with Kerlix and used soiled scissors to cut the excess. Without sanitizing his hands, he then placed a [MEDICATION NAME] pad on the left heel and wrapped the left leg with Kerlix; RN #1 used the soiled scissors again to cut the excess gauze. During an interview on 1/13/2011 at 4:25 PM, RN #1 confirmed that he did not apply any treatment to the bony prominence of the left big toe. He confirmed that he performed the dressing change on both legs at the same time. RN #1 confirmed he repeatedly wiped the wounds with the same cloth. He stated that he knew he should have kept the wounds separate and stated that he should have done ""one swipe one cloth."" He confirmed that he did not use an applicator for the medications and confirmed that he used the same finger on multiple areas on both legs. RN #1 also confirmed he did not clean the scissors in between the clean and dirty parts of the dressing change. Review of the facility's policy on ""Treatment Change"" revealed ""dressing removed, gloves removed, hands washed, clean field established...treatment performed with out contaminating dressing supplies...cleanse wound per order, remove gloves and wash hands, apply dressing as ordered, remove gloves and perform hand hygiene."" Review of the Skin Worksheets revealed the resident had only one performed since her admission on 12/31/2010. The Worksheet was not dated, however the administrator and staff nurses stated that the audits were completed on the resident's shower days and the Worksheet was from Monday, January 10, 2011. The Worksheet indicated the abnormal area to the left big toe. Further review of the medical record (including wound notes, physician orders, progress notes, PUSH tool, skin alteration records, Medication Administration Records and nurses notes) revealed no documentation of the wound or any treatment to the bony prominence. The resident's Braden Scale was assessed as ""Low Risk."" The Pressure Ulcer Healing Chart dated 12/31/2010 and 01/06/2011 documented the wound to the left heel. Wound Nurse notes dated 12/31/2010 and 01/06/2011 described the wound to the left heel as a ""blister area...measures 2.5 cm (centimeters) x 2.5 cm. order for skin prep to (L) heel 2 x/day (twice per day)"". There was no documentation regarding the left big toe bony prominence. The resident's was also noted to always wear her shoes, even to sleep. During an interview on 1/13/2011, RN #1 confirmed no treatment had been done to the left bony prominence of the big toe. The Administrator confirmed the undated Skin Worksheet identifying the abnormal area on the left big toe. The Administrator also confirmed there was no documentation or treatment ordered related to the area. The Administrator stated that the nurses should have documented the area in the medical record and obtained an order for [REDACTED].",2014-04-01
10162,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,281,K,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies for Change of Condition and Laboratory Services, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.20 F-281 at a scope and severity of ""K"", starting 9/12/10. The facility Nursing staff repeatedly failed to identify a delay in the receipt of laboratory tests and subsequently failed to contact the attending physicians in a timely manner to obtain further medical direction for the assessment, monitoring and treatment of [REDACTED]. Residents # 1, 4, 5, 6, 7, 14, 15, 21,and 29 were 9 of 22 sampled residents reviewed for professional standards related to physician notification of laboratory results who were found to be affected by the deficient practice. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for ""Sputum Culture today"" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no follow-up to ensure that the results were received and called to the physician in a timely manner. She also reviewed the medical record and could locate no evidence that the physician was ever notified of the results which showed ""pseudomonas aeruginosa 2+"" and the gram stain with ""many"" positive rods and ""many"" white blood cells. Further review revealed that a weekly PT ([MEDICATION NAME])/INR (International Normalization Ratio) was done and the report available to the facility on [DATE] via computer. The lab report noted that the resident was currently ""on 2 mg [MEDICATION NAME]"" and was faxed to the physician on 11-3-10 (2 days later). The PT was 12.9 seconds with a reference range of 10.0 to 13.0. The INR ratio was 1.0 L(ow) with a reference range of 2.0-3.0. The physician wrote an order on the lab report on 11-4-10 to ""Please ^ (increase) to 3 mg"". This order was transcribed onto a Physician's Interim Order form on 11-5-10. During an interview on 12-15-10 at 8:50 AM, Licensed Practical Nurse #4 reviewed the medical record and confirmed that the [MEDICATION NAME] was not increased until 11-5-10 based on the 11-1-10 PT/INR results. There was no documentation that the nursing staff identified the delay in contacting the physician and initiated corrective action. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 12/13/10 revealed the resident had a Urine Culture and Sensitivity obtained on 9/16/10. The resident was started empirically on Bactrim on 9/17/10. Per the lab result, a report of the lab was available on 9/18/10 which indicated the resident had an E-Coli infection which was not sensitive to the Bactrim as ordered. Review of the nurses notes revealed on 9/20/10 the resident expressed to the nursing staff that she thought the Bactrim was ""not strong enough to cure UTI"" (urinary tract infection). On 9/21/10 the resident complained of burning all over and asked to go to the emergency room . The resident returned from the emergency with a new order for Keflex for 10 days and a [DIAGNOSES REDACTED]. There was no documentation that the facility tried to access the lab result after 48 hours, or attempted to access the result once the resident complained of not feeling better. On 12/14/10 during an interview with the ADON (Assistant Director of Nursing) who was also the Unit Manager she stated that just because the lab result was available in the computer did not mean the facility could access the information. She then called the lab to learn that if the report indicated the result was available it would indeed be available in the computer for the facility staff to access. There was no explanation provided by the Assistant Director of Nursing as to why there was a delay in the receipt of the lab result or fax to the physician. The resident was not included on the audit log on the nursing unit for monitoring for the return of the result or physician notification. Resident # 15 was admitted on [DATE]. A PT/INR ([MEDICATION NAME] time/International normalized ratio) was obtained on 11/29/10. The lab report indicated that the result was available on 11/29/10. The report was faxed to the facility on [DATE] and the physician notified on 12/1/10 who ordered for the [MEDICATION NAME] to be held one day on 12/1/10. The result of the [MEDICATION NAME] was 27.0 (high) and INR 3.4 (high) Resident # 15 had a urine culture obtained on 11/19/10. The lab report indicated the result was available on on 11/21/10. A physician order [REDACTED]. There was no indication that the nursing staff followed the facility protocol for lab services or questioned the delay in treatment for [REDACTED]. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review of laboratory reports it was found that a sputum culture was done on 6/10/10 with a report date of 6/12/10. The results were not faxed to the Physician until 6/15/10 at which time the resident was [MEDICATION NAME] mg PO BID for 5 days for a Pseudomonas infection. A Pro-Time of 10/18/10 with a report date of 10/18/10 was not sent to the Physician until 10/21/10 . The result of the lab test was a [MEDICATION NAME] time 18.6 (high) and 1.8 (low). A Pro-time was drawn on 11/1/10 with a report date of 11/1/10 . The result of the test was 21.3 (high) and 2.3. The physician was faxed the results on 11/3/10. There was no documentation found that nursing identified the delay in treatment. The facility admitted Resident # 7 on 11-23-10 with [DIAGNOSES REDACTED]. On 12-13-10 at approximately 11:30 AM, review of the Medical Record revealed that the resident was on an anticoagulant therapy. Review of the physicians orders revealed the following order dated 12-6-10: ""^ (increase) [MEDICATION NAME] to 7 mg (milligrams) Q (every) day. INR on Friday 12/10/10"". Further review revealed that no labs had been drawn for Resident # 7 on Friday 12-10-10. Licensed Practical Nurse (LPN # 2) confirmed that the lab had not been written in the log book, nor drawn on 12-10-10. A new lab order was written on 12/13/10 after it was brought to the attention of the staff by the surveyor. The results revealed a low INR of 1.1 ratio. The results were faxed to the physician at 8:10 PM on 12-13-10, and new orders were put in place to begin on 12-14-10. The delay of treatment was 4 days. The facility admitted Resident #4 on 7/26/10. The resident was being maintained on bedrest with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed the resident to be on [MEDICATION NAME] Therapy requiring PT/INR's ([MEDICATION NAME] Time/ International Normalization Ratio) to be drawn routinely. Further record review revealed the labs were drawn timely; however, copies of the lab results did not return timely to the facility nor were they found to have been acted upon timely. Resident #4 had anticoagulant monitoring labs drawn on 8/24/10 which were not called to the Doctor until 8/26/10 when an order was received to increase the [MEDICATION NAME] dose. A PT/INR done and reported on 9/2710 was not received by the facility until 10/21. There was no order change required for this lab. On 10/11 a PT/INR was drawn and reported. and faxed to the physician on 10/13. On 10/25/10 a PT/INR was drawn and results available on 10/25/10. There were three fax dates noted on the report. (10/29/10, 11/1/10, and 11/2/10). On 11/210 the physician faxed an order to the facility to increase the [MEDICATION NAME] dose to 4 milligrams. This was not transcribed to a telephone order nor started until 11/5/10. During an interview with RN #1 (Registered Nurse), the nurse showed this surveyor an audit form that was being used to track labs. However, check marks were only placed if report was faxed, placed in folder, or phone call made to Physician. Some sheets only had the dates reports were received and dates reports were placed in the chart. No follow-up was done by the nurses if a report had been delayed to ascertain the result or the reason why the lab was delayed. The lab test for the 10/25/10 PT/INR for Resident #4 was not been listed on the audit sheet as confirmed by RN #1. The facility admitted Resident #5 on 8/26/09 and readmitted the resident on 11/17/10 with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed a lab report for a Complete Blood Count (CBC) and a Basic Metabolic Profile (BMP) drawn on 2/08/10. Iron studies were not ordered until 2/14/10 based on the result of the lab of 2/8/10. CBC and BMP were done and reported to the facility on [DATE] with multiple abnormal values noted. The lab report documented an unsuccessful attempt to fax the report to the physician. There was no evidence of subsequent follow up. On 12/14/10, Registered Nurse # 1 was unable to provide an explanation. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 ""complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the ""sputum culture was obtained from resp(iratory) therapist."" On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. The physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for intravenous antibiotics (IV) for ""[MEDICAL CONDITION]."" On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and intramuscular (IM) [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, ""new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum."" Review of the Physician's Telephone Orders revealed the following: 11/29/2010, ""Sputum C&S""; 12/7/2010 ""Send to ER (emergency room ) for increased temperature""; 12/7/2010 "" [MEDICATION NAME] 1 gram IV every day for 10 days"". 12/8/2010 ""DC(discontinue) [MEDICATION NAME] and [MEDICATION NAME] mg (milligrams) BID(twice a day), [MEDICATION NAME] 120 mg IM for 7 days""; 12/9/2010 "" airborne precautions, move to room [ROOM NUMBER]"". Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes revealed the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility notified the the Attending Physician on 12/8/2010, two days after receipt of the report. On 12/8/2010 the antibiotic treatment was altered for Resident #21 because [MEDICAL CONDITION] was not sensitive to the current treatment. There was no documentation noted that the nursing staff followed up to assure the timely receipt of the culture, which resulted in the resident not being place on appropriate transmission based precautions in a timely manner. The resident resided in a room with three other residents at high risk for infection related to cormorbidities. The facility admitted Resident #29 on 1/2/2010 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The results of the culture were made available to the facility on [DATE]. The physician was not notified of the positive culture until 11/15/2010. Further review revealed a PT/INR dated 10/11/2010 was available the same day and the physician was not notified until 10/13/2010. An additional PT/INR was available to the facility on [DATE], with physician notification occurring on the 28th . A PT/INR was dated 11/1/2010 and the results were available to the facility on [DATE] but the physician was not notified until 11/3/2010. During an interview the Nurse Manager from Station II, confirmed the delay in obtaining the culture results from 11/30/2010 for Resident #21 and confirmed the delay in notification for the culture and PT/INR results for Resident #29. She stated that normally cultures take 2-3 days to report. She stated that it was the nurses' responsibility to call and check on the results if they were delayed. The nurse stated that the lab normally faxed over the results when they were available. Lab results were also available through the computer. The Nurse Manager stated that the fax machine was located in the business office or the Admissions office, both of which were locked after 5 PM and on weekends. She/he stated that if a lab was faxed on the weekend, the nurses would not receive the results until the following Monday. If the lab was faxed after 5 PM, the nurses would receive the results the next day. The Nurse Manager confirmed that there had been a two day delay in notifying the physician of [MEDICAL CONDITION] positive culture. She stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for [MEDICAL CONDITION] pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview,a representative from the contract Lab stated that sputum cultures take 1-2 days to report. She/he stated that all cultures were sent to --- Hospital. She stated that if there was a delay in obtaining the results that a lab tech would call the hospital to check on the results. She stated that no documentation of the phone calls were kept. The Lab tech stated that the facility had access to the lab results on the computer and the results were available to the facility on the date reported. She also stated that a fax was automatically generated and sent to the facility upon report of the lab. She stated that there was no confirmation receipt kept for specific lab reports. During an interview, the Director of Nursing confirmed the delay in obtaining the culture report and confirmed the delays in reporting the result to the physician for both Resident #21 and #29. She/he also stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. The facility provided policy entitled Change of Condition Care Guard Program stated on page 2 of 3...: ""With the patient/resident's medical record in front of you and the documented assessment on the Change of Condition Nurses Notes form verbally report patient/resident's status to the physician and provide detailed description of the observed signs and symptoms, and any laboratory and or radiology test results that have been obtained."" The facility provided policy entitled Laboratory Services: Procedure for processing page 2 of 2 (1/99) stated...""The nurse will screen the reports for abnormal results and document the follow up as needed."" The facility Administrator and two Corporate Nurse Consultants were present on 12/14/10 at 10:30AM when advised by the Team Leader that Immediate Jeopardy and Substandard Quality of Care had been identified by the survey team as existing in the facility on 9/12/10 after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-04-01
10163,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,505,K,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.75 F-505 which was identified at a scope and severity of ""K"" which began on 9/12/10. The facility failed to assure laboratory test results were returned to the facility in a timely manner and promptly provided to the physician to use for assessment, diagnoses, treatment and initiation of appropriate infection control practice. The systematic failure to provide lab services and notify the physician promptly placed residents at risk for serious harm. The immediate jeopardy was not removed upon exit from the facility. Residents #'s 1,4,5,6,14,15,21 and 29 who were 8 of 22 sampled residents reviewed for Physician notification of lab services were identified with concerns related to physician notification resulting in a delay of treatment. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for ""Sputum Culture today"" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no follow-up to ensure that the results were received and called to the physician in a timely manner. She also reviewed the medical record and could locate no evidence that the physician was ever notified of the results which showed ""pseudomonas aeruginosa 2+"" and the gram stain with ""many"" positive rods and ""many"" white blood cells. Further review revealed that a weekly PT ([MEDICATION NAME])/INR (International Normalization Ratio) was done and the report available to the facility on [DATE] via computer. The lab report noted that the resident was currently ""on 2 mg [MEDICATION NAME]"" and was faxed to the physician on 11-3-10 (2 days later). The PT was 12.9 seconds with a reference range of 10.0 to 13.0. The INR ratio was 1.0 L(ow) with a reference range of 2.0-3.0. The physician wrote an order on the lab report on 11-4-10 to ""Please ^ (increase) to 3 mg"". This order was transcribed onto a Physician's Interim Order form on 11-5-10. During an interview on 12-15-10 at 8:50 AM, Licensed Practical Nurse #4 reviewed the medical record and confirmed that the [MEDICATION NAME] was not increased until 11-5-10 based on the 11-1-10 PT/INR results. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 12/13/10 revealed the resident had a Urine Culture and Sensitivity obtained on 9/16/10. The resident was started empirically on Bactrim on 9/17/10. Per the lab result, a report of the lab was available on 9/18/10 which indicated the resident had an E-Coli infection which was not sensitive to the Bactrim as ordered. Nurses notes documented on 9/20/10 that the resident expressed to the nursing staff that she thought the Bactrim was ""not strong enough to cure UTI"" (urinary tract infection). On 9/21/10 the resident complained of burning all over and asked to go to the emergency room . The resident returned from the emergency room with a new order for Keflex for 10 days and a [DIAGNOSES REDACTED]. The lab report filed in the medical record indicated the result was possibly faxed to the facility on [DATE] and clearly faxed on 9/22/10 and faxed to the physician on 9/22/10. There was no documentation that the facility tried to access the lab result after 48 hours, or attempted to access the result once the resident complained of not feeling better. On 12/14/10 during an interview with the ADON (Assistant Director of Nursing) who was also the Unit Manager she stated that just because the lab result was available in the computer did not mean the facility could access the information. She then called the lab and learn that if the report indicated the result was available it would indeed be available in the computer for the facility staff to access. There was no explanation provided by the Assistant Director of Nursing as to why there was a delay in the receipt of the lab result or fax to the physician. The resident was not included on the audit log on the nursing unit for monitoring for the return of the result or physician notification. Resident # 15 was admitted on [DATE]. A PT/INR ([MEDICATION NAME] time/International Normalization Ratio) was obtained on 11/29/10. The lab report indicated that the result was available on 11/29/10. The report was faxed to the facility on [DATE] and the physician notified on 12/1/10 who then ordered for the [MEDICATION NAME] to be held one day on 12/1/10. The result of the [MEDICATION NAME] was 27.0 (high) and INR 3.4 (high) Resident # 15 had a urine culture obtained on 11/19/10. The lab report indicated the result was available on on 11/21/10. A physician order [REDACTED]. Further interview with the Director of Nursing (DON) revealed that there had been intermittent problems with accessing lab results on the facility computers. A back up plan was for the lab results to be faxed to the facility. However, the fax was located in the business office which closed at 5:30PM and was not open on weekends. Additionally, the DON stated she had trained new hires on how to access labs but now was aware that the weekend supervisor (who worked a 16 hour shift) and potentially other staff hired prior to her arrival did not know to access the labs. Therefore, any lab result received on the weekend was not currently accessible to the nursing staff. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review of laboratory reports it was found that a sputum culture was done on 6/10/10 with a report date of 6/12/10. The results were not faxed to the Physician until 6/15/10 at which time the resident was [MEDICATION NAME] mg PO BID for 5 days for a Pseudomonas infection. A Pro-Time of 10/18/10 with a report date of 10/18/10 was not sent to the Physician until 10/21/10 . The result of the lab test was a [MEDICATION NAME] time 18.6 (high) and 1.8 (low). A Pro-time was drawn on 11/1/10 with a report date of 11/1/10 . The result of the test was 21.3 (high) and 2.3. The physician was faxed the results on 11/3/10. There was no documentation found that nursing identified the delay in treatment. The facility admitted Resident #4 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed the resident to be on [MEDICATION NAME] Therapy requiring PT/INR's ([MEDICATION NAME] Time/ International Nationalizing Ratio) to be drawn routinely. Further record review revealed the labs to be drawn timely; however, copies of the lab results did not appear to return timely to the facility or to be acted upon timely. Resident #4 had labs drawn: 8/24/10 not called to Doctor until 8/26/10 with an order for [REDACTED]. During an interview with RN #1 (Registered Nurse), the nurse showed an audit form that was being used to track labs. However, check marks were only placed if report faxed, placed in folder, or phone call made to Physician. Some sheets only had dates report received and date report placed in the chart. No follow-up was done by the nurses if a report had been delayed to find out why report delayed or to ask what results were. The lab test for 10/25/10 PT/INR for Resident #4 had not been listed on the audit sheet. This was confirmed by RN #1. Therefore, no one questioned why the result was not faxed until 10/29 and not faxed to doctor until 11/2. The Physician ordered an increase of 1 mg (milligram) to the current [MEDICATION NAME] order on 11/2/10. The facility admitted Resident #5 on 8/26/09 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 12/13/20 revealed a lab report for a Complete Blood Count (CBC) and a Basic Metabolic Profile (BMP) drawn on 2/08/10. The report was reviewed on 2/14/10 and iron studies ordered. A lab report done on 8/30/10 and sent to facility on 8/30/10 for CBC and BMP had irregularities noted. Note on bottom of report faxed to doctor- fax unsuccessful. There was no documentation of any follow up to refax or call to the doctor. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 ""complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the ""sputum culture was obtained from resp(iratory) therapist."" On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. The physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for intravenous antibiotics (IV) for ""[MEDICAL CONDITION]."" On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and intramuscular (IM) [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, ""new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum."" Review of the Physician's Telephone Orders revealed the following: 11/29/2010, ""Sputum C&S""; 12/7/2010 ""Send to ER (emergency room ) for increased temperature""; 12/7/2010 "" [MEDICATION NAME] 1 gram IV every day for 10 days"". 12/8/2010 ""DC(discontinue) [MEDICATION NAME] and [MEDICATION NAME] mg (milligrams) BID(twice a day), [MEDICATION NAME] 120 mg IM for 7 days""; 12/9/2010 "" airborne precautions, move to room [ROOM NUMBER]"". Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes revealed the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility notified the the Attending Physician on 12/8/2010, two days after receipt of the report. On 12/8/2010 the antibiotic treatment was altered for Resident #21 because [MEDICAL CONDITION] was not sensitive to the current treatment. There was no documentation noted that the nursing staff followed up to assure the timely receipt of the culture, which resulted in the resident not being place on appropriate transmission based precautions in a timely manner. The resident resided in a room with three other residents at high risk for infection related to cormorbidities. The facility admitted Resident #29 on 1/2/2010 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The results of the culture were made available to the facility on [DATE]. The physician was not notified of the positive culture until 11/15/2010. Further review revealed a PT/INR dated 10/11/2010 was available the same day and the physician was not notified until 10/13/2010. An additional PT/INR was available to the facility on [DATE], with physician notification occurring on the 28th . A PT/INR was dated 11/1/2010 and the results were available to the facility on [DATE] but the physician was not notified until 11/3/2010. During an interview the Nurse Manager from Station II, confirmed the delay in obtaining the culture results from 11/30/2010 for Resident #21 and confirmed the delay in notification for the culture and PT/INR results for Resident #29. She stated that normally cultures take 2-3 days to report. She stated that it was the nurses' responsibility to call and check on the results if they were delayed. The nurse stated that the lab normally faxed over the results when they were available. Lab results were also available through the computer. The Nurse Manager stated that the fax machine was located in the business office or the Admissions office, both of which were locked after 5 PM and on weekends. She/he stated that if a lab was faxed on the weekend, the nurses would not receive the results until the following Monday. If the lab was faxed after 5 PM, the nurses would receive the results the next day. The Nurse Manager confirmed that there had been a two day delay in notifying the physician of [MEDICAL CONDITION] positive culture. She stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for [MEDICAL CONDITION] pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview,a representative from the contract Lab stated that sputum cultures take 1-2 days to report. She/he stated that all cultures were sent to --- Hospital. She stated that if there was a delay in obtaining the results that a lab tech would call the hospital to check on the results. She stated that no documentation of the phone calls were kept. The Lab tech stated that the facility had access to the lab results on the computer and the results were available to the facility on the date reported. She also stated that a fax was automatically generated and sent to the facility upon report of the lab. She stated that there was no confirmation receipt kept for specific lab reports. During an interview, the Director of Nursing confirmed the delay in obtaining the culture report and confirmed the delays in reporting the result to the physician for both Resident #21 and #29. She/he also stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. The facility's policy on Changes in Condition was reviewed. The policy documented that the nurses were to ""verbally report resident's status to the physician and provide detailed description of the observed signs and symptoms and any laboratory and or radiology test results. Communication...must occur in a timely manner..."" The facility Administrator and two Corporate Nurse Consultants were present on 12/14/10 at 10:30AM when advised by the Team Leader that Immediate Jeopardy and Substandard Quality of Care had been identified by the survey team after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/30/2010 at 10:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/22/2010 had been implemented by the facility and was in practice as of 12/22/2010, removing the immediacy of the deficient practice. The citation at F-505 remained at a lowered scope and severity of "" E"". The facility will be in compliance at F-505 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.",2014-04-01
10164,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,153,G,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, ""Goin Postal"" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: ""... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, ""HIPAA"") has imposed strict requirements on health care providers regarding the release of protected health information (""PHI"") Under HIPAA, a provider may release PHI of an individual to a personal representative authorized under state law to act on behalf of the individual. See 45 CFR 164.502(g). Further, HIPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. 164.514(h)(1)(i). Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living or the permanent administrator or executor of the estate if the individual is deceased . The center will not be able to release these records until it receives verification of the applicable representation. ..."" Resident #23 arrived at the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident assessments of [DATE] and [DATE] showed no memory, decision making, or communication problems. On admission, the resident's brother was listed as the Responsible Party but this was changed to his son on an unknown date. The resident's son did start receiving the resident's Statement of Account by [DATE]. Resident #23's son began requesting copies of the medical record on [DATE]. The resident was transferred to the hospital on [DATE] and expired later that day. His son continued to make multiple requests for copies of the medical record and enlisted the aide of The Regional Ombudsman. His requests were repeatedly denied by the corporation legal staff. The Power of Attorney document provided by the son was deemed unacceptable. The probate court's certification of the son as the resident's personal representative was also deemed insufficient. Resident #23's son was directed to produce a fiduciary letter. During an interview with the Administrator on [DATE] at 8:35 AM, a representative from the corporate legal department was called and confirmed that copies of the resident's medical record had not been provided because the son failed to produce fiduciary letters. Resident #39 entered the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's daughter was listed as her Responsible Party. Review of the resident assessment of [DATE] revealed the facility was unable to assess the resident's memory and decision making ability due to her medical status. Communication was impaired. Resident #39 was found unresponsive on [DATE]. Cardiopulmonary resuscitation was initiated and the resident was sent to the hospital where she expired. The daughter was notified of all the events leading to discharge. On [DATE], the resident's daughter requested copies of her mother's medical record and was denied that same day. The corporate representative stated during the interview on [DATE] that it was because she did not have the resident's Healthcare Power of Attorney. Information provided by the facility revealed the following information concerning lack of timeliness in addressing requests for copies of the medical record made by resident representatives: The resident representative for Resident C requested copies of the medical record on [DATE] and was initially denied on [DATE] but documents provided by the facility showed this decision was reversed at a later date. The second request, made on [DATE], showed corporate approval on [DATE] and a posting bill dated [DATE]. Resident D's representative made a request for copies on [DATE] and did not receive approval for the copies until [DATE]. Resident E's representative requested copies of the record on [DATE] but did not receive approval for the copies until [DATE].",2014-04-01
10165,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,225,D,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey and complaint investigations, based on review of the facility's investigation into allegations of abuse and/or neglect, the facility failed to thoroughly investigate 2 of the 5 allegations reviewed (Residents #24 and #26). The findings included: Resident #24 with [DIAGNOSES REDACTED].#4. A day shift CNA reported that same day that the resident was found on several mornings with soaked and/or stained linens. The facility obtained statements from the resident's roommate, the accused CNA, and one other CNA assigned to provide care to the resident on one of the ""several"" 11-7 shifts. The facility failed to investigate to determine the exact dates of the alleged verbal abuse and the exact dates of the alleged neglect of the resident. Their investigation failed to show evidence that other staff members were interviewed concerning the allegations in an effort to identify other potential perpetrators or witnesses to the alleged abuse and neglect. Resident #26 was admitted with [DIAGNOSES REDACTED]. Review of the facility's ""Initial 24-Hour Report"" dated 12/02/10 and the ""Five-Day Follow-Up Report"" dated 12/08/10 revealed the alleged perpetrator CNA (Certified Nursing Aide) #13 was not interviewed related to allegation of abuse. Further review of the completed investigative report submitted by the facility revealed that no one at the facility attempted to interview CNA #13. Review of the facility policy on Abuse and Neglect in the ""INVESTIGATING"" under page 1 of 3 #1 *""Investigation documentation will include, but not be limited to, the following: ""Date and time of the alleged occurrence. Patient/resident's full name and room number. Names of the accused and any witnesses. Names of the healthcare center/agency staff who investigated the allegations. Any physical evidence and description of emotional state of patient/resident (s). Details of the alleged incident and injury. Signed statements from pertinent parties."" On page 2 of 3 under ""INVESTIGATING"" the second paragraph indicated ""Interviews will be conducted of all pertinent parties, utilizing open-ended questions. Written signed statements from any involved parties will be obtained and notarized, if indicated. Statements will be gathered from the suspect, person making accusations, patient/resident involved, reliable patient/residents who may have witnessed the incident, and any other persons who may have some information."" During an interview with this surveyor on 12/13/10 at 10:30 AM, the DON (Director of Nursing) stated she had the responsibility of investigating allegations of staff to resident abuse and neglect. The DON further confirmed she made no effort to obtain a written statement from CNA #13. The DON stated that no one had attempted to get a witness statement from the alleged perpetrator. The DON confirmed CNA #13 and alleged suspect was a ""pertinent party"" involved and stated she did not follow the abuse policy related to investigation in obtaining a statement from the CNA.",2014-04-01
10166,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,498,F,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, review of staff development records, review of the facility policy entitled ""NURSING: PERINEAL CARE"" (revised 4/07),the facility provided policy for Handwashing and review of the South Carolina Nurse Aide Candidate Handbook (January 2010), the facility failed to ensure that nurse aides were able to demonstrate competency related to implementation of infection control precautions in the provision of incontinent care. Nurse Aides failed to provide appropriate care and services to prevent infections for 13 of 20 residents (Residents #1, #5, #14, #15, #16, #17, #18, #19, #20, #30, #31, #32, #34) during 14 observations for incontinent care. Deficient practice and substandard quality of care was identified (CFR F- 315) during provision of incontinent care by nine of eleven Certified Nursing Assistants (CNAs) on two of three shifts and on three of three nursing units. The findings included: The facility admitted Resident #20 on 11-27-09 with Chronic [MEDICAL CONDITION] and multiple cormorbidities. During observation of incontinent care on 12-13-10 at 5:10 AM, after Certified Nursing Assistants (CNAs) #9 and #10 washed their hands and applied gloves, CNA #10 uncovered the resident from waist to feet and detached his incontinent brief. CNA #9 was unable to locate supplies at the bedside to provide incontinent care. She removed her gloves and left the room to obtain disposable wipes. CNA #9 reentered the room, applied gloves without washing her hands, and proceeded to provide care to the resident who had been incontinent of urine and feces. CNA #9 used one disposable wipe to cleanse both upper inner thighs and groin areas, then the penis, without changing the position of the cloth. When cleansing the penis, the CNA wiped down the shaft, toward the urethra, then cleansed the glans penis. The resident was positioned onto his right side and the CNA proceeded to cleanse the perianal area and buttocks of fecal material, using a single wipe repeatedly over the same areas without moving the position of the cloth. The testicles were never cleansed. The facility admitted Resident #30 on 11-19-10 with [DIAGNOSES REDACTED]. During observation of incontinent care on 12-13-10 at 5:15 AM, after Certified Nursing Assistants (CNAs) #9 and #10 washed their hands and applied gloves, CNA #9 was again unable to locate supplies at the bedside to provide incontinent care. She removed her gloves and left the room to obtain disposable wipes. CNA #9 reentered the room, again applied gloves without washing her hands, and proceeded to assist CNA #10 to provide care to the resident who had been incontinent of urine and feces. CNA #10 used one disposable wipe to cleanse both sides of the groin and pubic areas. With a second wipe, the CNA cleansed down the penile shaft repeatedly toward the urethra, without changing the position of the cloth. CNA #10 then pulled the foreskin back and cleansed the glans penis with another cloth, but again wiped repeatedly over the same areas. The resident was positioned onto his right side and the CNA proceeded to cleanse the buttocks of a large amount of fecal material, using a single wipe repeatedly over the same areas without moving the position of the cloth. The buttocks and perianal areas were cleansed using at least 6 disposable wipes, each of which were used repeatedly over the same areas from four to nine times. During an interview on 12-15-10 at 8:05 AM, when CNAs #9 and #10 were asked what could have been done better during the incontinent care provided to Residents #20 and #30, CNA #10 stated ""handwashing"". She further stated, ""You should use one wipe and throw it away"" and ""wipe front to back."" The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. On 12-13-10 at 9:35 AM, the surveyor knocked and entered the room after obtaining permission to do so. CNA #8 was positioning the resident onto her right side to provide incontinent care. The CNA used disposable wipes to cleanse the buttocks and reddened perianal area of fecal material, wiping back to front repeatedly, toward the vaginal/urethral area, using the same position of the cloths. After repositioning the resident onto her back, the CNA noted fecal material present and cleansed the right outer labia, front to back, repeatedly with the same cloth. She took another cloth and cleansed the left outer labia, then the right, going over the same area twice, then the inner labia, without changing the position of the cloth. CNA #8 positioned the resident onto her left side and cleansed the right buttock and perianal areas from back to front using the same area of the cloth. The CNA repositioned the resident onto her back, obtained another wipe, and cleansed the left and right outer labia, then the inner labia using the same position on the cloth. Review of staff development records provided by the Clinical Competency Coordinator (CCC) on 12-15-10 revealed that CNAs #8 and #10 had been hired on 12-1-10. CNA #8 had documented orientation training on peri-care on 12-10-10. CNA #10 had documented orientation training on 12-6-10 on peri-care. The Orientation Checklist for CNA #10 was signed off by CNA #9. Review of CNA #9's personnel file provided by Human Resources on 12-15-10 at 9:55 AM revealed that her Skills Competency Checklist was blank. On 12-15-10 at 12:05 PM, the CCC stated she had no records of orientation for CNA #9. The CCC did provide a list of ongoing training for CNA #9 which did include attendance at an inservice on handwashing in 3-10. Resident #31 was observed for incontinent care by CNA #12 on 12/13/10 at approximately 5 AM. The CNA washed her hands and gloved before starting the procedure. She cleansed the resident, applied A&D ointment, applied a new brief, adjusted the resident's booties, positioned the resident, and pulled up the bed linens with the same gloves. While still wearing the gloves used to cleanse the resident, CNA #12 used the bed cranks to adjust the knees and head of the bed, then she restarted the feeding pump. After she finished these tasks, CNA #12 removed her gloves and washed her hands. Resident #32 was observed during incontinent care on 12/13/10 at approximately 5:30 AM. CNA #12 provided the care after washing her hands and applying gloves. The CNA removed the wet brief, cleansed the resident, applied a new brief, then positioned the resident and adjusted the bed linens while wearing the same soiled gloves. The facility was asked to produce training records for CNA #12. A one page document was provided on 12/15/10 titled Course Completion with a Date Range 1/1/2010 - 12/15/2010. There was no evidence showing CNA #12 completed training related to appropriate incontinent care or appropriate infection control resident care measures. The facility admitted Resident # 34 on 2-5-10. On 12/13/10, CNA # 7 was observed providing incontinent care for Resident # 7. CNA # 7 knocked, entered the room, provided privacy, explained the procedure to the resident, washed her hands and gloved. She then positioned the resident on her back and unfastened her brief. Using the wipes located on the over the bed table, CNA # 7 cleaned the front perineal area, discarding the wipes as used, and turned the resident on to her right side and began cleaning the back. Feces was present, and multiple wipes were used and discarded as needed. Using a tube of A & D Ointment which was on the over the bed table, CNA # 7 then put a liberal amount on her soiled gloved hands and spread it over a large area of the buttocks. The CNA stated that the resident's skin was irritated. No training records were available for review for CNA # 7 as stated by the CCC during an interview conducted on 12/14/10 at approximately 5:05PM. Resident # 16 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Certified Nursing Assistant # 4 had begun care prior to the surveyor entering the room. The resident had been incontinent of both bowel and bladder. The CNA was observed wetting a bath towel in the sink, which she then used to clean feces from the resident who was positioned on his right side. The towel was rolled in a large ball and rubbed up and down the resident's buttocks and lower back. The CNA was observed to remove her soiled gloves and without washing her hands, walk to the utility room to obtain more wipes and then to the clean linen room to obtain clean linens. CNA # 4 returned to the resident's room and applied gloves without washing her hands. Using wipes she again began cleaning feces in an upward, downward motion. Without changing gloves, she then put a clean sheet, lift sheet and soaker pad on the resident's bed. After repositioning the resident and adjusting the linens, the CNA then pulled the brief up between the resident's legs. The CNA was asked by this surveyor to re-open the brief. Large amounts of loose feces were observed in the inner groin folds which had not been cleaned by the CNA. The CNA cleaned the inner groin folds and resident testicle area but did not clean the penis. Wearing the soiled gloves, a clean brief was obtained from the closet and applied. Before removing her gloves and washing her hands, the CNA applied the resident's gown, removed the soiled linen from the bed, tucked in the clean linen on the right side of the bed, and placed wipes in the bedside table. Resident # 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CNA asked the resident, ""You not need no diaper change?"" The resident replied: ""Yeah, I'm wet."" It was determined that the resident's suprapubic Foley had leaked and he required assistance. CNA# 4 was observed to use one wipe and cleanse multiple times down the left side of the groin and repeat the same action on the right side of the groin. Without having the resident turn fully on his side, the CNA reached under and using one wipe, repeatedly cleansed the buttock area which could not be visualized. The resident was noted to be red in the inner groin folds. No attempt to clean the resident's testicles or penis was observed. Continuing to wear the same gloves, the CNA raised the head of the bed, covered the resident, emptied the bedside drainage bag, and wiped spilled urine from the floor with a paper towel before removing her gloves and washing her hands. A review of the training record provided by the facility on 12/15/10 for CNA # 4 revealed an undated skills competency list where all skills were marked as satisfactory at the same time/date and one handwashing video which did not require a return demonstration dated 3/28/10. A review of the training record provided by the facility on 12/15/10 for CNA # 4 revealed an undated skills competency list where all skills were marked as satisfactory at the same time/date and one handwashing video which did not require a return demonstration dated 3/28/10. Resident # 17 was last admitted to the facility on [DATE]. An observation of Certified Nursing Assistant # 5 performing incontinent/perineal care for the resident was conducted on 12/13/10 at 5AM. The CNA was observed to tidy the roommate's area before beginning care for Resident # 17. CNA # 5 was observed to apply gloves without first washing her hands after caring for the resident in the A bed. The CNA unfastened the resident's brief and assisted her to turn over. The buttock area was cleaned using separate wipes. There was slight fecal staining of the wipes noted. The soiled brief was removed and a new brief placed under the resident. Without changing gloves and using single wipes, the CNA cleansed down the right side of the labia, and twice down the left side. No attempt was observed to clean the inner labia. The brief was fastened, clothing adjusted, and call light placed before removing the soiled gloves. The CNA then gathered the trash, returned the wipes to the drawer, raised the head of the bed, opened the curtain, opened the door to the soiled utility room and discarded the trash. There were no paper towels in the utility room so the CNA was observed to use hand sanitizer hung in the hallway to clean her hands. Resident # 18 was admitted to the facility on [DATE]. An observation of perineal/incontinent care was observed on 12/13/10 at approximately 5:10AM. CNA # 5 applied gloves, obtained wipes from the bedside stand, and unfastened the resident's brief. The resident was noted to be incontinent of urine and stool. The CNA wiped down the right and left side of the groin using separate wipes. She then opened the bedside stand to obtain more wipes and found none. The resident's brief was fastened, the resident covered, curtain opened before the soiled gloves were removed. At 5:22AM the CNA returned to the room, applied gloves and opened the resident's brief. Using separate wipes, the CNA cleaned the right and left side of the labia, and made one swipe down the center without opening the labia. The resident was turned on her side and after cleaning the feces from the perineal area, the CNA was observed to raise the resident's leg and using a clean wipe, wiped twice near the front labia. After adjusting the resident's clothing, the soiled gloves were removed, the resident covered, curtain opened, table moved, wipes returned to storage before the CNA washed her hands. A review of the training record for CNA # 5 provided by the facility on 12/15/10 revealed no skills check list and no print out of hourly in-services. The CNA was hired by the facility on 10/13/10. Resident # 5 was last admitted to the facility on [DATE]. On 12/14/10 at 11:45AM, an observation of perineal/incontinence care was conducted when the resident was found to have been incontinent of urine when pressure ulcer care was to be done. With the wound care nurse present, CNA # 3 was observed to use one wipe and wipe once across/under the abdominal fold, multiple times in the right, left groin folds and down the center of the labia. A clean brief was placed on the resident without cleaning the buttock area. Following the procedure, the CNA was interviewed. When asked if she had been trained in incontinence/perineal care, she stated yes, in 2005. She denied having received further training since that time, stating she had only worked at the facility for about a month. When asked if the facility had evaluated her competency/skill, she stated""no"". When asked about her orientation to the facility, she stated she had walked with a CNA and ""watched"". When asked if she could identify any concerns related to the care she had provided, she stated she may not have cleaned her well and may not have wiped the right way. On 12/14/10, in an interview conducted with the wound care nurse who was present during the incontinent/perineal care, she was asked if she had any concerns related to her observation. She confirmed that the incontinence care was not appropriate and that she should have stopped the CNA and corrected her. A copy of the training record for CNA # 3 was requested but was not provided as the CNA had been recently hired and her orientation check sheet ""had not been returned."" There was no documentation that the CNA's competency had been tested upon hire to the facility or her skills evaluated. The facility admitted Resident #5 on 8/26/09 and readmitted on [DATE]. During 5:00 AM rounds , CNA #11 (Certified Nursing Assistant), was observed to do perineal care on Resident #5. The CNA took a disposable wipe and cleansed back and forth across the pubic area, down the right groin area, down the left groin area, and then down the center of the vagina area. The CNA used the same cloth without changing sides to clean the above areas. Once the resident was turned to the side, the CNA took another disposable wipe and cleaned back and forth over right and left buttocks, and front to back over the creases and anal area. The same cloth was used without changing sides over all these areas. A second observation of perineal/incontinence care was conducted when the resident was found to have been incontinent of urine when pressure ulcer care was to be done. With the wound care nurse present, CNA # 3 was observed to use one wipe and wipe once across/under the abdominal fold, multiple times in the right, left groin folds and down the center of the labia. A clean brief was placed on the resident without cleaning the buttock area. Following the procedure, the CNA was interviewed. When asked if she had been trained in incontinence/perineal care, she stated, ""Yes, in 2005"". She denied having received further training since that time, stating she had only worked at the facility for about a month. When asked if the facility had evaluated her competency/skill, she stated, ""No"". When asked about her orientation to the facility, she stated she had walked with a CNA and ""watched"". When asked if she could identify any concerns related to the care she had provided, she stated she may not have cleaned her (the resident) well and may not have wiped the right way. On 12/14/10, in an interview conducted with the wound care nurse who was present during the incontinent/perineal care, she was asked if she had any concerns related to her observation. She confirmed that the incontinence care was not appropriate and that she should have stopped the CNA and corrected her. A copy of the training record for CNA # 3 was requested but was not provided as the CNA had been recently hired and her orientation check sheet ""had not been returned."" There was no documentation that the CNA's competency had been tested upon hire to the facility or her skills evaluated. The facility admitted Resident # 14 on 12/08/08. During 5:00 AM rounds, CNA #11 (Certified Nursing Assistant), was observed to provide perineal care on Resident #14. The CNA took a disposable wipe and cleansed back and forth across the pubic area, down the right groin area, down the left groin area, and then down the center of the vagina area. The CNA used the same cloth without changing sides to clean the above areas. Once the resident was turned to side, the CNA took another disposable wipe and cleaned back and forth over right and left buttocks, and front to back over the creases and anal area. The same cloth was used without changing sides over all these areas. The facility admitted Resident # 19 on 12/02/08. During 5:00 AM rounds with CNA #11 (Certified Nursing Assistant), CNA # 11 was observed to do perineal care on Resident #19. . The CNA took a disposable wipe and swiped back and forth across the pubic area, down the right groin area, down the left groin area, and then down the center of the vagina area. The CNA used the same cloth without changing sides to clean the above areas. Once the resident was turned to side, the CNA took another disposable wipe and cleaned back and forth over right and left buttocks, and front to back over the creases and anal area. The same cloth was used without changing sides over all these areas. After removing gloves the CNA did not wash hands before leaving the room to take soiled linen to the soiled utility room. On 12/15/10 all inservices and skills check off list were requested for CNA # 11 (Certified Nursing Assistant). Records reviewed documented an inservice on Handwashing 3/24/10 and a skills check-off including peri-care (not dated as to completion date). No other inservice documentation was provided. Review of the facility policy entitled ""NURSING: PERINEAL CARE"" (revised 4/07) revealed the following: ""GENERAL INFORMATION: ...3. Cleanse perineal area from front to back....PROCEDURE: 1. Wash hands. 2. Assemble necessary equipment... 10. For females: -Separate labia then clean downward from front to back with one stroke. -Repeat using a clean part of the washcloth/wipe for each stroke. More than one...may need to be used... -Clean rectal area from the vagina to the anus with one stroke. -Repeat until area is clean using a clean part of the washcloth/wipe with each stroke... 11. For males: -If uncircumcised retract foreskin. -Grasp penis. -Clean the tip using a circular motion. Start at the urethra and work outward. Repeat as needed, using a clean part of the washcloth/wipe each time... -Return the foreskin to its natural position. -Clean the shaft of the penis and top of the scrotal sack. Use firm downward [MEDICAL CONDITION] -...Cleanse rectal area and bottom of scrotal sack. Clean from front to back with one stroke... 19. Wash hands thoroughly."" Review of the South Carolina Nurse Aide Candidate Handbook (January 2010) revealed the following under ""SKILLS LISTING"": ...""Washes Hands is listed first as a reminder of the importance of performing this skill before all other skills."" Directions for providing peri-care to females included: ""...8. Washes genital area, moving from front to back, while using a clean area of the washcloth for each stroke...11. After washing genital area, turns to side..."" The facility provided policy titled Handwashing Techniques (8/)*) stated: ""Hands should be washed before and after patient/resident contact and as necessary during patient/resident care."" The purpose of the policy was to: ""Thoroughly cleanse hands before and after resident/patient contact and or contact with the patient/resident environment to reduce microbial count and prevent the spread of infection. Cross Refer 42 CFR 483.25(d)(2) Related to facility failure to provide appropriate treatment and services to prevent urinary tract infections. On the days of the survey, based on observations, interviews, review of the facility policy entitled ""NURSING: PERINEAL CARE"" (revised 4/07), and review of the South Carolina Nurse Aide Candidate Handbook (January 2010), substandard quality of care was identified based on facility failure to provide appropriate care and services to prevent infections for 14 of 20 residents (Residents #1, #4, #5, #14, #15, #16, #17, #18, #19, #20, #30, #31, #32, #34) who were observed for incontinent care. Deficient practice was identified during provision of incontinent care by nine of eleven Certified Nursing Assistants (CNAs) on two of three shifts and on three of three nursing units.",2014-04-01
10167,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2010-12-15,441,F,,,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the facility policy and procedure related to Infection Control, the facility failed to establish and maintain an effective Infection Control Program. The facility failed to maintain accurate records of infections to determine tracking and trending by resident and organism. (Resident # 30) The facility failed to initiate transmission based precautions in a timely manner for Resident # 21 with a known drug resistant respiratory infection who was located in a multi-bed room; Resident personal equipment was not labelled for individual use; Oxygen equipment was not maintained in a sanitary manner for Resident # 32; and 1 of 3 housekeeping staff was not knowledgeable in housekeeping procedures required to clean resident room who were on isolation. The facility failed to ensure staff used appropriate handwashing during resident care. The facility failed to handle soiled linen in a way which prevented the spread of infection as observed during resident care and observation of the laundry process. The findings included: During Initial Tour of the facility on 12-13-10 at approximately 5:05 AM, this surveyor observed Certified Nursing Assistant (CNA) # 7 coming out of room # 117 with a bag of soiled linen. CNA # 7 went into the soiled utility room, placed the linen in a linen barrel, left the room, and went into the clean linen room. She then proceeded to obtain clean linen and returned to room # 117 to make up the bed. CNA # 7 did not wash her hands after disposing of the soiled linen and before she handled the clean linen. At approximately 6:00 AM, CNA # 7 entered room # 113 in response to a call light, and assisted a resident into the bathroom. On the counter beside the sink in the room were two used urinals with no resident identification. CNA # 7 put each urinal into separate bags and set them in the bathroom, The room was occupied by 2 male residents, but the CNA did not label the urinals as to whom they belonged. During an interview with the CCC (Clinical Competency Coordinator) on 12-14-10 at approximately 5:05 PM, she confirmed that CNA # 7 should have washed hands after depositing soiled linen in the soiled linen room, and that urinals should be labeled with the resident's name and should always be bagged and left in the bathroom instead of at the sink. Resident #32 received incontinent care from CNA #12 on the morning of 12/13/10, at approximately 5:30 AM. The resident's oxygen nasal cannula and the face mask for a positive pressure delivery system were observed on the floor by the bed. After providing the incontinent care and positioning the resident, CNA #12, while wearing the same gloves, picked up the face mask and placed it into a plastic bag that was on top of the dresser next to the pressure machine. As CNA #12 picked up the nasal cannula, the resident asked for it to be applied. The CNA gave the cannula to the resident who proceeded to apply the cannula, beginning by inserting the nasal prongs into her nose. Neither appliance was observed to have been cleansed or sanitized. When interviewed about the facility Infection Control Logs, the CCC who was designated as the person responsible for the facility infection control program, she stated that the nurses were responsible to complete an infection report on each lab which indicated an infection. The report was to be submitted into her for evaluation and entry into the Infection Control log via computer. She commented that the reports were often incomplete, without the organism type listed, with missing data related to symptom onset, antibiotic used or interventions which had been put into place. She further stated that the reports were not given to her in a timely fashion. The CCC stated that sometimes she was not informed about isolation precautions until after they were implemented. She further stated that she had been out sick the first part of December and when she returned she found that a number of labs had been missed by the nurses on each unit. She made a list of the missing labs and gave it to the Director of Nursing. The CCC also stated that she provided the training for isolation, use personal protective equipment, hand washing and that she was responsible for new hires orientation. Review of the nine Certified Nursing Assistants (CNA) which were identified as giving incorrect incontinent care during the survey, revealed that not all of the cited nursing assistants had attended the inservice for Handwashing dated 3/23/10 and the Infection Control inservice dated 4-7-10. An incomplete list of training for Infection Control Inservice was provided during the survey. Review of the Infection Control Logs revealed the logs were incomplete, with only 22 of 282 infection reports identified by organism. The October 2010 monthly summary report was also not included in the information given to the survey team. The CCC stated that she did not monitor trends until the end of each month. When asked how she would know if a virus or outbreak of infections was occurring, she stated that she depended on the nurses to relay that information to her. Review of the personnel file for the Clinical Competency Coordinator on 12-15-10 at approximately 8:45 AM revealed that there were no job descriptions in the file listing duties, responsibilities related to infection control or staff development. During observations of the laundry process on 12/13/10 at approximately 10:55 AM, a laundry aid was observed sorting soiled laundry prior to loading the washers. The laundry aid was wearing an ill -fitting protective gown and as the laundry was sorted, soiled items touched the aides uniform multiple times. This was verified during an interview with the laundry aide immediately following the observation. The facility admitted Resident #30 on 11-19-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 11:30 AM revealed that the resident was discharged from the hospital with orders for ""TOBI ([MEDICATION NAME]) 300 mg (milligrams) inhaled with respiratory therapy daily"" for respiratory infection. Review of Physician's Orders revealed that the TOBI was discontinued on 12-8-10. Further review of the medical record revealed 11-24-10 Physician's Orders for ""Sputum C(ulture) + S(ensitivity). UA (Urinalysis) C+S. [MEDICATION NAME] 500 mg via G(astrostomy)/T(ube) QD (daily) X 7 days (for) fever."" Review of the record revealed that the UA was negative, but no laboratory results were on file for the sputum culture. At 12:45 PM on 12-14-10, Registered Nurse (RN) #3 reviewed the medical record and physician's communication book and found no culture results. The Lab Book contained no information related to receipt of the culture. The computerized laboratory reports were checked and it was found that the resident had 1+ [MEDICAL CONDITION][MEDICATION NAME] in the sputum. There was no evidence in the record and the RN was unable to determine when or if the physician was notified of the results. Review of the infection control surveillance logs on 12-15-10 at 8:15 AM with the Infection Control Preventionist (ICP) revealed no reference to the respiratory infection that the resident was admitted with or the results of cultures done because of the resident's elevated temperature. The ICP stated that the nurses on the units were responsible for completing computerized infection reports with the data and that she simply compiled the information. She stated it was not her responsibility to follow up in the charts to assure that culture reports were received in a timely manner or that residents were placed on appropriate medication/antibiotics or transmission-based precautions. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 ""complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the ""sputum culture was obtained from resp(iratory) therapist."" On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. the Attending Physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for Intravenous antibiotics for ""bronchitis."" On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and Intramuscular [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, ""new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum."" Review of the Physician's Telephone orders revealed the following orders: ""11/29/2010, Sputum C&S. 12/7/2010, Send to ER for increased temperature. 12/7/2010, [MEDICATION NAME] 1 gram IV every day for 10 days. 12/8/2010, DC [MEDICATION NAME] and [MEDICATION NAME] mg BID, [MEDICATION NAME] 120 mg IM for 7 days. 12/9/2010, airborne precautions, move to room [ROOM NUMBER]. Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes documented the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility waited two days before faxing the results to the Attending Physician on 12/8/2010. On 12/8/2010 the antibiotic treatment had to be altered for Resident #21 to be given an antibiotic that would treat the MRSA infection. Review of the Infection Control Log revealed an Infection report generated on 12/7/2010 that indicated Resident #21 had an Upper Respiratory Tract Infection. Another report was generated on 12/9/2010 that indicated airborne precautions. Neither report documented he had MRSA pneumonia. During an interview, the Nurse Manager from Station II, she confirmed the delay in obtaining the culture results from 11/30/2010, and confirmed the 2 day delay in notifying the physician of the positive culture. She/he stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for the MRSA pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview, the Infection Control Nurse stated that she was not aware of any resident on isolation precautions. She stated that she was unaware that Resident #21 had MRSA pneumonia and had been placed on isolation. She stated that the isolation should have been initiated immediately upon receipt of the positive culture. The Infection Control Nurse stated that the floor nurses were responsible for generating the infection reports. She stated that she reviews the reports every 2-3 days and prints them off for the Infection notebook. She stated that she would not have reprinted any infection reports related to Resident #21's pneumonia. She stated that she/he would not have known he had MRSA and was on isolation unless the nurses informed her. During an interview, the Respiratory Therapy Supervisor stated that if there was a change in sputum characteristics, the nurse and the doctor would be notified and a sputum culture obtained if ordered. She stated that no precautions would be taken until the results of the culture indicated a need for isolation precautions. During an interview, the Director of Nursing stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. Interview with the facility Medical Director conducted on 12/14/10 at approximately 2 PM revealed that he would have expected a resident with a known drug resistant respiratory infection to be placed on transmission based precautions immediately upon receipt of the laboratory results or as soon as possible. Review of the facility's policy on Infection Control revealed ""The Infection Control Practitioner does surveillance of all infections by: review of culture reports, antibiotic orders and other pertinent lab data..."" ""MRSA Procedure: It is the policy of this healthcare center to place patients/residents in a private room, where available, and on droplet or contact precautions who are displaying symptoms of active infections with MRSA under the following conditions: if the patient is infected with MRSA in the respiratory tract and has a productive cough...""",2014-04-01
10168,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,281,K,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on chart reviews, interviews, review of The South Carolina State Board of Nursing Advisory Option # 9 B, and review of the facility policies, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident reviewed with a PICC (Peripheral Inserted Central Catheter) line (Resident # 11). The facility nurses failed to clarify with the Physician a discontinued order related to flushing a PICC line. In addition, LPNs (Licensed Practical Nurses) documented that they administered medications through the PICC line with no documentation of advanced training and there was no RN (Registered Nurse) on site when the LPN administered the medications via the PICC line. The facility nurses failed to document consistently that they were flushing the PICC line and failed to note medications used for the flush were taken from a container of expired [MEDICATION NAME] Lock Flushes with a large number of expired [MEDICATION NAME] syringes. In addition the facility nurses failed to recognize signs and symptoms of infection of a surgical wound in a timely manner for Resident # 11, which delayed treatment. The findings included: The facility originally admitted Resident # 11 on [DATE] and after a brief hospital stay readmitted Resident #11 on [DATE] with diagnoses, which included Aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. On [DATE], review of the progress notes revealed that on [DATE] at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On [DATE] at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On [DATE] at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on [DATE] LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On [DATE] an order for [REDACTED]."" Interview on [DATE] with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on [DATE] and that there was a delay in treatment. On [DATE] the resident was transferred to the hospital at 5:00 AM for Incision and Drainage of the right shoulder surgical wound. Further review of the record revealed that Resident # 11 returned to the facility on [DATE] with a PICC line in the ""left upper arm."" Review of the Physician orders [REDACTED]. The first dose was to be given at 8:00 PM on [DATE], the evening she was readmitted to the facility. The final dose was to be given [DATE]. In addition the Physician ordered to flush the PICC line with 5 ccs (cubic centimeters) normal saline before and after each use, followed by 3 ccs of [MEDICATION NAME]. On [DATE], observation of the facility's Medication Room revealed a brown cardboard box located on the top shelf of an open cart to the right of the doorway as you entered the room. The box contained ,[DATE] millimeter (ml) [MEDICATION NAME] Lock Flushes. Review of the flushes revealed that 75 of the 79 had expired. The 4 unexpired flushes were located at the bottom of the box. The expiration dates were: ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]; ,[DATE] ml. [MEDICATION NAME] Lock Flush expired [DATE], ,[DATE] ml. [MEDICATION NAME] Lock Flush syringes expired [DATE]. Interview on [DATE] at 4:00 PM was held with RN #1. The RN confirmed that the [MEDICATION NAME] used to flush Resident #11's PICC line was taken from the box to the right of the medication room door. The box identified by RN #1 contained the [MEDICATION NAME] syringes that were noted by the surveyor and LPN #1 to have 75 of 79 syringes expired. Review of the MAR (Medication Administration Sheets) for November and [DATE], revealed that the IV flush was discontinued on [DATE] on the MAR without an order to discontinue the IV flush. Review of the resident progress notes (interdisciplinary notes used by all disciplines at the facility) revealed documentation that the PICC line had been flushed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] however there was no documentation as to what medication had been used to flush the IV or PICC line. On [DATE] during an interview with the DON she stated that there was no formal system in place to review that orders were entered into the computer system correctly. She stated that the facility pharmacy had discontinued the IV flush in error. The DON confirmed that the staff had documented on the MAR that the IV flushes had been done. Interview with RN # 1 on [DATE] at 4:00 PM, revealed that she had been flushing the PICC line with 5 cs of normal saline before and after administration of the IV antibiotic and following with 3 ccs of [MEDICATION NAME]. When questioned where this would be documented, she initially stated on the MAR. The surveyor shared with her that the IV flush had been discontinued on the MAR beginning [DATE]. She stated that maybe she had documented this in the progress notes. Asked why she had not questioned the IV flush not being on the MAR and calling the Physician, she confirmed that she had not called the MD that she had continued the IV flush of the PICC line because it was a standard of practice. When RN #1 was questioned if the nurses should have been documenting that the IV flushes were done and what medication was to be used per standards of practice, she stated yes. Further review of the MARs for November and [DATE], revealed that on [DATE], [DATE], [DATE] and [DATE] LPNs had initialed in the EMAR (Electronic Medication Administration Record) that they had administered the IV [MEDICATION NAME] via the PICC line. Review of the South Carolina Board of Nursing document related cardiovascular system Licensed Practical Nurse with Specialized Education and Training revealed that any LPN that administered medication via a PICC line must complete an intravenous therapy course relative to the administration of fluids and medications via peripheral and central venous devices. This document also stated: see Advisory Opinion # 9 B on the role of LPNs in IV (intravenous) therapy. Review of the South Carolina Department of Labor, Licensing and Regulation State Board of Nursing Advisory Opinion # 9 revealed that the Board of Nursing for South Carolina acknowledges it is within the extended role practice of the selected LPN to perform procedures and to administer ordered treatments via peripheral and central venous access devices and lines according to the following stipulations: 1. The agency has established policy and procedures that are approved by the nursing administrator and applicable medical director. Procedures include: a.criteria for the qualification and selection of the LPN; b. description of the additional education and training necessary for assuming additional rates.c. specific standing orders for the administration, monitoring and discontinuation of peripheral and central venous lines.d. specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN.2. The selected LPN shall document completion of special education and training to include:a. Cardiopulmonary resuscitationb. Intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/line that includes both didactic and supervised clinical training with return demonstration. The facility policy reviewed on [DATE] titled Care and maintenance of the Central Line Protocol, listed under Standards of Practice - Central line care is performed by a Registered Nurse and under Documentation - Document the [MEDICATION NAME] Flush/Saline Flush on the Medication Administration Record. Documentation includes: site assessment, resident subjective complaints, and any interventions completed and resident response. On [DATE] at approximately 4:00 PM, in an interview with LPN # 3, she stated that she had administered medication via the PICC line and flushed the line. She stated that she had additional training. Interview with the facility DON revealed that the facility did not have any documentation of the advanced training for any of the LPNs and stated that the facility policy stated that only RNs administer medications via a PICC line. She stated that she had not been aware that any LPNs were administering meds via the PICC line, however confirmed that she was aware that the facility did not always have RN coverage. Review of the facility monthly time schedule revealed that there was no RN coverage on [DATE] and [DATE], which was confirmed by the facility administrator. Review of the facility protocol for the Care and maintenance of the Central Line Protocol, revealed that only a Registered Nurse was to perform care to a central line. In addition, the policy stated that flushes should be documented on the MAR. Interview with the facility Medical Director (and the attending Physician for Resident #11) on [DATE] at approximately 9:30 AM, revealed that he was unaware that LPNs were administering medication/flushing PICC lines and had no knowledge of the expired medication used as an IV flush. Immediate Jeopardy was cited at F281 with a scope and severity of ""K"" related to failure of nursing staff to clarify orders to flush a PICC line when the original order was discontinued without a physician's orders [REDACTED]. documenting on the MAR when administering medication. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing.",2014-04-01
10169,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,425,J,,,GN4K12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, the facility failed to ensure that expired medications were not stored with medications readily available for resident use resulting in expired Heparin Lock Flush available for use. Seventy Five of 79-3 millimeter Heparin Lock Flushes, were observed in the medication room with expiration dates prior to the survey, an additional 30 were found 12/13/2010 in the bio-hazard container with an expiration date of 8/1/2010 and 2 used Heparin 3 millimeter syringes were found in the sharps container on 12/13/2010 with expiration dates of 8/1/2010 and 11/1/2010. One of one resident sampled with a Peripherally Inserted Central Catheter (PICC), Resident #11, had a IV flush daily with a Heparin Lock Flush ordered. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on 11/16/2010 with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to ""Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc Heparin Once a Day at 8PM, start date 11/16/2010"". On 12/8/2010, during observation of the facility's medication room, expired supplies were noted to be in the same area as the supplies used for resident care. The medication room contained 14-3 ml. Heparin Lock Flush syringes expired 8/1/2010; 60-3 ml. Heparin Lock Flush expired 11/1/2010 and 1-3 ml. Heparin Lock Flush syringes expired 10/20/2010. The Heparin Lock Flushes were observed to be in an open brown cardboard box, sitting on a cart to the right as you entered the medication room. At 10:45 AM on 12/8/2010, expired items (Heparin Lock Flushes) in the medication room were verified by LPN #1 who then removed them from the medication room. LPN #1 stated all nurses were responsible for ensuring any expired meds were removed from the medication room, but there was no system in place to determine when it should be checked or how often it was to be done. During an interview with the Pharmacist on 12/8/2010 at 3:55 PM, he stated that it was the responsibility of the facility's Pharmacy Consultant to ensure that all expired medications and supplies were removed from the facility. The Pharmacist also stated that the pharmacy had not sent Heparin Flushes to the facility in over a year. During the interview with the facility's Pharmacist the surveyors requested the invoices for Heparin delivered to the facility. The Pharmacist stated that he was unable to locate any. When asked how he tracked the lot numbers of the Heparin, he stated that they did not charge for it so they did not track the lot numbers. When asked by the surveyors whose responsibility it was to monitor the facility's medications he stated that the Pharmacy contracted with a consultant who was responsible for that. During an interview with Registered Nurse #1 on 12/8/2010 at 4:00 PM, she stated that the Heparin Flushes she used currently were located on a cart to the right of the door as you walked into the medication room. The container identified by RN #1 was the one noted to hold the expired Heparin Lock Flushes. During an interview with the Nursing Home Administrator on 12/8/2010 at 4:15 PM, the Administrator stated that the Pharmacy Consultant was responsible for monitoring the medication room and medication carts for expired medications. She also stated that the consultant had been to the facility for review on 11/17/2010, and that she had no idea where the expired Heparin in the facility came from. The NHA verified that the Pharmacy had not sent Heparin to the facility in over a year at 5:25 PM on 12/8/2010. On 12/13/2010, an additional box of 30-3 ml. Heparin Lock Flush expired 11/1/2010 was observed in the bio-hazard box by a surveyor and 1 used-3 ml. Heparin Lock Flush syringe expired 8/1/2010 and 1 used 3-ml Heparin Flush syringe expired 11/1/2010 was retrieved by that surveyor from the sharps container located on the medication cart. In an interview with the Interim Director of Nursing (DON) on 12/13/2010, The DON stated that the bio-hazard material had been picked up on 12/1/2010 and provided documentation of that pick-up. She also stated that the medication cart sharps container was emptied approximately every 3 weeks because the facility did not use many sharps. On 12/13/2010 during an interview with the Pharmacy Consultant, the Consultant confirmed she was responsible for ensuring expired medications were removed from the medication room. She stated she was in the facility monthly for medication review and checked the medication room and carts at that time. She stated she was unaware the Heparin was in the building. On 12/13/2010 at 4:15 PM, during an interview with the facility's Pharmacist, he stated that he did not have lot numbers of Heparin Flushes received prior to September 16, 2010. When asked how he would recall medications from facility's when the Federal Drug Administration recalled medications by lot number, he stated that he would recall the medication by name, not lot number. When asked if his process would include medication lot numbers not included in the recall he stated that it would. Immediate Jeopardy was cited at F425 with a scope and severity of ""J"" related to expired Heparin Lock Flushes (75 of 79) stored in an area readily available for resident use. The Immediate Jeopardy existed when a resident (Resident #11) was admitted and was using the IV flushes daily per physician order [REDACTED]. In addition 2 used syringes of the IV Heparin Lock Flush were found in a sharps container and noted to have dates that were expired. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired Heparin to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/29/2010 at 11:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/13/2010 with an addendum submitted on 12/23/2010 had been implemented by the facility and was in practice as of 12/18/2010, removing the immediacy of the deficient practice. The citation at F-425 remained at a lowered scope and severity of "" D"". The facility will be in compliance at F-425 when an acceptable Plan of Correction is submitted and a follow up visit is conducted, to determine that the facility has implemented their Plan of Correction as stated.",2014-04-01
10170,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,490,K,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Surveys based on observations, interviews and full and/or limited record reviews, the facility's administrator failed to assure that the facility established and maintained services in the building that met Professional Standards of Practice. The administrator failed to develop a system to ensure that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. The findings included: Cross refers to the following citations: 483.20 (k)(3) Professional Standards F281, with a scope and severity of ""K"" due to facility failure to clarify orders for Peripherally Inserted Central Catheter (PICC Line) Flushes, Licensed Practical Nurses (LPNs) administering Intravenous (IV) medications via PICC Line and [MEDICATION NAME] Flushes without evidence of advance practice certification. 483.30 (b) Nursing Services F354 with a scope and severity level of ""F"" due to failure to ensure an (RN) Registered Nurse was working 8 consecutive hours every day and the facility employs a full time Director of Nurses not to be shared with another facility. 483.60 Pharmacy Services F425 with a scope and severity level of ""J"" due to the facility's failure to ensure that expired medications were not stored with medications available for resident use. 483.75 (l) Clinical Records F514 with a scope and severity of ""J"" due to inaccurately documenting Medication Administration Records (MARs). Interview with the Nursing Home Administrator was held on 12/8/2010 and again on 12/13/2010. The Nursing Home Administrator confirmed the Director of Nursing was shared with the Senior Community Assisted Living Facility. Time sheets were provided to the surveyors and did reveal there were dates without 8 consecutive hours of RN coverage. The NHA also confirmed that there was not a security feature on the electronic records and if the nurse did not completely log off before leaving the facility, her/his name would be listed as giving medications on the MAR (Medication Administration Record) as opposed to the nurse that was on duty. In addition, the Administrator confirmed that she did not have evidence that an employed LPN did have advanced training required to access and administer medications to a resident with a Peripherally Inserted Central Catheter. Immediate Jeopardy was cited at F490 with a scope and severity of ""K"" related to the facility administrator's failure to assure that the facility establish and maintain services in the building that meet Professional Standards of Practice. The administrator failed to develop a system to ensure that the Pharmacy was providing the necessary contracted services, that outside resources were utilized effectively and that systems were in place within the facility to ensure well being of the residents. On 12/8/2010 at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of 11/16/2010 related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility 12/13/2010 and is ongoing.",2014-04-01
10171,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,514,J,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on full and/or limited record reviews and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The findings included: Resident #11 was originally admitted on [DATE] and was readmitted after a hospital stay on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was admitted back to the facility on [DATE] with a PICC line and was ordered by the physician to ""Flush PICC with 5cc Normal Saline before and after each use, followed by 3cc [MEDICATION NAME] Once a Day at 8PM, start date [DATE]"". On [DATE], review of Resident #11's Medication Record (MAR) revealed 4 dates, [DATE], [DATE], [DATE] and [DATE], which indicated that Licensed Practical Nurses (LPNs) had administered IV antibiotics and IV flushes via a Peripherally Inserted Central Catheter (PICC) Line. During an interview with one of the LPN's that signed off the MAR indicated [REDACTED]'s antibiotic and both saline and [MEDICATION NAME] flushes through the resident's PICC line and that she had advanced training and certification to allow her to administer medications via a PICC Line. On [DATE], during an interview with the facility's Administrator, the Administrator stated that there was a ""glitch"" in the e-mar (electronic) record keeping system that inserted the wrong nurse's initials onto the MAR. She stated that if the nurse did not log out completely when the shift ended there was no security system that would log them out after a certain time had passed with no activity on the part of the staff member. The Administrator did state the nurses were just not taking the time to log out completely and that when medications were given it would be documented as the wrong nurse having administered the medication. She did state that at times it was not the LPN listed on Resident #11's MAR giving the injection. The Administrator stated she was informed LPN #3 had a certificate in advanced training but did not have any evidence of that training. The Administrator did confirm during the interview that this could impact the documentation on all of the resident's MAR's as it relates to their accuracy. Immediate Jeopardy was cited at F514 with a scope and severity of ""J"" related to the facility administrator's failure to ensure the facility maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. The electronic system in place for Medication Administration documentation did not ensure accuracy if not logged out properly by staff. Nursing staff were not taking the final step to log off the system and information documented related to medication administration was faulty. On [DATE] at 5:25 PM the survey team met with the Administrator and Director of Nursing to inform them of the determination of Immediate Jeopardy with a start date of [DATE] related to the system failure identified with using expired [MEDICATION NAME] to flush a PICC line; the failure to follow the facility policy for the care and maintenance of a central line and the failure to follow the South Carolina Board of Nursing policy related to the extended role of practice of the LPN. The Immediate Jeopardy was not removed at the time the survey team exited from the facility [DATE] and is ongoing.",2014-04-01
10172,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,272,D,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review, interview and review of the facility's policies entitled Smoking, the facility failed to assess for safety in a timely manner Resident #3. Resident #3 was 1 of 1 sampled resident observed while smoking. The findings included: The facility admitted Resident #3 on 9/28/2009 and readmitted her on 11/14/2009 with [DIAGNOSES REDACTED]. On 12/7/2010 at 3:00 PM, during the review of Resident #3's medical chart, the smoking assessments were reviewed. The chart contained a smoking assessment dated [DATE]. The surveyor could locate no other assessments related to smoking. When the surveyors asked Licensed Practical Nurse (LPN) #3 if staff accompanied residents outside to smoke, she stated no. When asked if the residents kept their smoking materials with them, LPN #3 stated that the smoking materials were locked in the Medication Room and that the residents asked for them when they went outside to smoke and returned them to the nurses when they came back inside. At 3:55 PM on 12/7/2010, during an interview with the Director Of Nursing (DON), she verified that there had been no smoking assessment completed on Resident #3 since 10/6/2009. Review of the resident's medical chart revealed that on 8/4/2010 her cognitive status was assessed as 0100 and on 11/2/2010 as 0110 indicating a change in cognitive status. The DON also stated that the facility policy does not require assessments unless the resident has a change in condition. Review on the facility's policy entitled ""Smoking"" revealed no information related to smoking assessments.",2014-04-01
10173,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,441,F,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on record reviews, interviews, review of the facility's Infection Control Logs and the facility's policy and procedure entitled Infection Control Program, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility also failed to ensure that expired [MEDICATION NAME] Lock Flushes (3 millimeter (ml), 100 unit (u)/ml (75 of 79), Intravenous (IV) supplies (3 start kits), 1 Biopatch Antimicrobial Dressing, and Vacutainer's (3) were not stored in an area away from resident use items. The findings included: On 12/7/2010, review of the facility's Infection Control Logs revealed that the facility logged resident's who were prescribed antibiotics (Abt.). On 12/8/2010 at 12:45 PM, during an interview, the Director of Nursing (DON) was asked if the facility logged Gastrointestinal illness (vomiting and diarrhea) and Multi Drug Resistant Organisms (MDROs). The DON stated that the facility only logged residents on Abt. (antibiotic) therapy. When asked if the facility tracked and trended to recognize outbreaks and potential educational needs, the DON stated no. Review of the facility's policy and procedures entitled Infection Control Program revealed ""I. GOALS: The goals of the Infection Control Program are to: A. Decrease the risk of infection to residents and personal. B. Monitor for occurrence of infection and implement appropriate control measures. C. Identify and correct problems relating to infection control practices. D. Insure compliance with state and federal regulations relating to infection control. II. Scope of the Infection Control Program. The Infection Control Program is comprehensive in that it address detection, prevention and control of infections among residents..."" On 12/8/2010, during observation of the facility's medication room, expired supplies were noted in the same area as the supplies used for resident care. The medication room contained 1 Biopatch Antimicrobial Dressing with an expiration date of 9/2010, 2-10 ml. Vacutainer's with an expiration date of 11/2010, 1-10 ml. Vacutainer expired 06/2009, 2- IV start kits expired 9/20/2010, 1-IV start kit expired 6/2009, 14-3 ml. [MEDICATION NAME] Lock Flush syringes expired 8/1/2010, 60-3 ml. [MEDICATION NAME] Lock Flush expired 11/1/10 and 1-3 ml. [MEDICATION NAME] Lock Flush syringes expired 10/20/2010. The [MEDICATION NAME] Lock Flushes were observed to be in a brown cardboard box, sitting on a cart to the right as you entered the medication room. The Vacationers were in a caddy sitting on the same cart. During an interview with the Pharmacist on 12/8/2010 at 3:55 PM, she stated that it was the responsibility of the Pharmacy Consultant to ensure that all expired medications and supplies were removed from the facility. She also stated that the pharmacy had not sent [MEDICATION NAME] Flushes to the facility in over a year. In an interview with the Nursing Home Administrator, she stated that the Pharmacy Consultant was responsible for monitoring the medication room and the medication carts.",2014-04-01
10174,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,500,C,,,GN4K11,"On the days of the Recertification and Extended Survey, based on record reviews and interviews, the facility failed to provide a contract for emergency dental services for the residents. The findings included: On 12/9/2010, review of the facility's required contracts, the facility failed to provide a contract for emergency dental services. In an interview with the Nursing Home Administrator, the Administrator stated that the facility did not have a dental contract. No signed dated contract for dental services was provided prior to the survey team exiting the facility on 12/13/2010.",2014-04-01
10175,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,156,C,,,GN4K11,"On the days of the Recertification and Extended Survey, based on observations and interview, the facility failed to post how to apply for Medicaid and how to apply for refunds from Medicare. In addition, the facility failed to post how to contact the Department of Environmental Control (DHEC). The findings included: On 12/7/2010 and 12/8/2010, observations revealed that the facility failed to post how to apply for Medicaid and how to apply for a refund from Medicare. In addition there was no posting related to how to contact DHEC. Interview with the facility Administrator on 12/8/2010 at approximately 5:00 PM, revealed that she was unaware that the facility did not have the information posted. She confirmed that the information was not posted. The Administrator stated that the information must have been taken down during renovations of the facility and not re-posted.",2014-04-01
10176,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,157,G,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to notify the attending Physician of the signs and symptoms of an infected surgical wound for one of one resident reviewed with an infected surgical wound. (Resident # 11) The findings included: The facility admitted Resident # 11 on 11/1/2010 with diagnoses, which included aftercare for Reverse Total Shoulder Arthroplasty, Hypertension, [MEDICAL CONDITION] and [MEDICATION NAME] Degeneration. Resident #11 was re-admitted [DATE] after a hospital stay. On 12/8/2010, review of the progress notes (nurses notes) revealed that on 11/4/2010 at 3:15 PM LPN # 3 documented that the surgical wound had intact staples, and a small amount of serous yellow tinged drainage. On 11/5/2010 at 3:56 PM, LPN # 3 documented that the wound had increased serous yellow tinged drainage and increased pain. On 11/6/2010 at 2:42 PM. LPN # 3 documented that the wound continued to drain a moderate amount of serous yellow drainage that was blood tinged. There was no documentation of the Physician being notified. At 2:35 PM on 11/8/2010 LPN # 3 documented a moderate amount of blood tinged yellow drainage was observed on the dressing when removed. On 11/8/2010 an order for [REDACTED]."" Interview with the DON (Director of Nurses) at approximately 12:00 PM, revealed that the nursing staff should document Physician notification in the progress notes. She confirmed that the nursing staff failed to recognize signs and symptoms of the surgical wound being infected even though the nurse had documented possible signs and symptoms on 11/5/2010 and that the resident's MD (in addition to the resident' attending physician this was also the facility's Medical Director) had not been notified of the change of condition of the wound until 11/8/2010 which resulted in a delay in treatment. On 11/12/2010 the resident was transferred to the hospital at 5:00 AM for Incision and Drainage of the right shoulder surgical wound. Cross refers this tag to F-281 as it relates to the facility's nursing staffs failure to provide care and services that met professional standards of practice.",2014-04-01
10177,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,159,D,,,GN4K12,"On the days of the Recertification and Extended Survey, based on review of the facility's petty cash fund and interview, the facility failed to adhere to acceptable accounting practices for three of three resident's funds that were reviewed. The findings included: On 12/8/2010, interview with the facility's Business office person # 1, revealed that the facility accepted monies of ""less than $50.00 dollars"" and kept this in petty cash. Review of the accounting for the funds revealed that Resident # 1's account did not accurately reflect the amount of money that the resident had in petty cash. Review of Resident # 5 accounting of funds, revealed that a receipt from Walgreen ' s for $1.06 however there was no request/authorization for the funds to be spent from the resident/responsible party.Review of Resident A's accounting of funds revealed a receipt for Walgreen ' s for $17.00 dollars and no request/authorization for the funds to be spent from the resident/responsible party.Business office person # 1 confirmed this.",2014-04-01
10178,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,315,E,,,GN4K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record reviews, observation and review of the facility procedure for suprapubic catheter care, the facility failed to provide appropriate catheter care for two of two residents reviewed for catheter care. During Residents' # 2 and # 4 suprapubic catheter care, the facility staff failed to provide treatment in a manner that would prevent possible infection and failed to follow Physician orders [REDACTED]. The findings included: The facility readmitted Resident # 2 on 2/8/2008 with diagnoses, which included Urinary Tract Infection, [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 12/8/2010 at approximately 3:00 PM, LPN (Licensed Practical Nurse) # 2 was observed to perform suprapubic catheter care on resident # 2. The nurse failed to wash her hands prior to donning gloves and was observed to use her gloved hand to turn on the faucet and run water into a basin. She placed the basin on the resident's overbed table, returned to the bathroom and using her right gloved hand dispensed soap onto a hand towel touching the trigger of the wall soap dispenser. LPN # 2 draped the resident with a towel. There was no dressing around the insertion site and the left side of the insertion site was observed to have a small amount of red tinged drainage. Using the hand towel, LPN # 2 cleaned around the catheter insertion site with a back and forth motion without changing position of the hand towel. Next LPN # 2 cleansed down the catheter tubing. LPN # 2 placed the hand towel back into the hand basin filled with water and was observed to use the same towel and again used a back and forth motion around the insertion site without changing position of the hand towel and then wiped down the catheter tubing. Bright red tinged drainage was observed on the right side of the catheter site. LPN # 2 returned the hand towel to the basin and picked up the towel she had used to drape the resident and using the side that had been touching the resident's body dried around the insertion site and down the tubing. Review of the resident # 2's medical record revealed a Physician order [REDACTED]."" During an interview with LPN # 2 after the treatment on 12/8/2010, the LPN confirmed that she had not followed appropriate infection control practices. When questioned if she had read the physician orders [REDACTED]. She confirmed that she had cleansed the catheter with soap and not normal saline. When questioned why she had not placed a dressing on the site related to the drainage, she initially stated that she had not seen any, however did state that she was aware of the drainage at the end of the treatment but she contributed this to the site having just been cleansed. The facility admitted Resident # 4 on 12/29/2004 with diagnoses, which included [MEDICAL CONDITION], Hypertension and Convulsions. On 12/8/2010, at approximately 4:00 PM, CNA (Certified Nursing Assistant) # 1 was observed performing suprapubic catheter care on Resident # 4. CNA # 1 was observed to use [MEDICATION NAME] Foaming Cleanser to cleanse during the treatment. There was no dressing around the insertion site. No dressing was applied after the treatment. After completion of the cleansing, CNA # 1 was observed to disconnect the catheter collection bag. Next CNA # 1 emptied the collected urine into the toilet and then placed the collection bag into the sink to ""wash it off."" CNA # 1 then dried the collection bag and reconnected it to the catheter tubing. Review of Resident # 4's clinical record revealed a physician's orders [REDACTED]. Review of the facility procedure for providing suprapubic catheter care revealed under the section titled Preparation : ""1. Check physician's orders [REDACTED]. ...4. Perform hand hygiene. "" Interview with the DON (Director of Nurses) on 12/8/2010 confirmed that the LPN # 2 and CNA# 1 had not followed appropriate infection control practices and had not followed the MD orders related to the cleansing of the suprapubic catheter.",2014-04-01
10179,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,354,F,,,GN4K12,"On the days of the Recertification and Extended Survey, based on observation and interviews, the facility failed to have a RN (Registered Nurse) on duty for eight consecutive hours daily. In addition, the facility failed to employ a full time DON (Director of Nurses). The findings included: Review of the facility staffing revealed that on the following days that the facility failed to have a RN on duty for eight consecutive hours daily:10/23/ 1/6/ 1/13/ 1/20/ 2/4/2010 Interview with the facility administrator and the DON on 12/8/10 confirmed that the facility did not have the correct RN coverage on the above dates. In addition, the Administrator stated the DON did not work full time for the skilled area; that she also had duties for the Assisted Living area.",2014-04-01
10180,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2010-12-21,332,D,,,7CTK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews, the Drug Facts and Comparisons book (updated monthly) and the Drug Information Handbook for Nursing, 8 th Edition, 2007, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The medication error rate was 6.5 percent. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 12/20/10 at 4:29 PM, during observation of medication pass, Licensed Practical Nurse (LPN) #3 was observed to instill one drop of [MEDICATION NAME] Ophthalmic Suspension into each eye of Resident A without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under ""General Considerations in Topical Ophthalmic Drug Therapy""): ""Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug."" During an interview on 12/20/10 at 4:48 PM, LPN #3 confirmed she did not shake the [MEDICATION NAME] Ophthalmic Suspension before instillation into the resident's eyes and further stated that she knew that [MEDICATION NAME] should be shaken. Error #2: On 12/20/10 at 4:53 PM, during observation of medication pass, LPN #4 was observed to prepare and administer 1 [MEDICATION NAME] 150 milligram (mg) tablet and one other medication to Resident #23. Review of the current physician's orders [REDACTED]. [MEDICATION NAME] 150 MG TABLET TAKE 1 THREE TIMES DAILY - REC. (record) PULSE PER POLICY-"" LPN #4 was not observed to take the resident's pulse prior to administering the medication. Review of the facility's policy revealed that antiarrhythmic drugs (which included [MEDICATION NAME]) required a daily pulse. During an interview on 12/20/10 at 6:23 PM, LPN # 4 confirmed she had not taken the resident pulse and that there was no place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the pharmacy consultant, who was present during part of the interview with LPN #4, it was revealed that there was a notebook at the nurses station which contained vital signs, including pulse, which are recorded by the 7 AM to 3 PM medication nurses. Review of the notebook revealed that the morning pulse (12/20/10) for Resident #23 was 57 beats per minute. LPN #4 was not aware of the notebook and the information related to the resident's pulse. The Drug Facts and Comparisons book (updated monthly), page 429, states (under patient information) related to antiarrhythmic agents: ""Be aware of signs of overdosage or toxicity such as [MEDICAL CONDITION], excessive drowsiness, decreased heart rate or abnormal heartbeat."". In addition, the Drug Information Handbook for Nursing, 8 th Edition 2007, page 1039, states, under Nursing Actions, Physical Assessments for [MEDICATION NAME]: ""Monitor therapeutic response and adverse reactions at beginning of therapy, when titrating dosage, and on a regular basis with long-term therapy. Monitor cardiac status (BP, pulse) closely."". Error #3: On 12/21/10 at 8:28 AM, during observation of medication pass, Registered Nurse (RN) #1 prepared 1 [MEDICATION NAME] Coated (EC) Aspirin 81 mg tablet and 7 other medications for administration to Resident B. RN #1 was observed to crush the [MEDICATION NAME] Coated Aspirin Tablet and 4 other medications and mix them with applesauce for administration to the resident. Review of the current physician's orders [REDACTED].",2014-04-01
10181,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2010-08-11,441,F,,,58Y911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interviews, the facility staff failed to demonstrate appropriate knowledge related to infection control issues. The findings included: On 8/11/10 at approximately 9:30 AM during an interview with LPN # 1 when questioned what he/she would tell visitor's prior to entering a resident's room who had an order for [REDACTED]. On 8/11/10 at approximately 9:45 AM interview with Housekeeper # 1, who was responsible for cleaning a room with a ""Stop See the Nurse Prior to Entering."" sign was questioned what the sign meant. Housekeeper # 1 was unable to tell the surveyor why the sign was posted. When questioned if he/she would utilize any special cleaning procedures for a resident who was on contact isolation for Clostridium Difficile, he/she failed to identify to use any chemical to clean the room. On 8/11/10 at approximately 10:15 AM RN # 4 was questioned what he/she would tell a visitor prior to entering a resident's room who was on contact precautions. He/She stated that he/she was unsure what to tell a visitor. On 8/11/10 at approximately 11:00 AM, Housekeeper # 2 was questioned if he/she would use any special procedure to clean a resident's room who was on contact isolation for Clostridium Difficile, and he/she stated no. When questioned if he/she had been trained on cleaning procedures for rooms that had resident's with infection control precautions, he/she said no.",2014-04-01
10182,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2010-08-11,425,F,,,58Y911,"**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 medications were not stored with other medications in 2 of 4 medication rooms. The finding included: On 8/9/10 at approximately 11:15AM, inspection of the 1 South Medication Room revealed one orange colored Emergency Box sealed with a red integrity seal and bearing an outside label which read Meclizine expired 7-27-10. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg (milligram)/ml (milliliter), 50 ml. by Hospira, Lot 68-435-DK, expired 1 [DATE] (August 1, 2010). -One Extended Phenytoin Sodium 100mg capsule lot 39 expired 8-5-10 (packaged by NCS Healthcare of SC) -Two Ciprofloxacin 500mg tablets lot BEM51B LC expired 7-2-10 (packaged by NCS Healthcare of SC) -Five Meclizine HCl 25mg tablets lot 601 EH expired 7-27-10 (packaged by NCS Healthcare of SC) These findings were verified by RN (Registered Nurse) # 1 (Floor Manager) on 8/9/10 at approximately 11:25AM who stated that the Consultant Pharmacist is supposed to check for out- of-date medications during monthly visits and was unsure whether the nurse was also responsible for checking on an ongoing basis. RN # 1 a lso confirmed that this emergency box was used to supply medications to all residents on the first floor. On 8/9/10 at approximately 1:40PM, inspection of the 2 North Medication Room revealed one orange colored Emergency Box sealed with a green integrity seal. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg/ml, 50 ml. by Hospira, Lot 68-434-DK, expired 1 [DATE] (August 1, 2010) This finding was verified by LPN (Licensed Practical Nurse) # 1 on 8/9/10 at approximately 1:50PM. LPN # 1 stated that the box had been delivered on 8/6/10 by the Pharmacy and that the green integrity seal indicated that it had not been opened since delivery. This finding was also verified by RN # 2 (Floor Manager) on 8/9/10 at approximately 2:10PM who stated that the green seal meant that it had been unopened since delivery by the pharmacy and that if it had been opened it would have been resealed with a red integrity seal. RN # 2 also confirmed that this emergency box was used to supply medications to all residents on the second floor. On 8/9/10 at approximately 4:40PM the Facility Administrator provided a copy of the most recent ""Quality Improvement: Consultant Pharmacy Summary"" which covered 7/27/2010 to 7/28/2010 and had been signed 7/28/10. This summary showed on page 2 of 3 that out-of-date medications had been checked, but did not identify any of the expired medications found during the survey. The summary also showed that the emergency supply on ""1N, 1S and 2N needs to have e-box returned to pharmacy.""",2014-04-01
10183,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,279,D,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop, review and revise the resident's comprehensive plan of care for 2 of 9 resident care plans reviewed. No Care Plan for Resident #7 was developed for [MEDICATION NAME] Therapy and Resident #9 had no Care Plan related to allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. On 9/7/2010 at 3:20 PM, review of the medical chart for Resident #9 revealed that the resident had multiple medication allergies [REDACTED]. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OPsite, *No sleeping Pills Per POA (Power Of Attorney). Further review indicated that there was no Care Plan in the record related to Resident #9's numerous allergies [REDACTED].#9 had no Care Plan for allergies [REDACTED]. The facility admitted Resident # 7 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 9/7/10 revealed this resident to be receiving [MEDICATION NAME] 5 mg(milligrams) every night. Lab studies were done per physician's orders [REDACTED]. Continued review revealed no care plan had been developed related to anticoagulant therapy and the [MEDICATION NAME] usage since the resident was admitted . In an interview with the DON (Director of Nursing) on 9/8/10, s/he confirmed there was no care plan related to the [MEDICATION NAME] use. S/he also stated s/he would have expected a care plan to have been developed.",2014-04-01
10184,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,281,G,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews and review of the facility's protocol for Care Of Skin Abrasions, the facility failed to provide services for the residents which met the professional standards of quality for 1 of 9 residents sampled for professional standards and random observations during medication pass. Resident #9 had documented allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 9/7/2010 at 3:20 PM revealed that the resident had multiple allergy inconsistencies documented. The allergy sticker on the inside of the chart listed [MEDICATION NAME], Sulfa, [MEDICATION NAME], Amox. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OpSite, *No sleeping Pills Per POA (Power Of Attorney). Review of the Nurses' Notes dated 8/2/2010 at 0630 (6:30 AM), indicated that the resident had rubbed a scab off of the right side of her/his face. The nurse cleaned the area and applied ""TAO (Triple Antibiotic Ointment) and a band-aid"". At 5:00 PM, the Nurses' Notes revealed that the area on the right side of the resident's face was ""red & (and) irritated. Res. (resident) states is painful to touch. On MD (physician) book for eval. (evaluation)."" No other entries related to the resident's face were noted until 8/10/2010 at 4:40 PM which indicated that the physician had seen the resident and written new orders related to the ""area on side of face."" Review of the Treatment Administration Record (TAR) for Resident #9 for the month of August 2010 contained no documentation of the TAO being administered prior to the new order on 8/11/2010. On 9/7/2010 at 6:00 PM, during an interview with Licensed Practical Nurse (LPN) #4, she/he stated that a Telephone Order (TO) for the TAO should have been written and the TAO should have been documented on the TAR. Review of the TO dated 8/2/2010 stated per protocol apply TAO ointment to R (right) cheek abrasion and cover with dressing until healed. A TO dated 8/10/2010 indicated that the TAO had been discontinued on 8/10/2010. Review of the facility's protocol for Care Of Skin Abrasions revealed ""...Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol) 2. Review the resident's care plan, current orders and [DIAGNOSES REDACTED]. 3. Check the Treatment Record...."" Review of a Physician's Progress Note dated as dictated on 8/10/2010 contained documentation indicating ...""Allergic Reaction""...and to stop the topical antibiotics. On 9/8/2010 at 8:30 AM, during an interview with the Director Of Nursing (DON) and the Assistant Director Of Nursing (ADON), both verified the allergy information. The DON and ADON also verified the Nurses' Notes stating that the resident had received the TAO and that it was not documented as to how long and how often the resident received the treatment. On 9/8/2010 at 11:50 AM, during an interview with Resident #9, the resident's daughter, the Nurse Practitioner (NP) and the ADON present, the resident and her/his daughter stated that the resident had received the TAO for 3 days that they were sure of stating maybe 4 days. The NP stated that she/he was reviewing the resident's allergies [REDACTED]. During a random observation of the Medication Pass on 9/7/10 at 3:30PM, Licensed Practical Nurse # 6 was observed to leave a bottle of [MEDICATION NAME] on top of the medication cart when s/he entered the room to administer medications. The medication cart was not able to be seen from the resident's bedside. After entering the resident's room, the nurse was observed to leave the medication filled syringe on the bedside table as s/he left the room the wash his/her hands. After checking the resident's blood sugar and determining the need to call the physician for further direction, the nurse returned to the medication cart where s/he left both the bottle of insulin and the medication filled syringe on top of the cart unattended as s/he returned to the bathroom to wash his/her hands. On 9/8/10 at approximately 7:40AM, during observation of medication pass, Licensed Practical Nurse # 7 was observed to enter a resident's room and leave a medication cup containing nine medications and a bottle of [MEDICATION NAME] Nasal Spray on the bedside table when s/he left the room to wash his/her hands. The medications were not visible to the nurse as s/he washed his/her hands. On 9/8/10 at 10:30AM, the findings were shared with the Director of Nursing, who verified it was not facility policy to leave medications unattended.",2014-04-01
10185,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,371,F,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Four of 4 ovens were observed to have dried, baked on spills on the interior walls, racks and floors of the ovens which extended to the exterior surfaces of the oven doors. The resident refrigerators on 2 of 3 units contained 16 [MEDICATION NAME] Extra nutritional supplements which had expired. The findings included: On 9/7/2010, during initial tour of the facility's kitchen, 4 ovens were observed to have a build up of food spills which were baked onto the oven doors and interiors. On 9/8/2010 at 8:40 AM, during an additional tour of the kitchen the ovens remained unchanged. On 8:45 AM, Dietary Staff worker #1 verified the ovens with the build up. At 9:20 AM, the Dietary Manager stated that the ovens were on a cleaning schedule but there was not a check of to ensure the staff had completed the task. A cleaning check off was initiated and provided on 9/8/10. During initial observation of the resident refrigerator on the Orchard View unit, 13- 8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010 were noted. The location of the supplements and expiration date was verified by the Director Of Nursing. At 10:35 AM, Licensed Practical Nurse (LPN) #1 stated that the unit had 1 resident receiving the [MEDICATION NAME]. The resident refrigerator on the Overlook Point Unit contained 3-8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010. The location of the supplements and expiration date was verified by Certified Nursing Assistant (CNA) #3.",2014-04-01
10186,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,492,E,,,9VMS11,"On the days of the survey, based on review of personnel files, the facility failed to verify 2 of 3 LPN's (Licensed Practical Nurses) license were in good standing with the State Board of Nursing prior to hiring. The facility also failed to verify the criminal back ground for 1 of 3 LPNs prior to the hire date.The findings included:On 9/7/10 review of LPN #7's personnel file revealed that LPN # 7 started work on 6/16/10, however the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 6/30/10. Review of LPN #8's personnel file revealed that LPN #8 started work on 7/7/10, the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 7/20/10. The facility also failed to complete a criminal background check for LPN #8 until 7/20/10. LPN #9's hire date was 7/7/10 and the facility completed the license verification on 7/20/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the nurses. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started.",2014-04-01
10187,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,496,E,,,9VMS11,"On the days of the survey, based on employee personnel record reviews and interviews, the facility failed to verify certification checks and/or criminal background checks prior to beginning work for 3 of 2 Certified Nursing Assistant's reviewed for certification verification and criminal background checks.The findings included:On 9/7/10 review of employee personnel records revealed that the facility failed to verify certification for 2 of 2 CNAs (Certified Nursing Assistants) prior to beginning work. On 9/7/10, review of the CNA personnel records revealed:CNA # 1 began work on 6/9/10 with verification completed 8/11/10.CNA # 2 began work on 6/16/10 with her/his criminal background check completed on 6/17/10 and verification completed 7/31/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the CNA's. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started.",2014-04-01
10188,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,160,B,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds for conveyance upon death, the facility failed to convey one fund within 30 days of death, and failed to have proper authorization to convey 2 other resident funds. The findings included: An interview with the Business Office Manager on [DATE] related to conveyance of funds upon death revealed 3 of 4 accounts reviewed were refunded improperly. Account of Resident A, who expired on [DATE], was refunded by check written on [DATE]. The manager explained that corporate had recently found several accounts that had not been refunded, and she made out the check this day. Resident B had expired on [DATE] and a check had been made out to Colonial Trust on [DATE]. No legal authorization had been obtained to make the check out to this entity. Resident C expired on [DATE], and a check was made out on [DATE] to a son who had not been appointed as an administrator of the estate.",2014-04-01
10189,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,167,C,,,9VMS11,"On the days of the survey, based on observation and interview, the facility failed to post for resident review the Certification Survey for 8/20/09. The findings included: During a random observation on 9/7/10, the facility survey book, located upstairs in the skilled unit, was reviewed and found it contained last year's Licensure Survey, a Complaint Survey, and a Certification Survey dated 2008. The Certification Survey results for 8/20/09 were not included. The Director of Nursing (DON) reviewed the book and confirmed the survey was not included. The DON reviewed the survey book posted downstairs at the entrance and confirmed that book also did not have the 2009 Certification Survey included.",2014-04-01
10190,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,441,F,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of facility Infection Control Policies, Logs, and interviews, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection related to cleaning/non cleaning of glucometers, not making documented compliance rounds of all departments, and not keeping accurate infection control logs for trending and tracking of infections. There were also expired supplies in 2 of 3 medication rooms. The findings included: Review of the monthly infection control logs on [DATE] and [DATE] revealed list of x-rays done each month and pharmacy printouts for residents on antibiotics for each month with listings of residents, tests done, organisms identified, antibiotics started. However, these listings were not in order by date. When the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were interviewed regarding their infection control program, they stated the ADON filled out the log weekly or bi-weekly. They received the printouts from X-Rays and Pharmacy the next month so those were added to the logs then. The logs were not current. When asked how they did their tracking or trending for infections, they stated they had weekly meetings where infections were discussed. If they saw more infections were occurring, they would check to see which unit. No line listing of MDRO's ( Multi Drug Resistant Organisms) in the facility were being kept. The Admission's Coordinator would have to call someone in Nursing before placing a new resident. The ADON did not do compliance rounds to other departments for infection control. She stated she supposed the department heads did their own rounds. She did not receive any written reports for these. She did not do compliance rounds in nursing, but did competency checks on staff yearly. During observation of medication pass on [DATE] at 3:30PM, Licensed Practical Nurse #6 was observed to use a multi-resident glucometer to check a resident's blood sugar. The glucometer was not observed to be cleaned by the nurse either before or following its use. Random interviews related to cleaning of glucometers on [DATE] at 1:40PM and [DATE] at 4PM (two different units and two different shifts) revealed that both nurses stated they would use Alcohol to clean the glucometer. On [DATE] two boxes of Stat Let lancets with a manufacturers expiration date of ,[DATE] were observed stored in the Overlook Pointe medication room as verified by Licensed Practical Nurse #8. In the Orchard Medication Room, (2) IV 3000 Standard dressings with a manufacture's expiration date of ,[DATE] and (2) Allevyn thin dressings with a manufacturers expiration date of ,[DATE] were stored as verified by Licensed Practical Nurse # 1 at 5:45PM. Both nurses stated it was the responsibility of the third shift to check for outdated supplies.",2014-04-01
10191,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,309,D,,,9VMS11,"**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 follow a physician's order to monitor Resident # 14's blood pressure before administering a medication. Resident #14 was one of four sampled resident's receiving medications with physician ordered parameters for administration. The findings included: Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. On 9/8/10, a review of the closed medical record revealed a physician's order for ""[MEDICATION NAME] 60 milligrams, hold if pulse is less than 40"" and notify the physician. A review of the July and August 2010 Medication Administration Records revealed there was no documentation that the resident's pulse was obtained/documented prior to the medication administration given daily at 6AM, 12P, 6P, or 12AM. The findings were verified and not disputed when shared with the Director of Nursing on 7/8/10 at 10:30 AM.",2014-04-01
10192,THE LAKES AT LITCHFIELD SNF,425380,120 LAKES AT LITCHFIELD DRIVE,PAWLEYS ISLAND,SC,29585,2011-01-24,225,D,,,T04211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of the facility's investigative materials related to 2 of 2 resident falls with fractures, the facility failed to report timely and failed to thoroughly investigate a fall with fracture (Resident #1) and failed to report a fracture of unknown origin (Resident #2). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Because the resident had poor safety awareness and made attempts to get out of bed, a tab alarm, when in the chair and when in the bed, was ordered at 6 AM on 12/9/10. At 6:30 AM on 12/9/10, the resident was found on the floor of his room. The alarm did not sound because the resident held it in his hand. The previous order for the tab alarm was discontinued and a pressure pad alarm was ordered for the bed and chair. The resident fell again on 12/11/10 at 9:35 AM. According to the Nurse's Note, the resident was found sitting on his buttocks in the dining room. His urinary catheter was intact. No immediate signs of injury were noted. Later that morning, at 11:30 AM, the resident complained of left leg pain and he was sent to the hospital where a fractured femur was diagnosed . The facility reported this incident to the State survey and certification agency on 12/13/10, which exceeded the 24 hour limit for initial reports. During an interview with the Administrator and Director of Nurses on 1/24/10 at 1:10 PM, they stated they thought the facility had 24 ""business hours"" to report the incident. The resident fell on a Saturday and the initial facility report was made on Monday. Review of the facility's investigative materials revealed documentation on the fall report stating: ""Aide was returning tray to kitchen when resident attempted to stand up & fell . Alarm did not sound."" The Certified Nursing Assistant's (CNA's) statement said: ""Resident was in the dinning (sic) room talk I went to Clean up and take his plate to the kitchen he tried to get up and fell . Alarm didn't go off. When I heard that he fell and called both nurses. They came check him out and took him back to the desk."" The facility's investigation did reveal that the wrong type of alarm was used that day, a tab alarm instead of the pressure pad alarm. Their investigation did not show why the tab alarm was used, if it had been placed properly, if it was functioning properly, or if the resident silenced it somehow. The CNA's statement was never clarified concerning did she actually see the resident fall or simply ""heard that he fell ."" There was no information about other people present in the room, either as potential witnesses or potential perpetrators to the incident. Resident #2 with [DIAGNOSES REDACTED]. On 10/14/10, at 3:45 PM, the resident was found on the floor in her room. She complained of pain at the back of her head and in her back. A hospital evaluation revealed a right Colles fracture. The facility reported the incident to the Ombudsman and Health Licensing. It did not report the injury of unknown origin from an unwitnessed fall to the State survey and certification agency.",2014-04-01
10193,THE LAKES AT LITCHFIELD SNF,425380,120 LAKES AT LITCHFIELD DRIVE,PAWLEYS ISLAND,SC,29585,2011-01-24,323,D,,,T04211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record reviews and interviews, the facility failed to ensure that personal safety alarms were used as ordered for 1 of 1 resident who fell and sustained a fractured femur (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Because the resident had poor safety awareness and made attempts to get out of bed, a tab alarm when in the chair and a pressure pad alarm for the bed was ordered at 6 AM on 12/9/10. At 6:30 AM on 12/9/10, the resident was found on the floor of his room. The alarm did not sound because the resident held it in his hand. The previous order for the tab alarm was discontinued and a pressure pad alarm was ordered for the bed and chair. The fall report stated the pressure pad alarm ""was applied."" The Nurse's Notes entry on 12/9/10 at 2125 (9:25 PM) stated ""pressure pad alarm in place."" Review of the 11-7 Nurse's Notes for 12/10-11/10 showed the resident made numerous attempts to get out of bed unassisted. The resident fell again on 12/11/10 at 9:35 AM. According to the Nurse's Note, the resident was found sitting on his buttocks in the dining room. His urinary catheter was intact. No immediate signs of injury were noted. Later that morning, at 11:30 AM, the resident complained of left leg pain and he was sent to the hospital where a fractured femur was diagnosed . Review of the facility's investigative materials related to the fall with fracture revealed the safety alarm did not sound. The investigation also revealed the resident did not have the pressure pad alarm in place, but instead the tab alarm was in place that day. Their investigation did not show if the alarm was on and functioning, or why it did not sound on 12/11/10. Review of the Treatment Record showed nurses' initials for ""Pressure pad alarm WIB/WIC (when in bed/when in chair) d/t (due to) poor safety awareness"" for 3-11 and 11-7 on 12/9 and 12/10/10, and for 7-3 on 12/11/10. The initials indicated the treatment was done. Review of the 12/11/10 Daily Alarm Check For The Skilled Unit Nurses revealed a notation made beside the resident's name saying ""need pressure pad for W/C (wheelchair)."" An interview with the Administrator and Director of Nurses on 1/24/11 at 1:10 PM confirmed that a tab alarm, and not the pressure pad alarm, was in place on 12/11/10 at the time of the resident's fall.",2014-04-01
10073,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-02-14,225,E,1,0,TWHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interviews and review of the facility's reportable incidents, the facility failed to assure each reportable incident was reported within the mandated timeframes and to the appropriate agencies. Resident #1's injuries of unknown origin were not originally reported to the state certification agency until 3 days after the incident occurred (12/22/2010) and the 5 day follow up was not reported until 1/28/2011. Another injury of unknown origin occurred on 1/28/2011 that was not reported to the state certification agency. A random resident had a fracture that occurred during a transfer that was neither reported to the state certification agency nor thoroughly investigated. Another random resident with an allegation of verbal and physical abuse did not have the 5 day follow up reported to certification within the 5 days. One of three residents reviewed for injuries of unknown origin and 2 random reportable incidents. The findings included: The facility admitted Resident #1 on 1/6/2010 with diagnosed including: [DIAGNOSES REDACTED]. Review of the nursing notes revealed the following entries: ""11/18 2 bruises notes to upper extremities ... ...left upper extremity with a silver dollar sized bruise, unopened and not draining, bruise is with a purplish hue ... ...second bruise noted to right upper extremity dime sized ... ...elder had been combative during am care ... ...am care performed without the aid of PRN [MEDICATION NAME]. "" ""12/14 CNA found quarter sized skin tear on posterior right arm this am. Origin unknown."" ""12/16 Bruise to left upper posterior arm and right forearm ... ...also noted bruise under chin will continue to monitor and report. "" ""12/19 2:43 AM, elder has bruises to right and left arms, skin tear on right posterior upper arm, no combative behavior noted today, Urine for lab obtained."" ""12/19 3:02 AM, 3 small circular bruises noted on elder's left anterior upper arm at about 9 PM last night. Staff reported elder has been unusually sleepy and agitated last 24 hours. "" ""12/22 nurse called to the cottage by companion (CNA) because resident was not responding. She was found in her wheelchair slumped over and did not respond to verbal stimuli ... ...Pearson NP (nurse practitioner) arrived, diagnosis was [MEDICAL CONDITION]."" ""12/24 Therapy: for safety during care it is recommended that elder be provided assist of 2 persons ... ...requires extensive assist ... ...Recommend gait belt be utilized."" ""1/28/2011 companions reported bruise on left elbow of elder of unknown occurrence. Called and notified supervisor and required documentation completed."" Review of the incident report dated 11/18/2010 revealed the resident's bruises were identified during a body audit, the actions taken were ""advised companions to not attempt am care when elder combative ... ...AM or any other care until elder settles ... ...notify nursing immediately."" Review of the incident report dated 12/14/2010 revealed ""resident noted to have skin tear on posterior right arm by CNA this AM. Origin unknown."" The actions taken were ""the skin tear cleansed with wound cleanser and a dry dressing was applied. Resident reminded to use call light for assistance."" An Incident Investigation document that was not dated but appeared to reference the incident on 12/14/2010 indicated the elder sustained ""skin tears of unknown origin. Staff was interviewed by Administration. Elder possibly sustained skin tear during period of agitation while in bed."" An incident report dated 12/16 revealed the CNA's identified bruising to the chin and right forearm during care. The actions taken were ""elder taking [MEDICATION NAME] in am before care and PRN [MEDICATION NAME] because resident has tendency to be combative."" An incident report dated 12/18/2010 revealed ""1 new bruises found on left anterior upper arm by primary nurse on second shift. 3 small (1 cm) bruises to left anterior upper arm. Immediate investigation to rule out abuse. Inspected room, devises, side rails, bed, tables and did not find anything that could cause that shape, size and location of elder's bruise. Full investigation in progress by DON, Administrator and SW."" Review of an incident report that was not dated but appeared to reference the incident on 1/28/2011 revealed, ""companion notified nurse of bruise to left elbow, 2 purplish areas found on left elbow. The actions taken were ""observe elder for safety."" Review of the behavior and Mood Tracking Log revealed on 11/18 Resident #1 did not exhibit any behaviors that day on any shift. On 12/14/2010 the resident did not exhibit any behaviors on any shift. On 12/16, Resident #1 was noted to resist care at 12:02 AM and 11:47 AM; she was noted to yell at 12:02 AM, made negative statements at 12:03 AM, was physically abusive at 11:47 AM and 8:54 PM and was angry at 12:03 AM, 11:48 AM and 8:56 PM. On 12/18/2010 Resident #1 was noted to by physically abusive at 11:42 AM and was negative and angry at 11:46 AM. On 1/28/2011, no behaviors were documented as occurring. Review of the Physician's Progress Notes revealed Resident #1 was seen on 12/17/2010. The provider acknowledged the resident's behaviors as a result of her dementia. On 12/21/2010 the resident was again seen by a provider and addressed the resident's combative behaviors. She documented that the resident was noted to have a skin tear to the left elbow, a bruise 2 cm x 2 cm on the right elbow, right upper arm with 3 bruises. Obtain geri-sleeves. On 12/22/2010 the physician in reference to the episode of unresponsiveness again assessed Resident #1. The differential diagnoses were ""[MEDICAL CONDITION] versus bradycardic event, versus vasovagal episode... Spoke with daughter, had [MEDICAL CONDITION] and [MEDICAL CONDITION] in the past. [MEDICATION NAME] (for dementia) was discontinued."" No diagnosis of [MEDICAL CONDITION] was affirmatively made nor was any treatment for [REDACTED]. Review of the physician's orders [REDACTED]. A telephone order dated 12/21/2010 indicated to ""obtain Geri-sleeves."" Review of the 24 hour report to the state certification agency revealed the report was sent on 12/22/2010. The date and time of the reportable incident was ""12/14/2010-12/19/2010."" The report was sent 3 days late. Review of the 5 day follow up revealed it was sent to certification on 1/28/2011, greater than one month after the incident. No report to the state certification agency could be located related to the bruising on 11/18/2010 or the incident that occurred on 1/28/2011. During an interview on 2/14 CNA #1 stated that she routinely cared for Resident #1. She stated that the resident required 2 people to perform care at all times. CNA #1 stated that Resident #1 did not need a lift for any transfer. CNA #1 stated that she did not always use a gait belt but would stand in front of the resident and have the resident ""hug"" her to assist the resident to stand. CNA #1 confirmed the use of the CNA care plan and stated she was aware the resident's mode of transfer was a stand up lift. She further stated that she did not know how the resident obtained the bruises on her arms. During an interview on 2/14/2011, CNA #2 stated that she routinely cared for Resident #1 and stated that the resident required 2 people for care. She stated that she performed a 2 person transfer for Resident #1. CNA #1 stated that she would cradle her arms under the resident's upper arm and perform a stand and pivot transfer. She stated that she sometimes used a stand up lift. CNA #1 stated that she ""sometimes"" used a gait belt during transfers. CNA #1 stated that she found the bruises on first shift and immediately reported them to the nurses. She stated that she was unsure of how the bruising occurred. During an interview on 2/14/2011, CNA #3 stated that she routinely assisted with Resident #1. She stated that the resident required 2 people for care. She stated that the resident transferred via a 2 person pivot transfer. CNA #3 stated that she would stand in front of the resident and grab under the resident's arms with both hands or one CNA on each side facing the resident with their arms linked in the arm pit area. During an interview on 2/14/2011, the nurse assigned to Resident #1 stated that she had recently been assigned to the resident. She stated that she began working with the resident approximately 3 weeks ago. She stated that she was not aware of how the resident transferred or if the resident needed a mechanical device. Review of the reportable incidents revealed an allegation of abuse reported on 1/7/2011 within the mandatory timeframe. However, the 5 day follow up was not sent to the state certification agency until 1/28/2011. Further review of the reportable incidents revealed a fracture that occurred during a transfer. The incident was not reported to the state certification agency. During an interview on 2/14/2011, the Administrator confirmed the 24 hour report was not sent to the state certification agency within the 24 hour mandated timeframe from the time of the incident. She also confirmed the 5 day report was not sent to the state agency until 1/18/2011. The Administrator also confirmed that the incidents on 11/18/2010 and 1/28/2011 were not reported to the state agency. The Administrator confirmed the random resident reviewed with a fracture that was caused during a transfer was not reported to the state certification agency. She also confirmed the 5 day follow up for an allegation of abuse that was initially reported on 1/7/2011 was not sent to the state certification agency until 1/28/2011. The Administrator and Director of Nursing confirmed that Resident #1 did not have an affirmative diagnosis of [MEDICAL CONDITION] and was not and has not been treated for [REDACTED]. Three interviewable residents were interviewed on 2/14/2011; no concerns were voiced related to abuse, neglect, transfers or injuries. The Resident Council Minutes and Grievance Logs were reviewed without concern. Review of the facility's policy on Abuse and Neglect stated, ""All alleged violations and all substantiated incidents will be reported to the stated agency and to all other agencies required. Necessary, appropriate actions, depending upon the results of the investigation will be taken. Alleged violations involving mistreatment, neglect or abuse including injuries of unknown source are reported immediately to the Village Mentor (Administrator of the Village) or his/her designee. For Nurse Aide, abuse complaint, complaints of abuse by nurses or injuries of unknown source immediately notify the person in charge, Village Mentor, or Community Mentor (Director of Nursing). Call within 24 hours or the next working day: notify the state Ombudsman and the Division of Certification. Results of thorough investigation are sent within 5 working days in writing to the Division of Certification. Within 5 working days the following will be submitted in writing to the Bureau of Certification: All written investigative material including statements/interviews, conclusion regarding the abuse based upon the investigation as to whether allegation substantiated or not, corrective action, if any, taken as a result of the investigation.""",2014-06-01
10074,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-02-14,323,E,1,0,TWHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, interviews and review of the facility's policy on abuse and neglect and transfers, the facility failed to ensure Resident #1 was transferred in a safe and appropriate manner. Resident #1 was assessed as requiring the assistance of a stand up lift per the Certified Nursing Aide Care Plan. The Certified Nursing Aides who routinely cared for the resident failed to follow the recommendations, failed to utilize the appropriate devices during a transfer and failed to use the appropriate technique to transfer Resident #1. Resident #1 sustained multiple injuries of unknown origin. One of three residents reviewed for injuries of unknown origin. The findings included: The facility admitted Resident #1 on 1/6/2010 with diagnosed including: [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 was unable to complete the mental status interviews and was coded as having short and long term memory problems and was severely impaired in the ability to make daily decisions. Resident #1 was also coded as having resisted care, physically abusive and other behaviors occurring 1-3 times during the assessment period. Resident #1 was also coded as needing extensive one person assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, hygiene and bathing. The resident was also coded as needing limited one person assistance with eating. Resident #1 was assessed as needing a wheelchair and had bilateral range of motion impairments of her lower extremities. Review of Resident #1's care plan revealed a problem area of cognitive loss with an approach to ""gently redirect me when I become angry or combative. If I don't respond to redirection, leave me alone for a little while."" Another problem area of assist with transfers was identified which was updated on 1/4/2011 with approaches including no enabler bars (side rails), Geri-sleeves and elbow protectors. Review of the CNA (Certified Nursing Aide) Care Plan revealed Resident #1 was to be transferred with a stand up lift with the assistance of two people, required a low bed and fall mats and was to have Geri-sleeves and no side rails. Review of the nursing notes revealed the following entries: ""11/18 (2010) 2 bruises notes to upper extremities ... ...left upper extremity with a silver dollar sized bruise, unopened and not draining, bruise is with a purplish hue ... ...second bruise noted to right upper extremity dime sized1 ...elder had been combative during am care ... ...am care performed without the aid of PRN Ativan."" ""12/14 CNA found quarter sized skin tear on posterior right arm this am. Origin unknown."" ""12/16 Bruise to left upper posterior arm and right forearm ... ...also noted bruise under chin will continue to monitor and report. ""12/19 2:43 AM, elder has bruises to right and left arms, skin tear on right posterior upper arm, no combative behavior noted today, Urine for lab obtained."" ""12/19 3:02 AM 3 small circular bruises noted on elder's left anterior upper arm at about 9 PM last night. Staff reported elder has been unusually sleepy and agitated last 24 hours."" ""12/22 nurse called to the cottage by companion (CNA) because resident was not responding. She was found in her wheelchair slumped over and did not respond to verbal stimuli ... ...Pearson NP (nurse practitioner) arrived, diagnosis was seizure."" ""12/24 Therapy: for safety during care it is recommended that elder be provided assist of 2 persons ... ...requires extensive assist ... ...Recommend gait belt be utilized."" ""1/28/2011 companions reported bruise on left elbow of elder of unknown occurrence. Called and notified supervisor and required documentation completed."" Review of the incident report dated 11/18/2010 revealed the resident's bruises were identified during a body audit, the actions taken were ""advised companions to not attempt am care when elder combative ... ...AM or any other care until elder settles ... ...notify nursing immediately."" Review of the incident report dated 12/14/2010 revealed ""resident noted to have skin tear on posterior right arm by CNA this AM. Origin unknown."" The actions taken were the ""skin tear cleansed with wound cleanser and a dry dressing was applied. Resident reminded to use call light for assistance."" An Incident Investigation document that was not dated but appeared to reference the incident on 12/14/2010 indicated the elder sustained ""skin tears of unknown origin. Staff was interviewed by Administration. Elder possibly sustained skin tear during period of agitation while in bed."" An incident report dated 12/16 revealed the CNA's identified bruising to the chin and right forearm during care. The actions taken were ""elder taking Ativan in am before care and PRN Ativan because resident has tendency to be combative."" An incident report dated 12/18/2010 revealed, ""new bruises found on left anterior upper arm by primary nurse on second shift. 3 small (1 cm) bruises to left anterior upper arm. Immediate investigation to rule out abuse. Inspected room, devises, side rails, bed, tables and did not find anything that could cause that shape, size and location of elder's bruise. Full investigation in progress by DON, Administrator and SW."" Review of the incident report that was not dated but appeared to reference the incident on 1/28/2011 revealed, ""companion notified nurse of bruise to left elbow, 2 purplish areas found on left elbow."" The actions taken were ""observe elder for safety."" Review of the behavior and Mood Tracking Log revealed on 11/18/2010 Resident #1 did not exhibit any behaviors that day on any shift. On 12/14/2010 the resident did not exhibit any behaviors on any shift. On 12/16/2010, Resident #1 was noted to resist care at 12:02 AM and 11:47 AM; she was noted to yell at 12:02 AM, made negative statements at 12:03 AM, was physically abusive at 11:47 AM and 8:54 PM and was angry at 12:03 AM, 11:48 AM and 8:56 PM. On 12/18/2010 Resident #1 was noted to by physically abusive at 11:42 AM and was negative and angry at 11:46 AM. On 1/28/2011, no behaviors were documented as occurring. Review of the Physician's Progress Notes revealed Resident #1 was seen on 12/17/2010. The provider acknowledged the resident's behaviors as a result of her/his dementia. On 12/21/2010 the resident was again seen and addressed the resident's combative behaviors. She documented that the resident was noted to have a skin tear to the left elbow, a bruise 2 cm x 2 cm on the right elbow, right upper arm with 3 bruises. Obtain Geri-sleeves. On 12/22/2010 Resident #1 was again assessed in reference to the episode of unresponsiveness. The differential diagnoses were ""seizure versus bradycardic event, versus vasovagal episode. Spoke with daughter, had seizure and bradycardia in the past."" Razadyne (for dementia) was discontinued. No diagnosis of seizure was affirmatively made nor was any treatment for [REDACTED]. Review of the physician's orders [REDACTED]. A telephone order dated 12/21/2010 indicated to ""obtain Geri-sleeves."" During an interview on 2/14/2010 CNA #1 stated that she routinely cared for Resident #1. She stated that the resident required 2 people to perform care at all times. CNA #1 stated that Resident #1 did not need a lift for any transfer. CNA #1 stated that she did not always use a gait belt but would stand in front of the resident and have the resident ""hug"" her to assist the resident to stand. CNA #1 confirmed the use of the CNA care plan and stated she was aware the resident's mode of transfer was a stand up lift. She further stated that she did not know how the resident obtained the bruises on her arms. During an interview on 2/14/2011, CNA #2 stated that she routinely cared for Resident #1 and stated that the resident required 2 people for care. She stated that she performed a 2 person transfer for Resident #1. CNA #1 stated that she would cradle her arms under the resident's upper arm and perform a stand and pivot transfer. She stated that she sometimes used a stand up lift. CNA #1 stated that she ""sometimes "" used a gait belt during transfers. CNA #1 stated that she found the bruises on first shift and immediately reported them to the nurses. She stated that she was unsure how the bruising occurred. During an interview on 2/14/2011, CNA #3 stated that she routinely assisted with Resident #1. She stated that the resident required 2 people for care. She stated that the resident transferred via a 2 person pivot transfer. CNA #3 stated that she would stand in front of the resident and grab under the resident's arms with both hands or one CNA on each side facing the resident with their arms linked in the arm pit area. During an interview on 2/14/2011, the nurse assigned to Resident #1 stated that she had recently been assigned to the resident. She stated that she began working with the resident approximately 3 weeks ago. She stated that she was not aware how the resident transferred or if the resident needed a mechanical device. During an interview on 2/14/2011, the Physical Therapist stated that she had assessed the resident on 12/24/2010 as a routine annual assessment. The assessment was not related to any change in resident condition and was not referred from the nursing department. The Physical Therapist stated that based on her assessment the resident was able to bear weight at the time and recommended that a gait belt be used for all transfers. She further stated that if a resident had a change in condition and required a new lift mode then the CNA's would notify nursing who would then notify the therapy department to conduct an assessment as to what the appropriate lift device would be. She continued and stated that the CNA's could always upgrade the lift device if necessary but should never downgrade the type of lift without the therapy department's approval. The Therapist stated that CNA's should never hook under a resident's arms for a transfer. During an interview on 2/14/2011, the Rehab Manager stated that a gait belt should always be used by CNA's during transfers and CNA's should never pull a resident up by their arms. The Rehab Manager stated that if there was any change in the resident's condition and therapy evaluation was warranted. He stated that if the lift mechanism needed to be increased the nursing should notify the therapy department for an evaluation of the appropriate lift device. He stated that the therapists make their recommendations and write them in the chart as well as verbally inform the nursing department and then it is the nursing department's responsibility to disperse the information. He stated that he expected all therapy recommendations to be followed. During an interview on 2/14/2011, the Administrator stated that the injuries were of unknown source and that the incident on 12/22 where the resident was found unresponsive did not contribute to all of the injuries of unknown origin. The Administrator stated that the resident had not been nor is being treated for [REDACTED]. Five CNA's were interviewed in regards to appropriate transfers and knowledge of the transfers. All five CNA's stated that the method of transfer was documented on the CNA care plan and all five stated that they would always follow what was written. All five stated that they always used a gait belt. All five stated that if the resident could not transfer by way of what was recommended, they would immediately inform the nurse. Review of the facility's policy on the Care of Elders with Impaired Mobility revealed, ""elders who are unable to bear their own weight will be transferred using a mechanical device. The Cottage Nurse will determine whether an elder has the balance and strength necessary to be safely transferred using a transfer belt.""",2014-06-01
10075,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-02-01,323,E,1,0,669L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on observations, record review, interviews, review of the facility's policies, incident reports and the ankle transmitter log, the facility failed to provide adequate supervision to an exit seeking residents. Resident #1 was observed in the parking lot without an ankle transmitter attached. The facility failed to assure adequate checks of the resident's transmitters to assure safety. The findings included: During initial tour of the facility all fifteen residents with ankle transmitters were observed. 3 of 15 resident's transmitters were attached to their wheelchair. The wheelchairs were observed to have the resident's name on the wheelchairs. The facility admitted Resident #1 on 2/21/2008 with [DIAGNOSES REDACTED]. Observation of the resident on 2/7/2011 revealed the resident up in her wheelchair at the nurse's desk. The ankle transmitter was observed underneath the resident's wheelchair. The resident's name was taped to the inside of the back of the wheelchair. No transmitter was observed on the resident's ankle. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had short-term memory problems with moderately impaired daily decision-making skills. No behaviors were recorded as occurring during the assessment period. Review of the quarterly MDS dated [DATE] revealed no behaviors occurring within the assessment period. Review of the Care Plan dated 1/15/2011 revealed a problem area of ""Resident has exhibited exit seekings e/b (as evidenced by) going to front door and statements of going home."" Interventions included: ""place resident's name and picture on exit seeking board to alert staff of exit seeking behaviors, Monitor and assess changes in mood and behavior patterns, Assist staff in redirecting resident away from exit doors, Redirect resident away from exit doors, Give reality orientation as needed, Avoid making too many demands when redirecting resident away from exit doors, Call family when needed during periods when resident is hard to redirect, Med(ications) as ordered per MD, Ankle transmitter to back of w/c (wheelchair)."" Review of the Nursing Progress Notes dated 12/7/2010 at 2:20PM revealed ""Resident in parking lot and brought back to Unit I, stated, ""I was going home."" Ankle Transmitter re-applied..."" Further review of Nursing Progress Notes revealed weekly Behavior Summaries. Prior to 12/7/2010 no exit seeking behavior was documented. Review of the physician's orders [REDACTED]."" Review of the Incident/Accident Report dated 12/7/2010 at 1:50 PM revealed the resident eloped and was found in the parking lot. The 24 Hour follow up revealed ""cont(inue) with behavior tracking log and no attempts to elope."" Review of the Preventative Maintenance Log revealed the resident's transmitter was checked for placement and function on 12/5/2010. There was no method in place for assuring the placement and function of the transmitters more frequently. There was no documentation of the door checks. Review of the facility's investigation revealed on 12/7/2010 at 1:50 PM, ""resident was noted in the parking lot of the facility by staff members... Transmitter was not attached to resident's wheelchair as ordered. Investigation was initiated and transmitter placed on resident's ankle."" The CNA (certified nurse aide) assigned to the resident stated ""she put resident in the wheelchair that had her personal belongings on it. She stated she didn't notice that there was or wasn't a transmitter on her chair."" The resident's wheelchair was found in another resident's room. ""According to staff, therapy was looking for a different wheelchair for the other resident and swapped the chairs out. Therapy does not recall doing this. However, chairs had been changed and personal belongings switched over."" The resident ""now has a transmitter on her wheelchair and ankle. Her chair has been marked with her name. All resident's who have transmitters on their wheelchairs will have their chair marked with their name. Therapy staff has been inservice to check for these devices and to notify nursing when any wheelchairs are switched. RN (registered nurse) Supervisors will continue to be responsible for checking residents who exit seek routinely throughout their shifts."" Review of the Inservice Summary revealed only therapy staff were inservice and the topic discussed included wheelchair changes and/or modifications related to wheelchair alarms. Administration to provide therapy with a list of patients with alarms. All therapists, assistants, and technicians to check list, chairs and with nursing for alarms prior to changing chair and inform nursing of changes. No inservice was conducted with the nursing staff related to checking the placement and function of the transmitters more frequently to assure the residents' safety. Review of the ""Exit Seeker Checks"" completed by the RN Supervisors revealed the residents were checked at 6:30 AM, 7:30 AM, 2:30 PM, 3:30 PM, 7:30 PM, 10:30 PM, 11:30 PM and 3:30 AM. The check marks indicate that each resident was observed only. The RN Supervisors were not responsible for checking placement and/or function of the transmitters during the checks. On 12/7/2010, the RN Supervisor observed Resident #1 at 7:30 AM and 2:30 PM on first shift. No other documentation of the resident's was located prior to her elopement. Multiple days were missing documentation. Per the Administrator, the blank days were days when the RN Supervisors were not in the building. The Administrator stated that no one documents on the check sheet when the RN Supervisors are not working. Review of the facility's policy on Utilization of Door Alarm Bracelets revised 12/1/2009 revealed ""Assess individual residents through facility Physical Device/Restraint Reduction Committee to determine the appropriateness of an alarm bracelet...Assure all facility staff have been inservice on the alarm system and are aware of all residents wearing a door alarm bracelet...No device takes the place of observation, 1:1 intervention, and meaningful activities for the resident."" Review of the Exit Seeking Policy and Protocol revealed ""3. Evaluate the Environment, a. door alarms b. electric magnetic door locks, key pads, alarm bracelets, bed/chair alarms, stop signs."" Five interviewable residents were interviewed with no concerns voiced related to wandering residents. The Resident Council Minutes and Grievance Logs were reviewed from July 2010 through January 2011, with no concerns related to wandering residents. Four CNAs were interviewed; all stated that they do not check their assigned residents for the presence of the ankle transmitters. Four staff nurses were interviewed; all stated that they were not responsible for checking the placement of their assigned residents' ankle transmitters. The nurses stated that RN Supervisors were responsible for checking the placement and function of the ankle transmitters weekly. The RN Supervisors also were responsible for checking the doors nightly. During an interview on 2/7/2011, the Rehab Manager stated that Resident #1's wheelchair was switched with another resident. However, she stated that the therapy department did not switch the wheelchairs. She stated that Resident #1 was not receiving therapy at the time. The Rehab Manager stated that the therapy staff was inservice and was provided a list of exit seeking residents. She stated that prior to Resident's #1's elopement, there was no system in place to alert the therapy staff of an exit seeking resident. After the elopement, therapy staff was to double check the list provided by Administration and if there was a wheelchair transmitter, the wheelchair was to be sent to maintenance to have a new transmitter attached. When asked, the Rehab Manager was unable to produce the list. The Maintenance Director was observed to check all exit doors for function of the alarm system. All doors were functioning appropriately. He stated that he did not routinely check the doors, that nursing was responsible. He stated that there was no documentation of the door checks. During an interview on 2/7/2011, the two CNAs that found the resident outside stated, a "" dietary worker "" alerted them that a resident might be outside. Both CNAs ran around the building and saw Resident #1 rolling down the parking lot in a wheelchair. Both CNAs escorted the resident back inside and notified nursing. Both CNAs stated that they did not notice if there was an ankle transmitter attached to the resident or the wheelchair. During an interview on 2/7/2011, the CNA assigned to the resident at the time of elopement stated that she had placed the resident into a wheelchair that morning. She stated that the resident's personal belongings were in the wheelchair. She stated that she did not check for a transmitter nor did she notice if one was attached to the resident's or the wheelchair. During an interview on 2/7/2011, the Administrator stated that the RN Supervisors were to check the function of the doors nightly on third shift. She confirmed there was no documentation of those checks. The Administrator stated that the RN Supervisors checked placement and function of the transmitters weekly. She also stated that the RN Supervisors observed each exit seeking resident 8 times daily. The Administrator confirmed that the checks were an observation to assure the residents were in the building and the RN Supervisors did not check placement and/or function of the transmitters. The Administrator confirmed Resident's #1 did not have a transmitter attached to her ankle because the resident's legs swelled. The Administrator stated that there was no policy regarding the checks of the residents or how often the transmitters were checked for placement and/or function. The Administrator also confirmed that there were no formal assessments for exit seeking and elopement. She stated that she relied on the judgment of the nursing staff to determine if a resident needed an intervention related to exit seeking. The Administrator also confirmed that no inservice was conducted for the nursing staff related to checking the placement of the transmitters.",2014-06-01
10076,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2011-02-02,280,E,0,1,P4G911,"**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 revise the care plans of 3 of 3 residents diagnosed with [REDACTED]. (Residents #7, #10, & # 14) The findings included: Resident #14 was admitted [DATE] and diagnosed with [REDACTED]. Record review on 2/1/11 at approximately 4:10 PM revealed the Care Plan did not identify[DIAGNOSES REDACTED] as a need to be addressed. On 2/2/11 at approximately 9:20 am Licensed Practical Nurse (LPN) #1, after reviewing the care plan, verified that the Care Plan did not address the resident had been diagnosed with [REDACTED]. The facility admitted Resident #7 on 06-12-09 with readmission on 12-10-10 with [DIAGNOSES REDACTED]. Record review on 01-31-11 at approximately 5:42 PM of Resident #7's Hospital Medical Records-Discharge Summary with discharge date of [DATE] revealed a final [DIAGNOSES REDACTED]. Further record review on 01-31-11 at approximately 5:42 PM of the physician's orders [REDACTED]. Record review on 02-01-11 at 9:30 AM of the Nurses Notes dated 12-10-10 revealed Resident #7 was readmitted with ""[DIAGNOSES REDACTED]. The resident's Care Plan dated 10-28-10 to 01-28-11 had not been updated to reflect precautions and treatment for [REDACTED]. During an interview on 02-02-11 at 9:15 AM with Licensed Practical Nurse (LPN) #2, she verified the Care Plan had not been updated to reflect precautions and treatment for [REDACTED]. During an interview on 02-02-11 at approximately 3:05 PM with the Director of Nursing (DON), the DON stated the staff nurse should have updated Resident #7's Care Plan to include the [DIAGNOSES REDACTED]. She further verified transmission-based precautions should have been implemented; therefore, Resident #7 should have been placed on Contact Precautions at that time. During an interview on 02-02-11 at approximately 3:25 PM with Registered Nurse (RN) #2, she stated the staff nurses were responsible for updating the Care Plan when a culture was positive for [MEDICAL CONDITION] and Physician order [REDACTED]. The facility admitted Resident #10 on 06-15-10 with [DIAGNOSES REDACTED]. Record review on 02-01-11 at approximately 3:50 PM of the Physician's Telephone Orders dated 08-03-10 revealed a physician's orders [REDACTED]. Further record review of the Stool Culture Report dated 08-02-10 for [MEDICAL CONDITION] Toxin revealed a result of ""Positive"". Additional record review on 02-01-11 at 4:35 PM of the Comprehensive Plan of Care dated 08-03-10 for Rap/Problem /Need of [MEDICAL CONDITION] positive revealed Goal of ""[MEDICAL CONDITION] stool will be negative and be free of loose stools"". Additional review of the Comprehensive Plan of Care dated 08-03-10 for [MEDICAL CONDITION] positive revealed Approach of ""Take meds (medications) as ordered by Medical Doctor (M.D.)"". The Comprehensive Plan of Care had not been updated to reflect transmission-based precautions for the [DIAGNOSES REDACTED]. During an interview on 02-01-11 at 5:00 PM with Licensed Practical Nurse (LPN) #2, she verified the Comprehensive Plan of Care dated 08-03-10 for Rap/Problem/Need of [MEDICAL CONDITION] positive had not been updated to reflect transmission-based precautions. She stated, ""Universal precautions with glove use would only have been the necessary thing because the resident had been in a private room. No isolation would have been necessary or the segregation of linen"". After surveyor inquiry of the Comprehensive Plan of Care dated 08-03-10 related to [MEDICAL CONDITION] not being updated, the facility staff wrote a Care Plan with date of 08-03-11 to reflect a [DIAGNOSES REDACTED].",2014-06-01
10077,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2011-02-02,441,F,0,1,P4G911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, interviews, review of the ""Center for Disease Control (CDC) Guideline for Isolation Precautions: Appendix A"", and review of facility policies titled, ""Handwashing/Hand Hygiene"", ""Infection Control Policy"", and ""Isolation - Initiating Transmission-Based Precautions"", the facility failed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of disease and infection for 3 of 3 sampled residents with Clostridium Difficile (C-Diff) and 1 of 3 residents observed for Foley Catheter care. A facility staff member failed to wash her hands prior to exiting Resident #20""s room after completion of Foley Catheter care. The facility further failed to implement transmission-based precautions for the [DIAGNOSES REDACTED].#10, and Resident #14. The findings included: The facility admitted Resident #7 on 06-12-09 with readmission on 12-10-10 with [DIAGNOSES REDACTED]. Record review on 01-31-11 at approximately 5:42 PM of Resident #7's Hospital Medical Records-Discharge Summary with discharge date of [DATE] revealed final [DIAGNOSES REDACTED]. Further record review on 01-31-11 at approximately 5:42 PM of the Physician's Orders dated 12-10-10 through 12-31-10 revealed Physician's Orders for the following medications: and ""Keflex 500 mg capsule (cap) po twice a day (bid) x 7 days for[DIAGNOSES REDACTED]"". Record review on 02-01-11 at 9:30 AM of the Nurses Notes dated 12-10-10 revealed Resident #7 readmitted with ""[DIAGNOSES REDACTED]. Record review on 02-01-11 at approximately 9:30 AM of the Care Plan dated 10-28-10 to 01-28-11 for [DIAGNOSES REDACTED].#7's Infection Control Reporting Form dated 12-10 revealed the ""date of signs and symptoms of infection developed on 12-10"" with site as ""Gastrointestinal"". Further review of the Infection Control Reporting Form dated 12-10 revealed Resident #7 had been started on the following medication, ""[MEDICATION NAME] 250 mg po qid x 7 days (order from hospital)"". Additional review of the Infection Control Reporting Form revealed Resident #7 had also been started on ""Keflex 500 mg po bid x 7 days from the hospital"". During an interview on 02-02-11 at approximately 3:05 PM with the Director of Nursing (DON), the DON revealed transmission-based precautions should have been implemented; therefore, Resident #7 should have been placed on Contact Precautions at that time. The facility admitted Resident #10 on 06-15-10 with [DIAGNOSES REDACTED]. Record review on 02-01-11 at approximately 3:50 PM of the Physician's Telephone Orders dated 08-03-10 revealed a Physician's Order which stated, ""[MEDICATION NAME] 250 milligrams (mg) 4 times a day (qid)"". Further record review on 02-01-11 at approximately 4:35 PM of the Stool Culture Report dated 08-02-10 for[DIAGNOSES REDACTED]icile Toxin revealed a result of ""Positive"". Additional record review on 02-01-11 at 4:35 PM of the Comprehensive Plan of Care dated 08-03-10 revealed it had not been updated to reflect transmission-based precautions for the [DIAGNOSES REDACTED].#10's Infection Control Reporting Form dated 08-03-10 revealed the ""date of signs and symptoms infection developed on 07-19-10"". The Infection Control Reporting Form further revealed a Stool Culture report dated 07-30-10 with a result of ""C-Diff"" and Isolation Precautions needed: ""Contact"". Review on 02-02-11 at approximately 3:00 PM of the ""CDC Guideline for Isolation Precautions: Appendix A"" revealed, ""Type and Duration of Precautions Recommended for Selected Infections and Conditions: Infection/Condition: [DIAGNOSES REDACTED]icile: Type of Precaution: Contact, and Duration: DI-Duration of illness"". Review of the facility policy titled ""Isolation-Initiating Transmission-Based Precautions"" revealed the Policy Statement stated, ""Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions"". Additional review of the facility ""Infection Control Policy"" revealed Contact Precautions section (a) stated, ""Examples of infections requiring Contact Precautions include, but are not limited to: (2) Diarrhea associated with Clostridium difficile"". The facility admitted Resident #20 on 12-08-10 with [DIAGNOSES REDACTED]. On 02-02-11 at 9:45 AM, observation revealed Certified Nursing Assistant (CNA) #2 knocked on Resident #20's room door, identified self, afforded privacy, and proceeded to provide Foley Catheter care. After completion of the Foley Catheter care, CNA #2 removed her gloves, gave Resident #20 water, and proceeded to exit the room without washing her hands. During an interview on 02-02-11 at 2:05 PM with CNA #2, she verified she had not washed her hands prior to exiting Resident #20's room. Review of the facility policy titled ""Handwashing/Hand Hygiene"" documented under Policy Interpretation and Implementation #5 stated: ""Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: (a.) Before and after direct contact with residents and (d.) After removing gloves"". Resident #14 admitted [DATE] and diagnosed with [REDACTED]. Record review on 2/1/11 at approximately 4:10pm revealed a physician's order dated 1/20/11 ""Start [MEDICATION NAME] 500mg (milligram) TID (Three Times a Day) x (times) 7 days for[DIAGNOSES REDACTED]"". Nursing Notes dated: 1/20/11 - "". . .pt teaching of infection cycle and the intervention/effectiveness of ABT (Antibiotic Therapy) program based on lab results and overall effectiveness of med . . ."" 1/21/11 - "". . .educated to wash hands with soap and water frequently (sic)"". 1/22/11 - ""Medicated with [MEDICATION NAME] (sic) for episode of diarrhea."" 1/24/11 - ""continues to have some loose stool."" 1/27/11 - "". . .Res (Resident) continues on [MEDICATION NAME] 300 mg for[DIAGNOSES REDACTED]. x 1 loose stool noted . . ."" Interview with Licensed Practical Nurse (LPN) #1 on 2/2/11 at approximately 9:20am indicated that the resident was educated on frequent hand washing and if the resident left the room, the resident was to be checked for cleanliness. When asked how staff were informed, ""would verbalize to nursing staff that resident has an infectious condition and what steps to be taken."" When asked how the Certified Nursing Assistants and housekeeping staff were informed, LPN #1 stated they would be informed at Morning Meeting Further review on 2/2/11 revealed an ""Infection Control Reporting Form"" dated 1/20/11. The section headed ""This section to be completed by the Infection Preventionist"" ""Isolation Precautions needed: (specify type)"" was not completed.",2014-06-01
10078,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2011-02-02,315,D,0,1,P4G911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On two days of the survey, based on observations, interviews, review of the facility's competency evaluation ""Catheter Care Competency: Indwelling Catheter"", and review of facility policies titled ""Handwashing/Hand Hygiene"" and ""Catheter Care, Indwelling Catheter"", the facility failed to ensure 2 of 3 sampled residents observed for indwelling (Foley) Catheter care received appropriate care and services. During Foley Catheter care for Resident #3, the facility staff cleansed the penis with a downward motion toward the catheter insertion site and cleansed the scrotal area in an upward wiping motion toward the base of the penis. During Foley Catheter care for Resident #20, the facility staff cleansed the scrotal area in an upward wiping motion toward the base of the penis and further failed to wash her hands after gloves removed prior to Resident #20 given water and exiting the room. The findings included: The facility admitted Resident #3 on 02-18-10 with [DIAGNOSES REDACTED]. On 02-01-11 at 12:06 PM, observation revealed Certified Nursing Assistant (CNA) #1 knocked on Resident #3's room door, identified himself and procedure, and provided privacy. CNA #1 washed his hands, donned clean gloves, and proceeded to provide Foley Catheter care. After the Foley Catheter tubing had been cleansed in a circular manner downward away from the insertion site, CNA #1 cleansed the head of the penis with a downward wiping motion toward the catheter insertion site. CNA #1 afterwards cleansed Resident #3's scrotal area in an upward wiping motion toward the base of the penis and continued with the catheter care. During an interview on 02-02-11 at 1:50 PM with CNA #1, he verified the head of the penis and the scrotum had been cleansed by wiping in the wrong direction. He further revealed he had been nervous and forgot he could start over if warranted. During an interview on 02-02-11 with the facility Administrator, she stated staff were in the process of being evaluated for catheter care competency. Review of the facility's competency evaluation ""Catheter Care Competency: Indwelling Catheter"" on 02-02-11 revealed CNA #1 had demonstrated satisfactory competency on 01-14-11. The facility admitted Resident #20 on 12-08-10 with [DIAGNOSES REDACTED]. On 02-02-11 at 9:45 AM, observation revealed Certified Nursing Assistant (CNA) #2 knocked on Resident #20's room door, identified herself and procedure, and provided privacy. CNA #2 washed her hands, donned clean gloves, and proceeded to provide Foley Catheter care. After Resident #20's brief had been unfastened, CNA #2 cleansed Resident #20's scrotal area in an upward wiping motion toward the base of the penis. At the completion of the Foley Catheter care, CNA #2 removed her gloves, gave Resident #20 water, and exited the room without washing her hands. During an interview on 02-02-11 at 2:05 PM with CNA #2, she revealed she had seen the facility's Foley Catheter care policy and stated ""Okay"" in response to this Surveyor's observation. CNA #2 further verified she had not washed her hands prior to exiting Resident #20's room. Review of the facility policy titled ""Catheter Care, Indwelling Catheter"" revealed Procedure #4 stated ""....For Males cleanse at insertion site in circular motion working outward from catheter insertion site"". Procedure #11 stated ""Wash hands"". Review of the facility policy titled ""Handwashing/Hand Hygiene"" revealed Policy Interpretation and Implementation #5 stated ""Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: (a.) Before and after direct contact with residents and (d.) After removing gloves"".",2014-06-01
10079,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2010-08-18,431,E,0,1,SNPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain records of receipt and disposition of all controlled drugs in sufficient detail to ensure a determination that drug records were accurate and periodically reconciled for 3 of 7 sampled residents reviewed for the administration of controlled substances. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. The medical record documented the medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. In addition the facility failed to provide a separately locked, permanently affixed compartment for storage of discontinued controlled drugs (Schedule II and other drugs subject to abuse) which limited access to authorized personnel, in the First Floor Medication Room. (One of 2 medication rooms reviewed for medication storage). The findings included: On 8/18/10 at 8:53 AM, observation of the First Floor Medication Room revealed a locked cabinet used for storage of discontinued narcotics and other controlled medications (per the Consultant Pharmacist). The cabinet was locked but a hole was observed in the cabinet door. The hole was measured to be 20 inches from the bottom of the cabinet. The hole was large enough for this surveyor to insert a hand through the hole and inside the locked cabinet. Observation of the contents of the cabinet revealed the following multidose containers: 1 pack OxyContin CR (Controlled Release) 10 mg - 4 tablets remaining 1 pack Morphine ER (Extended Release) 15 mg - 4 tablets remaining 1 pack Temazepam 30 mg Capsules - 2 capsules remaining 1 pack Diazepam 5 mg Tablets - 30 tablets 1 pack Ambien 10 mg Tablets - 9 tablets remaining 1 pack Ambien 10 mg Tablets - 28 tablets remaining 1 pack Lortab 5/500 mg Tablets - 70 tablets remaining 1 pack Roxicet 5/325 mg Tablets - 50 tablets remaining. In addition to those listed above, there were 45 other (partial and full) containers of controlled medications stored in the cabinet. During an interview on 8/18/10 at 8:58 AM, the Consultant Pharmacist verified that the hole in the cabinet door was a possible means of access to the discontinued controlled medications by unauthorized personnel and that the discontinued controlled medications were in containers that would fit through the hole in the cabinet door. The facility last admitted Resident # 4 on 7/9/10. The resident's [DIAGNOSES REDACTED]. On 8/17/10 at 10:15AM, review of the current medical record revealed the resident was ordered by the physician to receive liquid Lortab 7.5/15 milliliters (ml)- 20 ml every four hours for pain. A review of the Narcotic Sign Out Record revealed on 7/28/10 at 1800 15 ml was signed out as administered with a notation of ""bottle completed"". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders, physician progress notes [REDACTED]. After the concern had been brought to the attention of the facility, the nurse responsible for the administration of the medication was sent to speak to this surveyor, accompanied by the Director of Nursing and the Consulting Pharmacist. The nurse stated s/he was aware that the full dose had not been administered. S/he stated it had brought it to the attention of the supervisor, and s/he had reassessed the resident. S/he stated 15 ml had been administered because that was all that was left in the bottle and an additional supply was not available at that time. When asked if s/he understood the surveyors concerns and that there was no documentation in the medical record, s/he stated ""yes."" The facility last admitted Resident # 17 on 8/14/10. The resident's [DIAGNOSES REDACTED]. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive Ativan .5 milligrams daily at 2PM. Review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Sign out Record indicated the medication was not removed from the controlled supply on 7/23 and 7/26/10. On 10:10AM, the Unit Manager stated the initial in the box for 7/23 and 7/26/10 was an ""R"" meaning that the medication was refused. The Unit Manager verified the initial was not circled and there was no further documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 7/6/10 Ativan 0.5 milligrams was documented as administered to Resident # 17 at 1400. However, the Narcotic Sign out record did not document the medication was removed for administration and the quantity of medication remained the same from 7/5-7/7/10. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive Ativan .5 milligrams daily at 2PM. Review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s refusal. The Ativan quantity available for administration on the narcotic sign out record remained the same from 8/7 (28 doses) to 8/12/10 (27 doses) . On 8/18/10 at 10:10AM the Unit Manager stated s/he was unable to find additional information to explain the doses which were not administered. A review of the facility provided policies revealed under Event Reporting that the ""following medication incidents should be reported; Any error or omission in providing a medication such as: 1. Per physician's written order 2. At the time and date prescribed 3. With the correct drug 4. In the correct quantity...."" The facility policy for Controlled Medications stated...: ""2. A declining inventory record is to be maintained for all controlled drugs. This ""Narcotic Sign Out Record"" is to account for each dose of medication given to a resident. Each line of the Narcotic Sign Out Record is to represent one dose.... 5. If a dose is removed from the container for administration but refused by the resident or not given for any reason, it is to be documented on the Narcotic Sign out record on the line representing that dose. The controlled medication should be placed in a small envelope that is stamped with the resident's name, prescription number, and name of controlled medication. This medication is to be given to the supervisor or DON (Director of Nursing) for proper destruction by the pharmacist. If unable to follow above procedure, two nurses may flush refused dose in the sewer system with appropriate documentation on the Narcotic Sign Out Record. 7. Any discrepancy in the count of controlled substances is to be reported immediately to the responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found...."" The facility policy for Oral Medication Administration Procedure stated: ""14. If a resident refuses medication, indicate on MAR by placing the letter ""R"". a. Note refusal or ingestion of less than 100% of dose in the ""Nurse's Medication Notes"" on the back of the MAR."" The facility admitted Resident #19 on 5/10/2006 with [DIAGNOSES REDACTED]. During review of the resident's medical chart on 8/17/2010 and 8/18/2010, records revealed multiple entries, for the month of July, on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No witnesses were documented. Resident #19 received Xanax 0.25 milligrams (mg) 1 tablet twice a day at 0900 (9:00 AM) and 1700 (5:00 PM). She/he also received Lortab 2.5/500 tablet 1-twice a day at 9:00 AM and 5:00 PM. There were also entries that indicated the medications were given on the MAR but were not signed out on the Narcotic Record. Xanax 0.25 mg tablets were signed out on the resident's Narcotic Record on 7/5 at 0900 and 7/14 at 0900, 7/25 at 0900. The MAR indicated [REDACTED]. Each entry stated that the resident had refused the medication with no second nurses' signature to witness the wasted narcotic. On 7/24 and 7/27/2010 the Xanax 0.25 mg tablet was signed as given on the MAR but was not signed on the Narcotic record as being removed from the supply. Resident #19 also received Lortab 2.5/500 at 9:00 AM and 5:00 PM. On 7/13, 7/14 at 9:00 AM, 7/23 at 5:00 PM, 7/25 at 9:00 AM , 7/28 at 9:00 AM and 7/30/2010 at 5:00 PM the Lortab was signed as removed from the narcotic supply to administer. The MAR indicated [REDACTED]. The records indicated that there had not been an additional nurses' signature verifying that the medications had been wasted properly. Review of Resident #19's Nurses' Notes revealed one entry on 7/25/10 that the resident had refused her/his medications. This entry contained no information related to a witness to the disposal of the controlled medications. On 8/18/2010 at 10:30 AM, during an interview with Registered Nurse #1, she/he verified that there had been no witnesses to the disposal of the Xanax and the Lortab documented. She/he also agreed that there should be two nurses that witness the disposal of any controlled medication. Cross refer to F281 related to facility policies for Medication Administration, Controlled Medications and Event Reporting.",2014-06-01
10080,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2010-08-18,281,E,0,1,SNPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain professional standards for the administration of controlled medications. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. Resident # 4's medical record documented medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Concerns were identified related to the disposal of controlled medications which were dispensed but refused by Resident # 19. Resident # 17 was documented as having refused his/her controlled medications without further explanation. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. (3 of 7 sampled residents reviewed for the administration of controlled substances.) The findings included: The facility last admitted Resident # 4 on 7/9/10. The resident's [DIAGNOSES REDACTED]. On 8/17/10 at 10:15AM, review of the current medical record revealed the resident was ordered by the physician to receive liquid [MEDICATION NAME] 7.5/15 milliliters (ml)- 20 ml every four hours for pain. A review of the Narcotic Sign Out Record revealed on 7/28/10 at 1800 15 ml was signed out as administered with a notation of ""bottle completed"". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders, physician progress notes [REDACTED]. After the concern had been brought to the attention of the facility, the nurse responsible for the administration of the medication was sent to speak to this surveyor, accompanied by the Director of Nursing and the Consulting Pharmacist. The nurse stated s/he was aware that the full dose had not been administered. S/he stated it had brought it to the attention of the supervisor, and s/he had reassessed the resident. S/he stated 15 ml had been administered because that was all that was left in the bottle and an additional supply was not available at that time. When asked if s/he understood the surveyors concerns and that there was no documentation in the medical record, s/he stated ""yes."" The facility last admitted Resident # 17 on 8/14/10. The resident's [DIAGNOSES REDACTED]. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive [MEDICATION NAME] .5 milligrams daily at 2PM. Review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Sign out Record indicated the medication was not removed from the controlled supply on 7/23 and 7/26/10. On 10:10AM, the Unit Manager stated the initial in the box for 7/23 and 7/26/10 was an ""R"" meaning that the medication was refused. The Unit Manager verified the initial was not circled and there was no further documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 7/6/10 [MEDICATION NAME] 0.5 milligrams was documented as administered to Resident # 17 at 1400. However, the Narcotic Sign out record did not document the medication was removed for administration and the quantity of medication remained the same from 7/5-7/7/10. A review of the facility provided policies revealed under Event Reporting that the ""following medication incidents should be reported; Any error or omission in providing a medication such as: 1. Per physician's written order 2. At the time and date prescribed 3. With the correct drug 4. In the correct quantity...."" The facility policy for Controlled Medications stated...: ""2. A declining inventory record is to be maintained for all controlled drugs. This ""Narcotic Sign Out Record"" is to account for each dose of medication given to a resident. Each line of the Narcotic Sign Out Record is to represent one dose.... 5. If a dose is removed from the container for administration but refused by the resident or not given for any reason, it is to be documented on the Narcotic Sign out record on the line representing that dose. The controlled medication should be placed in a small envelope that is stamped with the resident's name, prescription number, and name of controlled medication. This medication is to be given to the supervisor or DON (Director of Nursing) for proper destruction by the pharmacist. If unable to follow above procedure, two nurses may flush refused dose in the sewer system with appropriate documentation on the Narcotic Sign Out Record. 7. Any discrepancy in the count of controlled substances is to be reported immediately to the responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found...."" The facility policy for Oral Medication Administration Procedure stated: ""14. If a resident refuses medication, indicate on MAR by placing the letter ""R"". a. Note refusal or ingestion of less than 100% of dose in the ""Nurse's Medication Notes"" on the back of the MAR."" The facility admitted Resident #19 on 5/10/2006 with [DIAGNOSES REDACTED]. During review of the resident's medical chart on 8/17/2010 and 8/18/2010, records revealed multiple entries, for the month of July, on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No witnesses were documented. Resident #19 received [MEDICATION NAME] 0.25 milligrams (mg) 1 tablet twice a day at 0900 (9:00 AM) and 1700 (5:00 PM). She/he also received [MEDICATION NAME] 2.5/500 tablet 1-twice a day at 9:00 AM and 5:00 PM. There were also entries that indicated the medications were given on the MAR but were not signed out on the Narcotic Record. [MEDICATION NAME] 0.25 mg tablets were signed out on the resident's Narcotic Record on 7/5 at 0900 and 7/14 at 0900, 7/25 at 0900. The MAR indicated [REDACTED]. Each entry stated that the resident had refused the medication with no second nurses' signature to witness the wasted narcotic. On 7/24 and 7/27/2010 the [MEDICATION NAME] 0.25 mg tablet was signed as given on the MAR but was not signed on the Narcotic record as being removed from the supply. Resident #19 also received [MEDICATION NAME] 2.5/500 at 9:00 AM and 5:00 PM. On 7/13, 7/14 at 9:00 AM, 7/23 at 5:00 PM, 7/25 at 9:00 AM , 7/28 at 9:00 AM and 7/30/2010 at 5:00 PM the [MEDICATION NAME] was signed as removed from the narcotic supply to administer. The MAR indicated [REDACTED]. The records indicated that there had not been an additional nurses' signature verifying that the medications had been wasted properly. Review of Resident #19's Nurses' Notes revealed one entry on 7/25/10 that the resident had refused her/his medications. This entry contained no information related to a witness to the disposal of the controlled medications. On 8/18/2010 at 10:30 AM, during an interview with Registered Nurse #1, she/he verified that there had been no witnesses to the disposal of the [MEDICATION NAME] and the [MEDICATION NAME] documented. She/he also agreed that there should be two nurses that witness the disposal of any controlled medication.",2014-06-01
10081,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2010-08-18,441,E,0,1,SNPY11,"On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. The findings included: On 8/17/10 a review of the facility laundry system was completed. It was revealed that only personal laundry was processed within the facility. On 8/17/10 an interview with Laundry staff member # 2, who stated s/he was the primary person responsible for personal laundry was conducted. S/he stated that personal laundry was processed using cold water. Laundry worker # 2 stated that if a resident was on isolation, s/he would use hot water. However, s/he was unaware of the water temperatures available for use within the laundry. When asked if any bleach/sanitizing type product was used for processing personal laundry, s/he stated ""no"". S/he also stated s/he processed the cloth napkins used by residents using hot water (unknown temperature) and no bleach. A follow-up interview with the Laundry supervisor confirmed the process used. At 12 noon, a written statement was given the surveyor stating the water temperature was not 160 degrees. On 8/18/10 at 11AM, a meeting was conducted with the Administrator at his/her request and representatives from the Laundry Supply Company responsible for processing other linens used by the facility and processed at the hospital; hospital/facility laundry representatives, facility engineers, Maintenance, and the survey team. During the meeting it was stated that the Administrator was not aware until August 2010 of the changes in the regulation. Due a personal concern, s/he had sent the information to the Director of Nursing who then sent the information to the person in charge of the laundry. However, no action had been taken until the concern was identified by the survey team.",2014-06-01
10082,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2010-08-18,280,D,0,1,SNPY11,"**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 Resident # 15's care plan to accurately reflect the location and type of access port to receive [MEDICAL TREATMENT]. ( 1 of 1 [MEDICAL TREATMENT] resident reviewed for accuracy of care plan.) The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where e/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented "" several attempts were made at an AV fistula, all failed and e/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related to any dressing checks. Continued record review on 8/18/10 revealed care plan #7 for Potential for Complications related to [MEDICAL TREATMENT]. Listed under approaches was the following: 1. Monitor/report/record to MD (Medical Doctor) prn (as necessary) [MEDICAL TREATMENT] complications such as air embolism, bleeding, decreased cardiac output, local or systemic infection. 2. check [MEDICATION NAME] site for s/s (signs/symptoms) infection. (Marked D/C-discontinued). 3. Check shunt site for s/s of infection, pain, or bleeding daily and prn. Check for bruit, thrill. During an interview with RN #3, the care plan person, she stated she had updated the care plan in April when the resident had surgery to place a shunt and thought the resident was receiving [MEDICAL TREATMENT] through the shunt. LPN #1 checked documentation in the medical record and stated, ""The resident did not have a shunt placed in April."" Therefore, the care plan did not accurately reflect care necessary for this resident related to [MEDICAL TREATMENT].",2014-06-01
10083,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2010-08-18,309,D,0,1,SNPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility had no Policies/Procedures related to Caring for the [MEDICAL TREATMENT] Resident , had no education for staff on care of [MEDICAL TREATMENT] resident in 2009 nor 2010, and had no documentation of any assessment of the resident after [MEDICAL TREATMENT] visits or coordination of care with the [MEDICAL TREATMENT] clinic. Resident #15 was 1 of 1 resident reviewed receiving [MEDICAL TREATMENT]. The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Hypertension, End Stage [MEDICAL CONDITION], Chronic Pain, Adult Failure to Thrive, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Debility, [MEDICAL CONDITION], and [MEDICAL CONDITION] with [MEDICAL CONDITION]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where s/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented "" several attempts were made at an AV fistula, all failed and s/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related to any dressing checks. Continued record review on 8/18/10 revealed care plan #7 for Potential for Complications related to [MEDICAL TREATMENT]. Listed under approaches was the following: 1. Monitor/report/record to MD(Medical Doctor) prn(as necessary) [MEDICAL TREATMENT] complications such as air embolism, bleeding, decreased cardiac output, local or systemic infection. 2. check [MEDICATION NAME] site for s/s (signs/symptoms) infection. (Marked D/C-discontinued). 3. Check shunt site for s/s of infection, pain, or bleeding daily and prn. Check for bruit, thrill. During an interview with RN #3, the care plan person, she stated she had updated the care plan in April when the resident had surgery to place a shunt and thought the resident was receiving [MEDICAL TREATMENT] through the shunt. LPN #1 checked documentation in the medical record and stated, ""The resident did not have a shunt placed in April."" RN #4 and LPN #1 confirmed the facility did not have a Policy and Procedure for Care for the [MEDICAL TREATMENT] Resident. Resident # 15 did not have physician's order in the current medical record for [MEDICAL TREATMENT] nor any orders for the care for the site. This was confirmed by both nurses. Later, an order was found in a closed chart. An interview with the Education Director revealed no inservices had been done in 2009 nor thus far in 2010 related to care for the [MEDICAL TREATMENT] Resident. She stated the staff would know what to do for the resident by the physician's orders and the resident's care plan. There were no physician's orders related to care of the [MEDICAL TREATMENT] site. Nor was the care plan correct as to the site or care of.",2014-06-01
10084,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2011-02-25,225,D,1,0,WRSH11,"On the day of the complaint inspection based on interviews and review of facility files, the facility failed to ensure that all incidents of neglect were reported and/or investigated for 1 of 2 incidents. Review of personnel files due to a complaint that all incidents of neglect were not reported and/or investigated indicated that Certified Nurse Aide (CNA) #1 was reprimanded for leaving a resident ""soaked and improperly positioned""; the incident was not reported to the State Certification Agency. The findings included: Personnel files sampled due to a complaint received by the State Certification Agency on 02/24/2011, indicated that the facility failed to report and/or investigate all incidents of resident neglect. Review of six personnel files revealed a Corrective Action Form for Certified Nurse Aide (CNA) #1 dated 01/21/2011 which stated, ""Left resident ...soaked and improperly positioned on 1/20/11. Action Required: Check residents before clocking out at the end of your shift. Ask for help if needed."" Employee Comments section was left blank. The form was signed but not dated by CNA#1. This incident was not reported to the State Certification Agency and an investigation of the incident was not provided by the facility. In an interview with the surveyor on 02/25/2011 at approximately 8:30 PM the Director of Nursing confirmed the incident was not reported to the State Certification Agency.",2014-06-01
10085,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2011-02-25,456,D,1,0,WRSH11,"On the day of the survey, based on observation and interview, the facility failed to maintain equipment to ensure a safe environment for resident snacks. The West Unit refrigerator, which contained food for resident snacks thermometer reading was above 40 degrees Fahrenheit on the day of the survey. The findings included: During tour of the facility on 02/25/2011 at approximately 5:35 PM, the temperature in the refrigerator in the West Unit nursing station was observed due to a complaint about nighttime snacks; the temperature was 42 degrees. The thermometer was located on the shelf on the door of the refrigerator. The refrigerator contained 9 individual servings of ice cream that were melting. LPN #1 observed the ice cream with the surveyor confirmed that it was soft and melting. The refrigerator was rechecked at approximately 8:10 PM and the thermometer registered 36 degrees Fahrenheit (F). The thermometer was observed in the same position on the shelf on the door of the refrigerator. Nine individual servings of ice cream were noted to be soft and melting. In an interview with the surveyor on 02/25/2011 at 7:15 PM Resident A stated that she was offered snacks at night, that the snacks often were applesauce, peanut butter and jelly sandwiches and ice cream. She confirmed that when she asked for ice cream it was usually soft and melting. Observation on 02/25/2011 at 8:15 PM revealed that 11 individual servings of sliced fruit, 3 ice creams, 3 milks, 7 sandwiches (4 peanut butter/jelly and 3 ham), 1 container of apple juice and 2 Graham crackers were delivered to the West Unit for night time snacks and placed at the nursing station.",2014-06-01
10086,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,364,F,0,1,IGX111,"On the days of survey, based on interviews and review of the cycle menus and resident council meetings, the facility failed to ensure residents received meals that were prepared by methods that conserved nutritive value, flavor, and appearance and served food that was palatable and varied. Complaints about repetition of the menu and the palatability of the food were expressed by a former resident, 3 of 5 individual residents who were interviewed, and 4 residents attending the Resident Council meeting. The findings included: During the survey, complaints about the food from residents addressed the quality of the meals and receiving the same food all the time. The four week cycle menus, with any changes made, were requested and reviewed. Examples of repeated food items were as follows: Week I-Thursday supper- Sauerkraut and Friday dinner and Monday supper- coleslaw. Sunday supper and Wednesday lunch- Macaroni and Cheese. Spinach Wednesday lunch and greens Wednesday supper. Week 2-pasta Saturday supper-Week 1, Sunday supper, Tuesday lunch, Tuesday supper, Thursday supper, and Saturday supper. Peaches- Sunday lunch, Tuesday supper, and Saturday lunch. Vegetable blend- Thursday dinner and Friday supper; mixed vegetables Monday supper. Week 3-Turkey- Wednesday supper and Thursday lunch. Apples- Saturday Week 2 supper, Sunday lunch, and Monday supper. Pudding- Wednesday lunch and supper. Week 4-Breaded fish fillet- Monday supper and Friday lunch. Brownie-Tuesday lunch and Saturday lunch. Pasta- Sunday supper, Monday supper, Tuesday supper, Thursday supper, and Saturday supper. Vegetable blend- Tuesday supper, Friday Supper and Saturday supper. Fruit was served as a dessert for 27 of 56 meals. Fresh fruit (not identified) was served 6 times. Fruit crisp Monday supper was not identified. Banana pudding was served Wednesday lunch and fresh fruit served Thursday lunch. Review of Resident Council meeting for February documented that the food was not pleasing to sight. A Food Committee meeting (no date) documented that the vegetables were overcooked-broccoli an issue. They would like hot dogs or hamburgers on Saturday. Comments from individual residents interviewed included:"" good not always best,"""" meat was too soft,"" ""get a lot of things too frequently,"" ""same thing served too often though they cook it differently,"" ""chicken us to death,"" ""overcook vegetables like mush,"" "" used to ask us what we liked and disliked but don't do anymore,"" food not adequate."" Interview with the Food Service Supervisor and Certified Dietary Manager on 4/22/14 at approximately 4:00 PM concerning the repetitive menu choices revealed that they were trying to get menus adjusted to the residents' likes was difficult since the southeast menus were planned by the Corporate Dietitian.",2014-06-01
10087,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,274,D,0,1,IGX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record reviews, interviews, and review of CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to conduct a Significant Change in Status Assessment after an improvement in 4 areas of ADL assistance for Residents # 7 and #10, 2 of 5 residents reviewed for a significant change in status. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 4/24/14 at 11:18 AM, review of the MDS (Minimal Data Set) dated 11/16/13 revealed Resident # 7 was coded as receiving extensive assistance (3) with bed mobility, transfers, locomotion off the unit, and toileting. Further review revealed an MDS dated [DATE] which indicated the resident had improved and was newly coded as limited assistance (2) for bed mobility, transfers, locomotion off the unit, and toileting. During an interview on 4/24/14 at 11:58 AM, MDS Coordinator #1 confirmed the 4 areas of improvement and that a Significant Change in Status Assessment was warranted and should have been conducted but had not. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. On 4/23/14 at 12:06 PM, record review of the Admission MDS dated [DATE] revealed Resident #10 was coded as requiring extensive assistance (3) with bed mobility, transfers, toileting and bathing. Further review revealed that on the 3/20/14 MDS, the resident required supervision (1) with those 4 areas of ADLs. Additional record review of the 9/30/13 MDS revealed Resident #10 was coded as needing limited assistance (2) for bed mobility, transfers, and toileting and supervision with bathing. During an interview on 4/23/14 at 1:15 PM, MDS Coordinator #2 confirmed the 4 areas of improvement documented on the 9/30/13 MDS. When asked if a Significant Change in Status Assessment should have been done, the MDS Coordinator stated ""I'm thinking it should have been"" but further stated ""I'll have to research it to be sure."" At 1:27 PM, the MDS Coordinator returned and stated that the Interdisciplinary Team had discussed the resident's changes and decided that a significant change had not been indicated because the 9/30/14 MDS indicated the resident was back to the resident's baseline when s/he was at home prior to admission. When asked if the resident was the same as s/he was at admission, the MDS coordinator and the Director of Nursing confirmed the resident's status was not the same as it had been documented at admission and on the admission MDS. A review of CMS' RAI Version 3.0 Manual, Chapter 2, page 2-20 revealed ""The SCSA (Significant Change in Status Assessment) is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either improvement or decline."" The manual further states ""A SCSA is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments..."" The CFR regulation states ""A facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition."" The regulation's interpretive guidelines define the criteria for a significant change as a ""decline or improvement is consistently noted in 2 or more areas of decline or 2 or more areas of improvement."" The guidelines further state, in part, that a SCSA is ""Any improvement in ADL assistance where a resident is newly coded as 0, 1, or 2 when previously scored as a 3, 4, or 8.""",2014-06-01
10088,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,281,D,0,1,IGX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interview, manufacturer package insert and facility guidelines, the facility failed to ensure that services were provided by the nursing staff to meet professional standards of quality related to [MEDICATION NAME] Patch rotation for 1 of 3 residents receiving [MEDICATION NAME] Patches. In addition, the facility failed to accurately transcribe an order for [REDACTED].#10 and failed to administer a one-time dose of [MEDICATION NAME] for Resident #10, 1 of 14 residents reviewed for professional standards related to medication administration. Cross refer to F 309 as it relates to failure to follow physician orders. The findings include: Resident # 11 was admitted to the facility on [DATE]. The residents [DIAGNOSES REDACTED]. On 4/22/14 record reviews of MARs (medication administration records) 2/1/14 through 2/25/14 revealed the resident was receiving a daily [MEDICATION NAME] Patch 4.6 mg (milligram)/24 hr (hour) and MARs 2/26/14 through 4/22/14 revealed the resident was receiving a daily [MEDICATION NAME] Patch 9.6 mg/24 hr. A further review of MARs during the period from 2/1/14 through 4/22/14 revealed that application site rotation had not been documented for 29 out of 77 days and that for those days where site application had been documented there was an irregular pattern which was inconsistent with preventing the same application site from being used multiple times with a 14 day period. The manufacturer ([MEDICATION NAME]) package insert and facility guidelines state to not use the same area for application for at least 14 days. During an interview with LPN (Licensed Practical Nurse) # 1 on 4/22/14 at approximately 10:50 AM, s/he confirmed that [MEDICATION NAME] Patch application sites for Resident # 11 were not being documented and rotated accurately and that they should have been rotated every 14 days. The facility admitted Resident # 10 to the facility with [DIAGNOSES REDACTED]. On 4/22/14 at approximately 9:42 AM, record review revealed an order dated 4/16/14 for [MEDICATION NAME] 200 mg. (milligrams) for 1 dose. Further review revealed an order dated 3/12/14 to decrease the dose of [MEDICATION NAME] to 30 mg. for 5 days then discontinue the medication and start Escitalopam at 10 mg. a day for 3 days then increase to 15 mg. daily. On 4/24/14 at 10:36 AM, review of the Medication Administration Record for April, 2014 revealed no documentation that the [MEDICATION NAME] had been administered. Further review of the March MAR revealed the [MEDICATION NAME] order had been transcribed as 30 mg. for 3 days (not 5 as ordered) . The previous order for [MEDICATION NAME] 60 mg. daily at bedtime was not discontinued on the MAR and was signed off as administered on 11 days after the order to discontinue and while the resident was receiving the new medication. There was no documentation on the reverse side of the MAR to indicate a reason why the [MEDICATION NAME] was not administered. Review of the Nurses Notes revealed no documentation of the administration of the [MEDICATION NAME] or of any reason why the medication was not given. There was no documentation that the facility had recognized the error in the transcription and administration of the [MEDICATION NAME]. During an interview on 4/22/14 at approximately 10:41 AM, Licensed Practical Nurse (LPN) #1 confirmed the 3/12/14 [MEDICATION NAME] order had been transcribed incorrectly and further confirmed the MAR indicated the resident had also continued to receive the previous dose of 60 mg. daily. During an interview on 4/24/14 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 confirmed the [MEDICATION NAME] was not documented as administered on the MAR. The LPN also confirmed that there was no documentation in the Nurse's Notes to indicate the medication was administered or any documentation why it was not administered. LPN #1 also stated the s/he was unable to locate documentation that the medication was received from the pharmacy.",2014-06-01
10089,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,441,F,0,1,IGX111,"On the days of the survey, based on policy review, record review and interviews, the facility failed to provide monitoring to help prevent the development and transmission of disease and infection. There was no tracking of organisms in six months review of the Infection Control Surveillance and no transmission precautions implemented for suspected lice in 1 of 1 resident reviewed for suspected lice. The findings included: During review of Resident # 9's medical record on 04/22/14 at approximately 3:30 PM, an assessment in the nurses notes dated 04/21/14 at 5 PM stated: ...Resident appears to have lice in hair and eye lashes. White nits are noted to hair throughout hair. No other documentation was found regarding the potential of the resident having lice. The Resident was in a semi-private room with a roommate. Interview with the Unit Manager, Licensed Practical Nurse #1, at the time of the findings verified that no follow up had been done and the resident should have been moved to a private room and placed on transmission precautions immediately until a further assessment was done. On 4/24/14 review of the facility's Infection Control Data Logs for October, 2013 through March, 2014 revealed inconsistent documentation on the Log of culture dates, if the culture was positive, and documentation of the organisms present on positive cultures. Review of the Logs revealed 4 incidents of a culture date, documented as positive with no organism identified; 2 cultures identified with a date, documented as positive with the organism designated with an ""x"" in the ""other"" column with no explanation of the meaning of ""x."" There were 8 infections with documented organisms without a culture date or indication of a positive result. There were 12 cultures dated with no documentation of whether the culture was positive and no organism identified but, due to the inconsistency of the documentation, could not conclusively be considered negative. Comparison of the Infection Control Data Log for October, 2013 to the individual resident surveillance reports for October revealed one resident with a positive urine culture identified as Escherichia coli and one with a culture positive for Lactobacillus not documented on the monthly log. Review of the November, 2013 log and individual reports revealed one report of greater than 100,000 bacteria without an organism identified and the attached urinalysis indicated the culture results were pending. Comparison of the January documentation revealed 2 individual reports that indicated urine cultures were obtained with no documentation of the results. There were 2 other individual reports that were documented on the log with an organism that were not indicated as positive. Review of the February documentation revealed an 2 individual reports indicating a positive urine culture with identified organisms which were not documented on the monthly log and 4 individual reports that indicated urine cultures were done with no documented results on the individual report or the monthly log. Review of the individual reports and monthly data log for March, 2014 identified 6 urine cultures that were obtained in March with no documentation of the results. During an interview on 4/24/14 at 9:32 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the organisms were not consistently listed on the Infection Control Data Logs. The DON and NHA stated that there were color coded maps for each month but the DON later confirmed that those only identified the type of infection, not the organism. The DON also confirmed the lack of documentation of the organisms on many of the individual reports. The DON indicated that after morning report each day, the charts of any reported infections/ antibiotic orders/ cultures were reviewed for physician notification and treatment orders. The results of any cultures were then entered into the computer but verified that the identified organisms were not being consistently entered into the computer.",2014-06-01
10090,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,502,D,0,1,IGX111,"**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 obtain laboratory (lab) tests timely for Resident #8 and did not obtain lab tests as ordered for Resident #10, 2 of 14 residents reviewed for labs. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 4/22/14 at 3:23 PM, record review of the monthly Physician order [REDACTED]. Review of the lab results in the record revealed a HgbA1c was obtained on 9/25/13, at the time the the original order was written, and on 1/25/14, 4 months after the first test) and 2/17/14, less than 1 month since the previous test. Continued review revealed the lipid panel had been drawn on 2/17/14 as ordered but the [MEDICATION NAME] was not obtained until 2/19/14 and the hemoglobin was not drawn until 3/1/14. During an interview at 10:15 AM on 4/23/14, Licensed Practical Nurse (LPN) #3 confirmed the [MEDICATION NAME] and hemoglobin had not been drawn on 2/17/14 as ordered and the HgbA1c had not been obtained every 3 months as ordered. The LPN stated s/he would check with the laboratory and with medical records for any results that had not been filed or had been thinned from the record. No additional information was provided by the facility by the end of the survey. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. On 4/22/14 at approximately 9:42 AM, review of the monthly Physician order [REDACTED]. The orders were written at the time of admission on 6/25/13. Review of the labs in the record at 10:51 AM revealed the last HgbA1c result in the record was dated 7/1/13 and there were no results in the record for a CBC, BMP, TSH, or B12. During an interview at 10:51 AM, LPN #1 confirmed the labs were not in the record. The LPN stated s/he would look into it but no further information was provided by the facility at the time of exit.",2014-06-01
10091,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2014-04-24,309,D,0,1,IGX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide necessary care and services for 1 of 1 sampled residents reviewed with antidepressant medication patches and 1 of 1 sampled residents with antidepressant orders not followed. Resident # 11 medication patch sites were not routinely rotated not documented and Resident #10 had a medication ordered by the physician that was not administered. Resident # 10 also had medication orders incorrectly administered. Cross refer to F 281 as it relates to professional standards. The findings included: Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/22/14 record reviews of MARs (medication administration records) 2/1/14 through 2/25/14 revealed the resident was receiving a daily [MEDICATION NAME] Patch 4.6 mg (milligram)/24 hr (hour) and MARs 2/26/14 through 4/22/14 revealed the resident was receiving a daily [MEDICATION NAME] Patch 9.6 mg/24 hr. The MARS prompted the nurses to ""remove old patch prior to applying a new one- apply to different site each day"" A further review of MARs during the period from 2/1/14 through 4/22/14 revealed that application site rotation had not been documented for 29 out of 77 days and that for those days where site application had been documented there was an irregular pattern which was inconsistent with preventing the same application site from being used multiple times with a 14 day period. The manufacturer ([MEDICATION NAME]) package insert and facility guidelines state to not use the same area for application for at least 14 days which was verified by LPN (Licensed Practical Nurse) # 1 on 4/22/14 at approximately 10:50 AM. On 4/22/14 at approximately 9:42 AM, record review for Resident # 10 revealed an order dated 4/16/14 for [MEDICATION NAME] 200 mg. (milligrams) for 1 dose. On 4/24/14 at 10:36 AM, review of the Medication Administration Record for April, 2014 revealed no documentation that the [MEDICATION NAME] had been administered. Further review revealed an order dated 3/12/14 to decrease the dose of [MEDICATION NAME] to 30 mg. for 5 days then discontinue the medication and start Escitalopam at 10 mg. a day for 3 days then increase to 15 mg. daily. Further review of the March MAR revealed the [MEDICATION NAME] order had been transcribed as 30 mg. for 3 days (not 5 as ordered) . The previous order for [MEDICATION NAME] 60 mg. daily at bedtime was not discontinued on the MAR and was signed off as administered on 11 days after the order to discontinue and while the resident was receiving the new medication. During an interview on 4/24/14 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 verified the concerns. .",2014-06-01
10092,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2011-06-22,367,D,0,1,MCJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, the facility failed to provide supplemental nutrition to Resident #5 as ordered by the physician. (1 of 4 sampled residents with weight loss reviewed.). The findings included: The facility admitted Resident #5 on 5/16/11. Her [DIAGNOSES REDACTED]. On 6/20/11, review of the physician's orders [REDACTED]."" During the dinner meal observation on 6/20/11 at 5:47 PM, no ice cream was served to the resident and this was confirmed by Certified Nursing Assistant (CNA) # 1. On 6/22/11 at 12:30 PM, no ice cream was served on the resident's lunch tray and this was confirmed by CNA #2. Review of the tray tickets at the time the meals were served revealed that ice cream was listed on both tickets. After the concern was brought to the facility's attention, a note dated 6/22/11 at 12:45 stated resident was given two 4 ounce cups of ice cream and consumed 100%. Review of the Weight Change History at approximately 2:45 PM on 6/22/11 revealed Resident #5 weighed 130 pounds on admission and on 6/20/11 weighed 121 pounds. The resident was referred for a speech therapy evaluation on 6/16/11. During an interview on 6/22/11 at 12:45 PM, the Dietary Manger stated there ""shouldn't be any reason"" for ice cream not to be served and that the CNAs ""should be putting everything on the ticket on the tray."" Review of the care plan revealed a care plan for Problems Affecting Nutrition with an interventions of ""Provide diet as ordered"" and ""Supplements as ordered.""",2014-06-01
10093,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2011-06-22,252,E,0,1,MCJQ11,"On the days of the survey, based on observation and interview, the facility failed to provide a clean and homelike environment as evidenced by a worn, soiled carpet with a strong urine-like odor in the activity room on the 500 Hall. The findings included: During multiple observations (on 06/20/11 at 12:50 PM, 2:30 PM, 3:50 PM and 5:45 PM; on 06/21/11 at 9:30 AM and 5:30 PM ), the activity room carpet on the 500 Hall was observed to be worn and soiled with a strong urine- like odor. On 06/22/11 at 11:00 AM, Licensed Practical Nurse (LPN) #3 verified that the activity room carpet was worn, soiled and had a strong urine- like smell. LPN # 3 stated: "" They keep cleaning it but it still smells really bad. We're hoping they pull it up soon.""",2014-06-01
10094,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2011-06-22,371,D,0,1,MCJQ11,"On 2 days of the survey, based on random observations and review of the facility policy titled ""Procedures for Dietary Infection Control"", the facility failed to serve food under sanitary conditions. Two Certified Nursing Assistants were observed touching residents' food without gloves or utensils. The findings included: A random observation of the 300 Hall dinner trays dispersion on 06-20-11 at approximately 6:05 PM revealed a Certified Nursing Assistant (CNA) had pressed a resident's sandwich downward on the plate with the palm of her hand without use of gloves or utensils. A second random observation revealed the CNA afterwards proceeded to disperse dinner trays and again touched another resident's sandwich with her fingers to cut it in half with a knife. A third random observation on 06-22-11 at approximately 12:20 PM of the 300 Hall dining room lunch trays dispersion revealed a CNA who removed a dinner roll from a paper wrap with her bare hands and placed it onto the resident's tray. Review of the facility policy titled "" Procedures for Dietary Infection Control"" revealed #4 stated ""Holding, transporting, and serving foods: Use gloves or utensils when touching foods"".",2014-06-01
10095,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2011-06-22,492,D,0,1,MCJQ11,"On the days of the survey, based on record review and interview, the facility failed to provide services in compliance with all Federal, State, and local laws, regulations and codes for failing to document licensure verification prior to the date of hire for 1 of 1 licensed employee. The findings included: Record review on 6/22/11 for one of one employee files reviewed for licensure verification contained no documentation to indicate that the facility verified licensure of the staff member prior to the date of hire. During an interview on 6/22/11 with the Administrator, she stated that licensure verification is reviewed prior to any interview of the potential employee. She continued by stating that the verification had been checked but not printed. There was no documentation provided/available that the license had been verified prior to hiring of the Registered Nurse.",2014-06-01
10096,LIFE CARE CENTER OF COLUMBIA,425337,2514 FARAWAY DRIVE,COLUMBIA,SC,29223,2011-02-02,225,D,1,0,OYED11,"On the days of the complaint inspection, based on record reviews, interviews, and review of facility files, the facility failed to ensure that all injuries of unknown origin were reported and/or investigated for 2 of 2 residents who sustained injuries from unwitnessed falls (Residents #6 and #8) and for one resident who had a bruise of unknown origin on the side of the nose (Resident #2). The findings included: Resident #6 sustained bilateral knee fractures from an unwitnessed fall on 10/15/10. The facility's investigation revealed the resident was left sitting on the edge of the bed while her nursing assistant went to the bathroom to change soiled gloves. Resident #6 was heard yelling out, and the nursing assistant found the resident on her hands and knees on the floor. The incident was reported to Health Licensing but was not reported to the State survey and certification agency. Resident #8's safety alarm sounded on 12/18/10. The staff found her lying on the floor, unresponsive and bleeding from the forehead and bridge of the nose. Facility staff began cardiopulmonary resuscitation and called 911. The facility reported the incident to Health Licensing but did not report it to the State survey and certification agency. The Director of Nurses confirmed these injuries of unknown origin were not reported to the State survey and certification agency during an interview at 2 PM on 2/1/11. Resident #2 sustained a bruise of unknown origin on the right side of her nose, per documentation in the nurse's note on 11/23/10. Review of the resident's medical record and the facility's reportable incident files failed to show evidence the injury of unknown was reported to the State survey and certification agency and failed to show any investigation by the facility in an attempt to determine how the bruise may have occurred. The DON confirmed that Resident #2's bruise was not reported or investigated during an interview at 2:30 PM on 2/2/11.",2014-06-01
10097,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2014-05-13,221,D,0,1,G9QM12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Revisit Survey, based on observations, interview and record review, the facility failed to ensure that 1 of 1 sampled resident reviewed for a physical restraint was assessed for the restraint and that physician's orders were followed related the physical restraint. Resident #18 noted with a tray to geri chair was not assessed and the physician's orders were not followed regarding remove and reposition every 2 hours and as needed. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. An observation on 5/12/14 at approximately 1 PM revealed the resident seated in corner near nurses' station with tray attached to recliner chair. An interview on 5/12/14 with the DON (Director of Nursing) revealed the tray to geri chair was a physical restraint and the family consented to the physical restraint on 3/03/14. Further record review revealed there was no assessment in the chart regarding the physical restraint and no physician's orders for the restraint. The DON indicated the charts may have been thinned and that he/she would check with medical records to locate the requested information. An observation on 5/13/14 at 9:31 AM revealed resident seated in front of the nurses' station with tray attached to wheel chair. On 5/13/14 at 11:32 AM the initial restraint assessment and physician's orders for the physical restraint were reviewed. There was no documentation the ""Initial Restraint Assessment"" to indicate the tray to geri chair was assessed. There was also no documentation to indicated the physician's orders were followed related to remove and reposition every two hours and as needed. Review of the facility's ""Restraint Policy"" revised July 2009 revealed under Procedure: 1. All residents will be assessed upon admission and quarterly thereafter to determine the potential need for restraints. 9. Restraints shall be checked every thirty minutes and released every two hours. An interview on 5/13/14 at approximately 11:51 AM the DON reviewed the physical restraint assessment and the physician's orders then confirmed the findings that the assessment did not address the tray on geri chair restraints and that there was not documentation to indicate the physician's order was followed related to the restraint.",2014-06-01
10098,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2014-05-13,249,E,0,1,G9QM12,"On the days of the Revisit Survey, based on interviews, the facility failed to ensure that the Activity Director had the required education/license/training or experience to direct the activity program at the facility. The Activity /Social Services Director had no full time experience, training,education or licensed an Activity Director. The findings included: An interview on 5/12/14 at approximately 4:29 PM with the A/SSD (Activity/Social Services Director) revealed he/she had been employed at the facility for seven years as the Activity/Social Services Director. The A/SSD further stated he/she was not certified as an Activity Director and had no previous full time work experience in an activities program in a health care setting. The A/SSD stated he/she did not complete any training course approved by the State to be an Activity Director. An interview on 5/13/14 at approximately 10:38 AM with the Administrator and A/SSD confirmed the findings that the Activity/Social Services Director was not certified or had no previous training/education as a Activity Director. In reviewing the activity logs provided by the faciltiy, the Administrator and A/SSD stated the activity logs were to be driven by what's on the activity calendars. The Administrator reviewed the activity logs and activity calendar for May 2014 and indicated the logs did not address what on the activity calendar. The A/SSD stated the Licensed Practical Nurses' role regarding activities were take residents to and from activities.",2014-06-01
10099,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2014-05-13,280,D,0,1,G9QM12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Revisit Survey, based on observations, interview and record review, the facility failed to ensure that 2 of 3 sampled residents reviewed care plan was updated to address fall interventions. Resident #18 noted with a tray to geri chair was not care planned with measurable goals for the use of the restraint. Resident #14 noted attempting to get out of bed twice unassisted was not care plan to address incidents. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. An observation on 5/12/14 at approximately 1 PM revealed the resident seated in corner near nurse's station with tray attached to recliner chair. An interview on 5/12/14 with the DON (Director of Nursing) revealed the tray to geri chair was a physical restraint and the family consented to the physical restraint on 3/03/14. Further record review revealed a care plan updated on 3/04/14 that indicated ""Consent for tray table restraint received"". On 5/12/14 at 11:32 AM the initial restraint assessment and physician's orders [REDACTED]. There was no documentation the ""Initial Restraint Assessment"" to indicate the tray to geri chair was assessed. There was also no documentation to indicated the physician's orders [REDACTED]. An interview on 5/13/14 at approximately 11:51 AM the DON confirmed the use tray table restraint was not addressed on the care plan that the measurable goals for use and time periods for the restraint to be released was not documented on the care plan. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. A chart review on 5/13/14 at approximately 1:14 PM revealed a nurse's note dated 5/5/14 at 11:45 PM the CNA (Certified Nursing Assistant found resident trying to get out of bed. There was no documentation to indicate the resident was on the floor or that an alarm sounded. The nurse's note further indicated at 2:05 AM the same thing happened again accept the resident indicated a CNA told him to get out of bed. An interview on 5/13/14 at approximately 1:34 PM with the MDS (Minimum Data Set) Coordinator confirmed the resident was a falls risk and the care plan was not updated to reflect resident was a falls risk.",2014-06-01
10100,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2014-05-13,520,E,0,1,G9QM12,"On the days of the Revisit Survey, based on observations, record reviews and interviews, the facility failed to identify that the Activity/Social Services Director did not meet the professional qualifications to be an Activity Director. The findings included: Random observations on 5/12-13/14 revealed residents not involved in an on-going structured program of activities. Random interviews with residents revealed activities provided included watching television and no activities taking place. Reveal of the activity logs did not reflect the activities that were listed on the activity calendar for the month of May 2014. An interview on 5/12/14 at approximately 4:29 PM with the Activity/Social Services Director revealed he/she had no previous full time work experience nor certification/training as an Activity Director. An interview on 5/13/14 at approximately 10:38 AM with the Administrator revealed the Activity/Social Services Director was not certified nor employed full time as an Activity Director.",2014-06-01
10101,PRESBYTERIAN HOME OF SC - SUMMERVILLE,425389,201 W 9TH NORTH STREET,SUMMERVILLE,SC,29483,2011-10-18,281,D,0,1,8R2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, record reviews and interviews revealed that the facility failed to ensure that professional standards of quality related to documentation of controlled substances were followed for 1 of 1 resident. (Resident #4) The findings included: On 10/18/11 at approximately 11:45 AM, a review of the July, 2011 MAR (Medication Administration Record) and Contolled Substance Receipt/Count Sheet (CSR/CS) for Resident # 4 revealed: 1. [MEDICATION NAME] (a controlled substance) 150 mg (milligram) that the medication had been charted on the MAR indicated [REDACTED]. Subsequent review of the CSR/CS (RX # 4) for Resident # 4 revealed that ""One"" dose of [MEDICATION NAME] 150 mg. had been entered as given at 2100 in the ""QTY GIVEN"" space of the sheet on both 7/23/11 and 7/24/11, but there was no signature in the ""GIVEN BY OR DESTROYED BY "" space of the sheet. 2. [MEDICATION NAME] 150 mg (1 dose) had been charted on the MAR indicated GIVEN BY OR DESTROYED BY"" space on the CSR/CS (RX # 4) for that dose. 3. [MEDICATION NAME] 75 mg (1 dose) had been charted on the MAR indicated GIVEN BY OR DESTROYED BY"" space on the CSR/CS (TX # 7) for that dose. On 10/18/11 at approximately 1:30 PM the ADON (Assistant Director of /Nursing) verified that the signatures were missing and stated that a signature should have been on the CSR/CS by the nurse who administered the medication. A review of the facility Controlled Substance Policy on 10/18/11 at approximately 5:05 PM revealed that the ""Contents of Control Sheet"" (CSR/CS) must contain ""Signature of nurse administering medication.""",2014-06-01
10102,PRESBYTERIAN HOME OF SC - SUMMERVILLE,425389,201 W 9TH NORTH STREET,SUMMERVILLE,SC,29483,2011-10-18,431,D,0,1,8R2L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, records reviews and interviews revealed that the facility failed to follow a procedure to accurately reconcile controlled controlled substance medications for 1 of 1 resident. (Resident #4) The findings included: On 10/18/11 at approximately 11:45 AM, review of the July, 2011 MAR (Medication Administration Record) and Controlled Substance Receipt/Count Sheet (CSR/CS) for Resident # 4 revealed: 1. On 7/15/11 nine (9) capsules of Lyrica 75 mg (RX # 7) for Resident # 4 had been documented on the CSR/CS as ""sent LOA (leave of absence) with husband 1000"". On 7/1/11 2000 (8:00 PM), three (3) capsules of Lyrica 75 mg had been documented as ""resident returned with husband."" On 7/17/11 at 2000, the Nurses Notes read ""Resident returned to facility with husband and son with no complaints. All meds were returned with the correct count. 2100 (9:00 PM) meds were given on arrival."" Further review of the CSR/CS did not show documentation of what happened to the three (3) Lyrica capsules that had been returned to the facility by the husband. 2. On 7/30/22 one (1) capsule of Lyrica 75 mg (RX # 2) had been charted on the MAR indicated [REDACTED]. A review of the July, 2011 Physicians Orders revealed that Lyrica 150 mg should have been administered at 2100. Lyrica 150 mg was charted on the MAR indicated [REDACTED]. On 10/18/11 at approximately 1:30 PM the ADON (Assistant Director of Nursing) was unable to determine what had happened to the three (3) missing capsules of Lyrica 75 mg or account for the discrepancies on 7/24/11 and 7/30/11 and stated that the three (3) missing capsules on 7/17/11 could have been removed from the punch card and returned to the Pharmacy. On 10/18/11 at approximately 5:15 PM, the Consultant Pharmacist (CP) reviewed the discrepancies, could offer no explanation other than to acknowledge them and stated: - that he would further investigate as to whether the three (3) missing capsules of Lyrica 75 mg had been returned to the pharmacy. -that he does not routinely review CSR/CS unless a discrepancy is discovered during monthly MAR indicated [REDACTED]. -that 2 capsules of Lyrica 75 mg should not be used to equal a 150 mg dose of Lyrica, when the pharmacy had dispensed Lyrica 150 mg capsules for the 150 mg dose. On 10/19/11 at approximately 10:00 AM, the CP called and stated that he had checked pharmacy records and the contents of medication carts and had not found the three (3) missing capsules of Lyrica 75 mg.",2014-06-01
10103,PRESBYTERIAN HOME OF SC - SUMMERVILLE,425389,201 W 9TH NORTH STREET,SUMMERVILLE,SC,29483,2011-10-18,492,D,0,1,8R2L11,"On the days of the survey, based on personnel records review and interviews, the facility failed to follow Sections 44-7-2910 and 44-7-2920 of Chapter 7, Title 44, Article 23, ""Criminal Records Checks of Direct Care Staff"" of the 1976 SC Code of Laws, amended and effective July 6, 2004 and updated June 26, 2007. State criminal records background checks had not been completed for 2 of 2 new employees in the employees' resident state where the employees had previously resided for 1 year prior to employment. ( 1 Certified Nursing Assistant and 1 Licensed Practical Nurse) The findings included: On 10-18-11 at approximately 9:15 AM, a review of personnel records of 5 new employees hired within the past 4 months revealed 1 Certified Nursing Assistant (CNA) who had not resided in the state of SC for 1 year prior to employment did not have a state criminal records background check completed for the state where the employee had previously resided. Review of the Application for Employment for CNA #1 revealed she had been a resident out of the state of SC until 01-04-11. Further information in her personnel record revealed date of hire (DOH) as 09-20-11. Review of the personnel record of Licensed Practical Nurse (LPN) #4 revealed the employee had not resided in the state of SC for 1 year prior to employment and did not have a state criminal records background check completed for the state where she had resided resided. Review of the Application for Employment for LPN #4 revealed she had been a resident out of the state of SC until July 2011. Further information in her personnel record revealed DOH as 10-05-11. During an interview on 10-18-11 with the Administrator, she revealed a federal criminal background check using fingerprints had been conducted prior to DOH for CNA #1 and LPN #4. However, the results of the checks had not been received and a state criminal records background check had not been completed for the state where CNA #1 and LPN #4 had previously resided 1 year prior to employment. She stated, ""We didn't know to do this. The fingerprint check results do take a while to come back"". During an interview on 10-18-11 with the Assistant Administrator, she stated, ""We did the federal fingerprint checks but not a check outside of SC. We didn't know to do this. We did a check for the state of SC but of course nothing came up. The fingerprint checks do take a while to come back. We'll start doing a state background check for the state where new employees lived if they have not resided in the state of SC for the past year"".",2014-06-01
10104,PRESBYTERIAN HOME OF SC - COLUMBIA,425396,700 DAVEGA DRIVE,LEXINGTON,SC,29073,2011-02-22,225,D,1,0,NTHF11,"On the day of the complaint inspection, based on review of the facility's investigative file concerning an allegation of abuse related to Resident #1, the facility failed to report the alleged abuse within the Long Term Care Regulations allowed time frames. The findings included: On 11/3/10, the facility administration staff received an allegation of mental abuse involving Resident #1 and a Certified Nursing Assistant. The facility reported the allegation to the State survey and certification agency on 12/17/10, which exceeded the twenty-four hours allowed.",2014-06-01
10105,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-02-10,281,G,1,0,O8HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interview, the facility failed to provide nursing services which met professional standards of quality related to [MEDICATION NAME] administration for 2 of 5 of residents prescribed [MEDICATION NAME] (Residents #7 and #17); 1 of 1 residents who received 2 different medications for [MEDICAL CONDITION] for a period of 3 days (Resident # 2); 5 of 14 residents reviewed for admissions (Residents #1, #4, #7, #15 and #19); 2 of 9 residents reviewed for pain (Residents #10 and #11). The findings included: The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the hospital ""Discharge Summary"" dated 1/27/11 revealed Resident #7 was admitted on [DATE] with a right femoral neck fracture and a right hip hemiarthroplasty. Continued review revealed, ""Postoperatively, she was placed on [MEDICATION NAME] and foot pumps for [MEDICAL CONDITION]"". Under ""Transfer Instructions:"" was listed ...4. She is to continue [MEDICATION NAME] for a total of 3 weeks, maintaining a target INR (International Normalization Ratio) of 1.8-2.2, which will likely be low dose of 2 milligrams daily or every other day. INR on postoperative day #3 was 3.4, and [MEDICATION NAME] is being held at this time"". The ""Discharge Medication Reconciliation List"" included a typed entry for ""[MEDICATION NAME] Sliding Scale, Dose Daily, Oral As Directed"". Under ""Should Patient Continue Taking This Medication At Home"" was typed ""Yes"" and ""No"" with ""Yes"" being circled. During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. Review of the facilities ""Admission H&P"" signed by the Physician and dated 1/28/11 revealed the resident had been admitted after right hip arthroplasty. Under ""Assessment/Plan:"" at the bottom of the second page, the following entries contained a check mark: ""Admit for: Rehab(ilitation), PT/OT, ST, Continue current Meds, Routine Standing orders, Skilled Nursing Care, Rehab Potential: Good"". Review of ""Physician's Orders"" for 1/27/11 through 1/31/11 revealed that the Physician signed and dated the orders 2/1/11. The medications listed on the 1/27/11 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], and [MEDICATION NAME] 2 mg (milligrams) (1) PO (By Mouth) Daily X 3 weeks- to keep INR 1.8-2.2 (Stop 2/17/11)"". Under ""Lab Orders:"" was listed ""PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change"". Review of the lab section of the chart revealed a PT/INR drawn and resulted on 2/4/11 PT ""41.3 (CH) (Critical High)"" and the INR was ""4.1 (H) (High)"". On the lab was a handwritten note to ""Hold [MEDICATION NAME] X 2 days, Re(check) PT/INR 2/7/11"". Further review revealed a physician's order dated 2/4/11 that stated, ""Hold [MEDICATION NAME] X 2 days then start [MEDICATION NAME] 1.5 mg q HS (Bedtime), Re (check) PT/INR 2/7 and 2/14"". Further review of labs revealed a PT/INR drawn and resulted on 2/7/11. The PT was 62.0 (CH) and the INR was 5.79 (CH). On the lab was a handwritten note to ""Hold [MEDICATION NAME] until Friday 2-11-2011, 10 mg Vitamin K 1 X dose, Repeat PT/INR on Thursday 2-10-11, Call results to Dr. -- for further orders 2/10/11"". An order dated 2/7/11 stated ""Hold [MEDICATION NAME] 1.5 mg daily until 2-11-2011. Admin (ister) 10 mg Vitamin K IM 1 X dose. Repeat PT/INR on 2-10-11"". Review of the ""Medication Record"" for January and February 2011 revealed Resident #7 received [MEDICATION NAME] 2 mg from 1/27/11 through 2/4/11 at 9:00 PM. [MEDICATION NAME] 2 mg was held on 2/5/11 and 2/6/11; and next to the entry was a handwritten note ""Orders changed 2/4/11"". Included on the record was a listing for ""Vit(amin) K 10 mg IM 1 time"" documented as having been given on 2/7/11 at 5:00 PM. [MEDICATION NAME] 1.5 mg had also been held as ordered starting on 2/7/11. During an interview on 2/10/11 at 5:40 PM, Licensed Practical Nurse (LPN) #1 reviewed the resident's February MAR and verified her initials for the 2/4/11 dosage of [MEDICATION NAME] at 9:00 PM and stated she had given this. She stated she came in at 3:00 PM that day and was working 3 PM - 11 PM and was not told the [MEDICATION NAME] was on hold. She stated the order may have been taken off after the medpass, but after reviewing the Interim Order, was unable to tell what time it was taken off or written. She verified the Physician's Progress Note dated 2/4/11 at 4:00 PM stated the Physician had discussed the plan with the nursing staff regarding the resident's elevated INR and that it said to ""...see orders"". The facility admitted Resident #17 on 12/30/10 with [DIAGNOSES REDACTED]. An order dated 1/24/11 for an increase in [MEDICATION NAME] dosage was not carried out until 2/1/11. A PT/INR lab was not drawn as ordered on [DATE]. Review of labs revealed a PT of 17.0 (H) and an INR of 1.59 dated 1/24/11; a Physician's Interim Order dated 1/24/11 stated, ""1. (Increase) [MEDICATION NAME] 1 mg QD (Daily) (from 4 mg to 5 mg). Re-check PT-INR in one week"". Review of the Medication Record dated 1/14/11 through 1/31/11 revealed an entry for ""[MEDICATION NAME] 4 mg PO (By Mouth) q (Every) PM, NO (New Order) 1-17-11"". The entry had been initialed from 1/17/11 through 1/31/11 at 9:00 PM. The [MEDICATION NAME] dosage was not changed as ordered on [DATE] from 4 mg to 5 mg. Review of the Medication Record dated 2/1/11 through 2/28/11 revealed [MEDICATION NAME] 5 mg started on 2/1/11. Continued review of labs dated 1/27/11 revealed a PT of 27.3 (H) and an INR of 2.55, initialed by the Physician. The next PT/INR result dated 2/3/11 documented the PT of 64.8 and an INR of 6.06 (CH). Review of Physician's Interim Orders dated 2/3/11 revealed an order to ""Hold [MEDICATION NAME], Administer 1 time dose Vitamin K 10 mg Sub Q (Subcutaneously), Re-check PT/INR on 2-4-11"". Review of the Medication Record revealed Vitamin K 10 mg had been given at 3:00 PM on 2/3/11. During an interview on 2/10/11 at 6:00 PM, Licensed Practical Nurse (LPN) #1 stated she had received the order for the change in [MEDICATION NAME] dosage on 1/24/11 increasing the [MEDICATION NAME] from 4 mg to 5 mg daily. After reviewing the Medication Record for January 2011, she verified the [MEDICATION NAME] dosage had not been changed on the MAR to reflect the new order change and that [MEDICATION NAME] 4 mg had been given from 1/24/11 through 1/31/11. The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: ""Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening."" The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed that [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] was altered with the following statement: ""D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)""and that the [MEDICATION NAME] order had been hand written in with the following notation: ""*start when [MEDICATION NAME] completed 12/2/10."" Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident # 1 on 1-27-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the Admission/Nursing Evaluation Form for Resident # 1 was completed on 1-27-11 at 12:30 PM, but that there was no documented notification of the Medical Director, and the Physician's Orders were not signed by a Physician until 2-1-11. Medications (including [MEDICATION NAME], [MEDICATION NAME] Insulin, and Oxygen Therapy) were received from the pharmacy, and given to the Resident beginning on 1-28-11. The facility admitted Resident #4 on 12/2/10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2/7/10 between 3:30 PM and 5:00 PM revealed that the Admission/Nursing Evaluation Form was completed on 12/2/10. Review of ""Daily Skilled Nurses Notes"" dated 12/2/10 through 12/6/10 revealed no mention of contacting the Physician to acknowledge the resident's admission or to verify orders for the resident. Review of ""Physician's Orders"" for 12/2/10 through 12/31/10 revealed an entry that stated ""Meds Reviewed By: (Registered Nurse #1)"" with a date of 12/2/10. There was an entry that stated ""Physician's Signature"" in which the Physician had signed and dated the orders 12/6/10. The medications listed on the 12/2/10 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], Mag Ox, [MEDICATION NAME], and [MEDICATION NAME]. The resident's diet was listed as ""NPO (Nothing by Mouth)- [MEDICATION NAME] 1.2 @ 60 cc (cubic centimeters)/hr (hour) (Per Dietician), Flush - Water 100 ml Q (Every) 4 hrs (hours)"". During an interview on 2/9/11, RN #1 verified Resident #4 had been admitted [DATE] and stated she had completed the admission. She verified the blanks on the Admission/Nursing Evaluation Form and stated she had not called the Physician to acknowledge the resident's admission or to verify orders. She verified the Physician signed the resident ' s Physician ' s Orders and History and Physical on 12/6/10. The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the ""Admission/Nursing Evaluation Form"" and the resident's ""Face Sheet"" revealed Resident #7 had been admitted on [DATE]. Review of ""Physician's Orders"" for 1/27/11 through 1/31/11 revealed that the Physician signed and dated the orders 2/1/11. The medications listed on the 1/27/11 Physician's Orders were the following: 2nd step PPD (Purified Protein Derivative), [MEDICATION NAME], and [MEDICATION NAME] 2 mg (milligrams) (1) PO (By Mouth) Daily X 3 weeks- to keep INR 1.8-2.2 (Stop 2/17/11)"". Under ""Lab Orders:"" was listed ""PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change"". During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. The facility admitted Resident # 15 on 12-30-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-10-11 revealed that the resident's Physician / Medical Director did not review the admission assessment, medications and did not complete a History & Physical until 1-3-11. Resident # 15's admitting medications included the following: [MEDICATION NAME] 10/325, Calcitonin 200 units, Vitamin B 3 2000 units, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 75 mcg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 4.5 mg S,T,T, S and 5 mg on M,W,F, [MEDICATION NAME] 17 g, Tylenol ES 500 mg, Qvar 40 mcg, [MEDICATION NAME] 8.6 mg. During an interview on 2-10-11 at approximately 12:45 PM with the Admissions Nurse, RN # 1, she stated that she did had not notified the Physician except by notating the admission in the Physician's Log book. The facility admitted Resident # 19 on 1-13-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the resident's Physician/Medical Director did not review the admission assessment, medications or complete a History & Physical until 1-17-11. During an interview with RN# 1, who did the Initial Nursing Assessment Form on 1-13-11, she confirmed that she had not notified the Physician except by notating the admission in the Physician's Logbook. During an interview with the Admission Coordinator on 2-8-11 at approximately 10:45 AM, she stated that she routinely assesses residents for admission, at hospitals and from their homes. She further stated that when she has a candidate for admission, she contacts the Admission Nurse for help, but that she does not notify the Medical Director that a patient will be coming. The facility admitted Resident # 11 on 11-17-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-7-11 revealed that upon admission, Resident # 11's medications were as follows: [MEDICATION NAME], Nephro-vite, [MEDICATION NAME], Folic Acid, [MEDICATION NAME]. Also included in the medications were the following to control pain: [MEDICATION NAME] 10 mg every twelve hours, [MEDICATION NAME] Patch 100 mcg every 72 hours, and [MEDICATION NAME] 5/325 mg PRN (as needed) every 6 hours. Review of the MAR (Medical Administration Record) revealed for the month of November, [MEDICATION NAME] 5/325 mg was given to the resident a total of 22 times. Review of the month of December revealed that [MEDICATION NAME] 5/325 was given to the resident a total of 64 times. During the month of January, Resident # 11 was out of the facility in the hospital from 1-2 until 1-5, but she still received the PRN [MEDICATION NAME] 5/325 a total of 42 times. On 1-24-11 at 9:00 PM, the resident received [MEDICATION NAME] 5/325, but on 1-25-11 at 5:00 AM, Resident # 11 received [MEDICATION NAME] 7.5/500 mg for pain. During an interview with the resident on 2-9-11, she stated ""Recently, they ran out of the [MEDICATION NAME], and gave me [MEDICATION NAME] instead."" The facility admitted Resident # 10 on 11-8-10 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed the following medications [MEDICATION NAME], [MEDICATION NAME] HCT, and for pain Tylenol 650 mg PRN, [MEDICATION NAME] 5/325 mg PRN, and [MEDICATION NAME] 10/500. Review of the MAR for January revealed that [MEDICATION NAME] was given for pain relief beginning on 1-25-11. During an interview with the DON (Director of Nursing) on 2-8-11 at approximately 4:15 PM, she stated that on the early morning of 1-25-11, she had to get [MEDICATION NAME] from the back up pharmacy to supply pain medication for several residents. The DON identified 2 of those residents as Resident # 10 and Resident # 11. She further stated that she was unable to get [MEDICATION NAME] because it was a class II medication and required a written prescription from the back up pharmacy. When asked why the medication was not available in the facility, the DON said it was just an oversight by the nursing staff. On 2/7/11 at 5:17 PM, during observation of medication pass for Resident A, Registered Nurse (RN) #2 was observed to administer one [MEDICATION NAME] Extended Release 500 milligram (mg) tablet, one [MEDICATION NAME] 5 mg tablet, one [MEDICATION NAME] 30 mg tablet, and one [MEDICATION NAME] 25 mg/200 mg extended release capsule to the resident. During reconciliation of medication pass, review of current ""PHYSICIAN'S ORDERS"" (02/01/11 through 02/28/11) for Resident A, revealed that all 4 of the listed medications were ordered to be administered at 9 AM and 9 PM. Review of the current Medication Administration Record (MAR) (02/01/11 through 02/28/11) for Resident A, revealed that the 9 PM administration time for the medications had been marked out and changed to 5 PM. No physician's order to change the PM administration time could be found. During an interview on 2/7/11 at 5:48 PM, RN #2 verified that the physician's order for the medications was for 9 AM and 9 PM and that there was no order to change the PM administration time. During an interview on 2/8/11 at 12:26 PM, the facility's Medical Director revealed that every 12 hours (9 AM and 9 PM) would be preferred administration times for twice a day medications because that would give better medication coverage for the resident. He was not sure that 9 AM and 9 PM were on the ""PHYSICIAN'S ORDERS"" when he signed then but that would be the preferred times. During an interview on 2/8/11 at 11:33 PM, the Pharmacy Manager stated that when Physician Orders and MARs are sent to the facility they are preprinted with times of administration. If the pharmacy gets a notice of a change in times of administration, the pharmacy would print new times of administration and new MARs for the next month. During an interview on 2/8/11 at 3:35 PM, RN #1 stated that she had made the error and coded the evening dose for 5 PM instead of 9 PM on the MAR. Because of the color coding coding used on the MAR the evening dose was not legible and she coded it wrong. It was strictly human error. On 2/8/11 at 3:53 PM, review of the MARs on both medication carts, with the Director of Nursing (DON) revealed that some twice a day medications were listed as 9 AM and 9 PM and some were listed as 9 AM and 5 PM. There was no consistency in relation to twice a day times of administration.",2014-06-01
10106,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-02-10,309,G,1,0,O8HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for residents related to [MEDICATION NAME] not given as ordered for 2 of 5 of residents (Residents #7 and #17); 1 of 1 residents who received 2 different medications for [MEDICAL CONDITION] for a period of 3 days (Resident # 2); 5 of 14 residents reviewed for admissions (Residents #1, #4, #7, #15 and #19); 2 of 9 residents reviewed for pain management (Residents #10 and #11). The findings included: The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the hospital ""Discharge Summary"" dated 1/27/11 revealed Resident #7 had been admitted on [DATE] with a right femoral neck fracture and had undergone a right hip hemiarthroplasty the same day. Continued review revealed, ""Postoperatively, she was placed on [MEDICATION NAME] and foot pumps for [MEDICAL CONDITION]"". Under ""Transfer Instructions:"" was listed ...4. She is to continue [MEDICATION NAME] for a total of 3 weeks, maintaining a target INR (International Normalization Ratio) of 1.8- 2.2, which will likely be low dose of 2 milligrams daily or every other day. INR on postoperative day #3 was 3.4, and [MEDICATION NAME] is being held at this time"". The ""Discharge Medication Reconciliation List"" included a typed entry for ""[MEDICATION NAME] Sliding Scale, Dose Daily, Oral As Directed"". Under ""Should Patient Continue Taking This Medication At Home"" was typed ""Yes"" and ""No"" with ""Yes"" being circled. During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending physician when the resident was admitted , nor did she verify the resident's medications with the Physician. Review of the facilities ""Admission H&P"" signed by the Physician and dated 1/28/11 revealed the resident had been admitted after right hip arthroplasty. Under ""Assessment/Plan:"" at the bottom of the second page, the following entries contained a check mark: ""Admit for: Rehab(ilitation), PT/OT, ST, Continue current Meds, Routine Standing orders, Skilled Nursing Care, Rehab Potential: Good"". Review of ""physician's orders [REDACTED]. The medications listed on the 1/27/11 physician's orders [REDACTED]. Under ""Lab Orders:"" was listed ""PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change"". Review of the lab section of the chart revealed a PT/INR drawn and resulted on 2/4/11 PT ""41.3 (CH) (Critical High)"" and the INR was ""4.1 (H) (High)"". On the lab was a handwritten note to ""Hold [MEDICATION NAME] X 2 days, Re(check) PT/INR 2/7/11"". Further review revealed a physician's orders [REDACTED]. Further review of labs revealed a PT/INR drawn and resulted on 2/7/11. The PT was 62.0 (CH) and the INR was 5.79 (CH). On the lab was a handwritten note to ""Hold [MEDICATION NAME] until Friday 2-11-2011, 10 mg Vitamin K 1 X dose, Repeat PT/INR on Thursday 2-10-11, Call results to Dr. -- for further orders 2/10/11"". An order dated 2/7/11 stated ""Hold [MEDICATION NAME] 1.5 mg daily until 2-11-2011. Admin (ister) 10 mg Vitamin K IM 1 X dose. Repeat PT/INR on 2-10-11"". Review of the ""Medication Record"" for January and February 2011 revealed Resident #7 received [MEDICATION NAME] 2 mg from 1/27/11 through 2/4/11 at 9:00 PM. [MEDICATION NAME] 2 mg was held on 2/5/11 and 2/6/11; and next to the entry was a handwritten note ""Orders changed 2/4/11"". Included on the record was a listing for ""Vit(amin) K 10 mg IM 1 time"" documented as having been given on 2/7/11 at 5:00 PM. [MEDICATION NAME] 1.5 mg had also been held as ordered starting on 2/7/11. During an interview on 2/10/11 at 5:40 PM, Licensed Practical Nurse (LPN) #1 reviewed the resident's February MAR and verified her initials for the 2/4/11 dosage of [MEDICATION NAME] at 9:00 PM and stated she had given this. She stated she came in at 3:00 PM that day and was working 3 PM - 11 PM and was not told the [MEDICATION NAME] was on hold. She stated the order may have been taken off after the medpass, but after reviewing the Interim Order, was unable to tell what time it was taken off or written. She verified the Physician's Progress Note dated 2/4/11 at 4:00 PM stated the Physician had discussed the plan with the nursing staff regarding the resident's elevated INR and that it said to ""...see orders"". The facility admitted Resident #17 on 12/30/10 with [DIAGNOSES REDACTED]. An order dated 1/24/11 for an increase in [MEDICATION NAME] dosage was not carried out until 2/1/11. A PT/INR lab was not drawn as ordered on [DATE]. Review of labs revealed a PT of 17.0 (H) and an INR of 1.59 dated 1/24/11; a Physician's Interim Order dated 1/24/11 stated, ""1. (Increase) [MEDICATION NAME] 1 mg QD (Daily) (from 4 mg to 5 mg). Re-check PT-INR in one week"". Review of the Medication Record dated 1/14/11 through 1/31/11 revealed an entry for ""[MEDICATION NAME] 4 mg PO (By Mouth) q (Every) PM, NO (New Order) 1-17-11"". The entry had been initialed from 1/17/11 through 1/31/11 at 9:00 PM. The [MEDICATION NAME] dosage was not changed as ordered on [DATE] from 4 mg to 5 mg. Review of the Medication Record dated 2/1/11 through 2/28/11 revealed [MEDICATION NAME] 5 mg started on 2/1/11. Continued review of labs dated 1/27/11 revealed a PT of 27.3 (H) and an INR of 2.55, initialed by the Physician. The next PT/INR result dated 2/3/11 documented the PT of 64.8 and an INR of 6.06 (CH). Review of Physician's Interim Orders dated 2/3/11 revealed an order to ""Hold [MEDICATION NAME], Administer 1 time dose Vitamin K 10 mg Sub Q (Subcutaneously), Re-check PT/INR on 2-4-11"". Review of the Medication Record revealed Vitamin K 10 mg had been given at 3:00 PM on 2/3/11. During an interview on 2/10/11 at 6:00 PM, Licensed Practical Nurse (LPN) #1 stated she had received the order for the change in [MEDICATION NAME] dosage on 1/24/11 increasing the [MEDICATION NAME] from 4 mg to 5 mg daily. After reviewing the Medication Record for January 2011, she verified the [MEDICATION NAME] dosage had not been changed on the MAR to reflect the new order change and that [MEDICATION NAME] 4 mg had been given from 1/24/11 through 1/31/11. The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: ""Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening."" The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed that [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] was altered with the following statement: ""D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)""and that the [MEDICATION NAME] order had been hand written in with the following notation: ""*start when [MEDICATION NAME] completed 12/2/10."" Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident # 1 on 1-27-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the Admission/Nursing Evaluation Form for Resident # 1 was completed on 1-27-11 at 12:30 PM, but that there was no documented notification of the Medical Director, and the physician's orders [REDACTED]. Medications (including [MEDICATION NAME], [MEDICATION NAME] Insulin, and Oxygen Therapy) were received from the pharmacy, and given to the Resident beginning on 1-28-11. The facility admitted Resident #4 on 12/2/10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2/7/10 between 3:30 PM and 5:00 PM revealed that the Admission/Nursing Evaluation Form was completed on 12/2/10. Review of ""Daily Skilled Nurses Notes"" dated 12/2/10 through 12/6/10 revealed no mention of contacting the Physician to acknowledge the resident's admission or to verify orders for the resident. Review of ""physician's orders [REDACTED].#1)"" with a date of 12/2/10. There was an entry that stated ""Physician's Signature"" in which the Physician had signed and dated the orders 12/6/10. The medications listed on the 12/2/10 physician's orders [REDACTED]. The resident's diet was listed as ""NPO (Nothing by Mouth)- [MEDICATION NAME] 1.2 @ 60 cc (cubic centimeters)/hr (hour) (Per Dietician), Flush - Water 100 ml Q (Every) 4 hrs (hours)"". During an interview on 2/9/11, RN #1 verified Resident #4 had been admitted [DATE] and stated she had completed the admission. She verified the blanks on the Admission/Nursing Evaluation Form and stated she had not called the Physician to acknowledge the resident's admission or to verify orders. She verified the Physician signed the resident ' s physician's order [REDACTED]. The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the ""Admission/Nursing Evaluation Form"" and the resident's ""Face Sheet"" revealed Resident #7 had been admitted on [DATE]. Review of ""physician's orders [REDACTED]. The medications listed on the 1/27/11 physician's orders [REDACTED]. Under ""Lab Orders:"" was listed ""PT ([MEDICATION NAME])/INR within 14 days of admission, within 7-14 days after change in dose or at least monthly, if no dose change"". During an interview on 2/8/11, RN #1 verified she had completed the admission for Resident #7 on 1/27/11 and stated she had not notified the attending Physician when the resident was admitted , nor did she verify the resident's medications with the Physician. The facility admitted Resident # 15 on 12-30-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-10-11 revealed that the resident's Physician / Medical Director did not review the admission assessment, medications and did not complete a History & Physical until 1-3-11. Resident # 15's admitting medications included the following: [MEDICATION NAME] 10/325, Calcitonin 200 units, Vitamin B 3 2000 units, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 75 mcg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 4.5 mg S,T,T, S and 5 mg on M,W,F, [MEDICATION NAME] 17 g, Tylenol ES 500 mg, Qvar 40 mcg, [MEDICATION NAME] 8.6 mg. During an interview on 2-10-11 at approximately 12:45 PM with the Admissions Nurse, RN # 1, she stated that she did had not notified the Physician except by notating the admission in the Physician's Log book. The facility admitted Resident # 19 on 1-13-11 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed that the resident's Physician/Medical Director did not review the admission assessment, medications or complete a History & Physical until 1-17-11. During an interview with RN# 1, who did the Initial Nursing Assessment Form on 1-13-11, she confirmed that she had not notified the Physician except by notating the admission in the Physician's Logbook. During an interview with the Admission Coordinator on 2-8-11 at approximately 10:45 AM, she stated that she routinely assesses residents for admission, at hospitals and from their homes. She further stated that when she has a candidate for admission, she contacts the Admission Nurse for help, but that she does not notify the Medical Director that a patient will be coming. The facility admitted Resident # 11 on 11-17-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-7-11 revealed that upon admission, Resident # 11's medications were as follows: [MEDICATION NAME], Nephro-vite, [MEDICATION NAME], Folic Acid, [MEDICATION NAME]. Also included in the medications were the following to control pain: [MEDICATION NAME] 10 mg every twelve hours, [MEDICATION NAME] Patch 100 mcg every 72 hours, and [MEDICATION NAME] 5/325 mg PRN (as needed) every 6 hours. Review of the MAR (Medical Administration Record) revealed for the month of November, [MEDICATION NAME] 5/325 mg was given to the resident a total of 22 times. Review of the month of December revealed that [MEDICATION NAME] 5/325 was given to the resident a total of 64 times. During the month of January, Resident # 11 was out of the facility in the hospital from 1-2 until 1-5, but she still received the PRN [MEDICATION NAME] 5/325 a total of 42 times. On 1-24-11 at 9:00 PM, the resident received [MEDICATION NAME] 5/325, but on 1-25-11 at 5:00 AM, Resident # 11 received [MEDICATION NAME] 7.5/500 mg for pain. During an interview with the resident on 2-9-11, she stated ""Recently, they ran out of the [MEDICATION NAME], and gave me [MEDICATION NAME] instead."" The facility admitted Resident # 10 on 11-8-10 with [DIAGNOSES REDACTED]. Review of the Medical Record revealed the following medications [MEDICATION NAME], [MEDICATION NAME] HCT, and for pain Tylenol 650 mg PRN, [MEDICATION NAME] 5/325 mg PRN, and [MEDICATION NAME] 10/500. Review of the MAR for January revealed that [MEDICATION NAME] was given for pain relief beginning on 1-25-11. During an interview with the DON (Director of Nursing) on 2-8-11 at approximately 4:15 PM, she stated that on the early morning of 1-25-11, she had to get [MEDICATION NAME] from the back up pharmacy to supply pain medication for several residents. The DON identified 2 of those residents as Resident # 10 and Resident # 11. She further stated that she was unable to get [MEDICATION NAME] because it was a class II medication and required a written prescription from the back up pharmacy. When asked why the medication was not available in the facility, the DON said it was just an oversight by the nursing staff.",2014-06-01
10107,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-02-10,329,D,1,0,O8HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on observation, record review and interview the facility failed to ensure that residents remained free from unnecessary drugs, for 2 of 14 resident reviewed for medications. (Resident # 2, received [MEDICATION NAME] while continuing to receive [MEDICATION NAME], Resident #7 received [MEDICATION NAME] after an order was written to hold [MEDICATION NAME].) The findings included: The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: ""Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening."" The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed the [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] had been altered with the following statement: ""D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)""and that the [MEDICATION NAME] order had been hand written in with the following notation: ""*start when [MEDICATION NAME] completed 12/2/10."" Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident #7 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the hospital ""Discharge Summary"" dated 1/27/11 revealed Resident #7 had been admitted on [DATE] with a right femoral neck fracture and had undergone a right hip hemiarthroplasty the same day. Continued review revealed, ""Postoperatively, she was placed on [MEDICATION NAME] and foot pumps for [MEDICAL CONDITION]"". Under ""Transfer Instructions:"" was listed ...4. She is to continue [MEDICATION NAME] for a total of 3 weeks, maintaining a target INR (International Normalization Ratio) of 1.8- 2.2, which will likely be low dose of 2 milligrams daily or every other day. INR on postoperative day #3 was 3.4, and [MEDICATION NAME] is being held at this time"". The ""Discharge Medication Reconciliation List"" included a typed entry for ""[MEDICATION NAME] Sliding Scale, Dose Daily, Oral As Directed"". Under ""Should Patient Continue Taking This Medication At Home"" was typed ""Yes"" and ""No"" with ""Yes"" being circled. Review of the lab section of the chart revealed a PT/INR drawn and resulted on 2/4/11 PT ""41.3 (CH) (Critical High)"" and the INR was ""4.1 (H) (High)"". On the lab was a handwritten note to ""Hold [MEDICATION NAME] X 2 days, Re(check) PT/INR 2/7/11"". Further review revealed a physician's orders [REDACTED]. Further review of labs revealed a PT/INR drawn and resulted on 2/7/11. The PT was 62.0 (CH) and the INR was 5.79 (CH). On the lab was a handwritten note to ""Hold [MEDICATION NAME] until Friday 2-11-2011, 10 mg Vitamin K 1 X dose, Repeat PT/INR on Thursday 2-10-11, Call results to Dr. -- for further orders 2/10/11"". An order dated 2/7/11 stated ""Hold [MEDICATION NAME] 1.5 mg daily until 2-11-2011. Admin(ister) 10 mg Vitamin K IM 1 X dose. Repeat PT/INR on 2-10-11"". Review of the ""Medication Record"" for January and February 2011 revealed Resident #7 received [MEDICATION NAME] 2 mg from 1/27/11 through 2/4/11 at 9:00 PM. [MEDICATION NAME] 2 mg was held on 2/5/11 and 2/6/11; and next to the entry was a handwritten note ""Orders changed 2/4/11"". Included on the record was a listing for ""Vit(amin) K 10 mg IM 1 time"" documented as having been given on 2/7/11 at 5:00 PM. [MEDICATION NAME] 1.5 mg had also been held as ordered starting on 2/7/11. During an interview on 2/10/11 at 5:40 PM, Licensed Practical Nurse (LPN) #1 reviewed the resident's February MAR and verified her initials for the 2/4/11 dosage of [MEDICATION NAME] at 9:00 PM and stated she had given this. She stated she came in at 3:00 PM that day and was working 3 PM - 11 PM and was not told the [MEDICATION NAME] was on hold. She stated the order may have been taken off after the medpass, but after reviewing the Interim Order, was unable to tell what time it was taken off or written. She verified the Physician's Progress Note dated 2/4/11 at 4:00 PM stated the Physician had discussed the plan with the nursing staff regarding the resident's elevated INR and that it said to ""...see orders"".",2014-06-01
10108,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-02-10,514,D,1,0,O8HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interview, the facility failed to maintain clinical records on each resident that were complete, accurately documented, and readily accessible; Medication order placed on the MAR indicated [REDACTED] The findings included: The facility admitted Resident # 2 on 11-1-10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a pharmacy recommendation dated 12-1-11 which recommended the following: ""Discontinue the [MEDICATION NAME] when the current supply is exhausted and then start [MEDICATION NAME] 40 mg (milligram) orally every evening."" The Physician on 12-1-10 signed this recommendation. The pharmacy records revealed the [MEDICATION NAME] 20 mg was sent to the facility on [DATE], and that the new order for [MEDICATION NAME] 40 mg was sent to the facility on [DATE]. Review of the MAR (Medical Administration Record) for December revealed that the order for [MEDICATION NAME] had been altered with the following statement: ""D/C (discontinue) when supply exhausted then start [MEDICATION NAME] 40 mg (Stop 1/3/10)""and that the [MEDICATION NAME] order had been hand written in with the following notation: ""*start when [MEDICATION NAME] completed 12/2/10."" Both medications were signed off as given on 12-2, 12-3, and 12-5. This was confirmed with the Pharmacist Consultant on 2-8-11 at approximately 10:55 AM. The facility admitted Resident # 11 on 11-17-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-7-11 revealed that upon admission, Resident # 11's medications were as follows: [MEDICATION NAME], Nephro-vite, [MEDICATION NAME], Folic Acid, [MEDICATION NAME]. Also included in the medications were the following to control pain: [MEDICATION NAME] 10 mg every twelve hours, [MEDICATION NAME] Patch 100 mcg every 72 hours, and [MEDICATION NAME] 5/325 mg PRN (as needed) every 6 hours. Review of the MAR (Medical Administration Record) revealed for the month of November, [MEDICATION NAME] 5/325 mg was given to the resident a total of 22 times. Review of the month of December revealed that [MEDICATION NAME] 5/325 was given to the resident a total of 64 times. During the month of January, Resident # 11 received the PRN [MEDICATION NAME] 5/325 a total of 42 times. Review of the Medical Record also revealed allergies [REDACTED]. [MEDICATION NAME] was also included as an allergy on a History & Physical from the hospital dated 11-3-10 and was listed on the new orders processed on 1-6-11. When the Director of Nursing was asked about this on 2-8-11 at approximately 4:15 PM, she stated that she was unaware of the allergy. Again on 2-10-11 it was noted that the allergy continued to be listed on the chart. When this was brought to the DON's attention, she stated that Resident # 11 did receive [MEDICATION NAME] for itching, and she would be scheduling a meeting between the Physician and the Pharmacy to determine if it was a true allergy. The [MEDICATION NAME], continued to be given to Resident # 11. The facility admitted Resident # 15 on 12-30-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 2-10-11 revealed that the resident's Physician / Medical Director did not review the admission assessment, medications and did not complete a History & Physical until 1-3-11. Resident # 15's admitting medications included the following: [MEDICATION NAME] 10/325, Calcitonin 200 units, Vitamin B 3 2000 units, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 1000 mg, [MEDICATION NAME] 75 mcg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 15 mg, [MEDICATION NAME] 4.5 mg S,T,T,S and 5 mg on M,W,F, [MEDICATION NAME] 17 g, Tylenol ES 500 mg, Qvar 40 mcg, [MEDICATION NAME] 8.6 mg. Review of the Medical Record revealed at PT/INR should have been done on 1-3-11, however, it could not be found on the chart and there was no documentation in the chart that it had been done. The information was supplied at 3:15 PM on 2-10-11 by the facility.",2014-06-01
10109,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,156,E,0,1,HXLZ11,"On the days of the survey, based on review of Medicare Notices and interview, the facility failed to ensure that one of three residents reviewed for Notices had been provided with the mandated Notice of Medicare Provider Non-Coverage (CMS Form ). There was no documentation that Resident A or her Responsible Party had received the Notice of Medicare Provider Non-Coverage. The facility also failed to provide a Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) or one 5 Denial Letters to the resident or responsible party for Residents A, B, and C, three of three residents reviewed for Liability Notices. Based on observations and interviews, there was no information prominently displayed on the unit on how to receive refunds for previous payments covered by Medicare or how to contact the Adult Protection and Advocacy Network. The findings included: Review of 1 of 3 Notices of Medicare Provider Non-Coverage on 11/9/11 at approximately 4:00 PM revealed the notice for Resident A had not been signed or dated by the resident or responsible party. According to the Notice of Medicare Provider Non-Coverage, the resident's covered services would end on 9/5/11. Attached to the notice was an e-mail from the facility to the resident's son which stated ""Please sign and return the attached documents regarding your mother's transition. Please call ... if you have any questions"". The e-mail and the Notice of Medicare Provider Non-Coverage had been sent on 9/2/11. During an interview on 11/9/11 at approximately 4:00 PM, the Accounting Director stated she had not received an answer back from the e-mail and had no way of knowing if the son had received and/or understood the information. When asked, she stated that the facility had not mailed the Notice of Medicare Provider Non-Coverage or tried to call the resident's son. Review on 11/9/11 of the ""30-Day List"" provided by the facility revealed Residents A, B, and C had been listed as having been covered for Medicare, dropped below Medicare coverage criteria with days remaining on the benefit period and remained in the facility. According to the list, Resident A's first non-covered day was 9/6/11. She had 71 days remaining in the benefit period and had moved to Assisted Living. Resident B's first non-covered day was 9/22/11. She had 76 days remaining in the benefit period and had moved to a Skilled Nursing Facility (SNF) non-certified bed. Resident C's first non-covered day was 10/5/11. She had 49 days remaining in the benefit period and had moved to a SNF non-certified bed. During an interview on 11/9/11 at approximately 4:00 PM, the Accounting Director verified Residents A, B, and C had stayed in the same facility community. When asked if a SNFABN or 1 of 5 Denial Letters had been completed for these residents, the Accounting Director stated she thought that the Notice was not required since the residents were no longer in a certified bed. During an interview on 11/9/11 at 4:15 PM the Accounting Director was asked if there was a posting on the unit on how to receive refunds. She stated that she didn't know, but that she had not created one. After checking for the posting on the unit bulletin board with the surveyor on 11/9/11 at 5:05 PM, the Accounting Director verified there was no posting related to how to receive refunds for previous payments covered by Medicare. Observations on 11/8/11 at approximately 10:30AM, during the initial tour of the facility, no posting of contact information for the South Carolina Protection and Advocacy Agency was noted. Interview on 11/9/11 at approximately 9:15AM with the Administrator confirmed that there was no posting of the contact information for the South Carolina Protection and Advocacy Agency.",2014-06-01
10110,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,278,D,0,1,HXLZ11,"**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 ensure accuracy of the Minimum Data Set (MDS) Assessments for 2 of 5 residents reviewed for accuracy of assessments. Residents #3 and #4 did not have their [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #3 on 10/24/11 with [DIAGNOSES REDACTED]. Record review on 11/9/11 revealed a hospital Transfer Summary dated 10/24/11 which included under Discharge [DIAGNOSES REDACTED]. The ""Discharge Medications"" included ""[MEDICATION NAME] 500 mg (milligrams) daily via PEG for three more days"". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]""[MEDICATION NAME] 500 mg qd (daily) via PEG for three more days then D/C (Discontinue), Pneumonia..."". The medication had been initialed as having been given daily from 10/25/11 through 10/27/11. Review of a hospital Consultation Report dated 10/20/11 revealed Resident #3 was being seen for ""Dysphagia"". According to the report, Resident #3 had a swallowing evaluation done 10/19/11 which showed marked aspiration with almost all consistencies. The report further stated that ""It is felt by the prime physician and the patient family that if he gets proper nutrition and gets strengthening that possibly his swallowing can come back, that he will be able to swallow good, and perhaps he can start back taking P.O. (By Mouth) at a future time"". It was decided to go ahead and place the PEG tube. Review of Speech Therapy notes dated 10/25/11 through 10/31/11 revealed the resident was being fed trials of pureed by mouth and tolerating the pureed diet with honey thick liquids. Review on 11/9/11 at 11:00 AM of the Admission MDS Assessment for Resident #3 revealed an Assessment Reference Date (ARD) of 10/31/11. Review of Section I- Active [DIAGNOSES REDACTED]. During an interview on 11/9/11 at 11:30 AM, the MDS Coordinator verified the two [DIAGNOSES REDACTED]. She stated that Pneumonia had not been coded since the resident had no signs or symptoms of Pneumonia. When it was brought to her attention that the resident had received an antibiotic for Pneumonia during the 7 day look back period, she stated she still would not code Pneumonia as an active diagnosis. When asked why Dysphagia had not been coded under ""Additional active [DIAGNOSES REDACTED]. She stated she had put a call in to IT (Information Technology) one day last week about the problem. During an interview on 11/9/11 at 12:42 PM, the facility Nurse Practitioner was asked if she thought Pneumonia would still be considered an active [DIAGNOSES REDACTED]. She was reminded that the resident had been discharged from the hospital with a [DIAGNOSES REDACTED]. She said ""Yes"", and added that there was a long recovery period for Pneumonia. The facility admitted Resident #4 on 2/1/99 and readmitted her on 9/14/11 with [DIAGNOSES REDACTED]. Record review on 11/9/11 at approximately 2:15 PM revealed a hospital Transfer Summary dated 9/12/11 which included Discharge [DIAGNOSES REDACTED]. According to the summary, Resident #4 recently had ""recurrent infection secondary to [MEDICAL CONDITION] Resistant Staph (MRSA)""...and ""underwent explant of her hardware with placement of antibiotic spacers..."". The report stated that since admission, her ""Staples have been removed and wound remains well approximated..."". The summary stated that Resident #4 was ""noted to be malnourished on admission as well with a pre [MEDICATION NAME] of 10.0. She was started on protein supplementation. Repeat pre [MEDICATION NAME] was increased at 14"". The report stated that Resident #4 had ""complaints of some sinus congestion and allergic rhinitis for which she was started on [MEDICATION NAME] and [MEDICATION NAME] with improvement..."". Discharge Medications included [MEDICATION NAME], and [MEDICATION NAME]. Review of the History and Physical dated 9/14/11 for Admission revealed the resident was admitted to the facility for skilled nursing care with a Hickman catheter for intra-articular antibiotics and Physical and Occupational therapy. Under Primary History was noted [DIAGNOSES REDACTED]. Under ""Assessment/Plan"", the Physician documented ""1) Knee Replacement (Secondary)[MEDICAL CONDITION] infection, 2) [MEDICAL CONDITION]"". Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of labs revealed a [MEDICATION NAME] level of 13.77 for Resident #4 drawn on 9/19/11. The normal range documented on the lab sheet was ""17.6 - 36.0 mg/dl"" (milligrams per deciliter). Review on 11/10/11 of the Admission MDS Assessment for Resident #4 revealed an ARD date of 9/21/11. Review of Section I- Active [DIAGNOSES REDACTED]. [MEDICAL CONDITION] had not been coded as a [DIAGNOSES REDACTED]. During an interview on 11/10/11 at 9:50 AM, the MDS Coordinator verified the 3 [DIAGNOSES REDACTED]. When asked why ""Allergic Rhinitis"" had not been coded, she stated that she had told the IT person in June of this year that she had problems coding additional diagnoses. During an interview on 11/10/11 at 8:50 AM, the Administrator stated she knew they had problems in the beginning with the software but did not know of any specific concerns related to not being able to code additional [DIAGNOSES REDACTED]. During an interview on 11/10/11 at 11:00 AM, the MDS Coordinator and the Technology Services Coordinator were present. According to the MDS Coordinator, she has never been able to add an additional [DIAGNOSES REDACTED]. She stated that in July when they started [MEDICATION NAME] transmitting the MDS Assessments, she realized she was not able to pull over diagnoses. She stated that her first active transmission was August 29, 2011 and the problem was identified at that time. During the interview, the Technology Services Coordinator stated that they are now (as of today) able to add additional [DIAGNOSES REDACTED]. She stated that she did not have anything in writing about when she was notified of the problem or anything that had been done to fix the problem up until now.",2014-06-01
10111,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,281,D,0,1,HXLZ11,"**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 adhere to accepted standards of practice for of 2 of 8 sampled residents reviewed for professional standards. Nursing Staff did not clarify with the Physician whether Resident #4 should continue a Multivitamin on admission to the facility. Resident #4 was given a dose of [MEDICATION NAME] after the time frame for the order had ended. There was no documentation of Resident #3's Oxygen Saturation for 8 shifts. The findings included: The facility admitted Resident #4 on 2/1/99 and readmitted her on 9/14/11 with [DIAGNOSES REDACTED]. Record review on 11/9/11 at approximately 2:20 PM revealed a hospital Transfer Summary dated 9/12/11. Discharge Medications included a ""Multivitamin once daily"". Review of the Transfer Summary revealed the facility Physician had initialed the Transfer Summary 9/14/11. There was nothing on the form to indicate he did not want the Multivitamin continued. Review of the History and Physical dated 9/14/11 on Admission to the facility revealed the Physician had included the Multivitamin on the list of Medications and had checked ""Continue current Meds(medications)"" under his ""Assessment/Plan"". However, review of the 9/14/11 Admission Physician Telephone Orders and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued record review on 11/9/11 revealed a Physician's Telephone Order dated 9/14/11 which stated ""Standing Order: [MEDICATION NAME] 30 ml (milliliters) P.O. (By Mouth) q (every) 4 (hours) PRN (as needed) 5 days, For Indigestion/Heartburn"". Review of the 9/14/11 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (9/28/11). On the back of the MAR indicated [MEDICATION NAME] 30 cc (cubic centimeters) Indigestion, Eff(ective) 12:30"". Continued review revealed another order had not been written to continue the [MEDICATION NAME] after 9/19/11. During an interview on 11/10/11 at approximately 8:00 AM, Registered Nurse (RN) #1 verified the above findings after reviewing the record. When asked, she stated she did not know if the Multivitamin should have been continued on admission but agreed that the nurse should have clarified whether the Physician wanted the resident to continue it or not. She stated the standing order for [MEDICATION NAME] had a limit of 5 days on how long it could be given and verified that a dose was given after the medication order had ended. The facility admitted Resident #3 on 10/24/11 with [DIAGNOSES REDACTED]. Record review on 11/8/11 at approximately 4:20 PM revealed a Physician's Telephone Order dated 10/24/11 which stated ""...Check O2 (Oxygen) Saturation q (every) shift + PRN (as needed) "". According to the documentation on the 11/7/11 Telephone Order, nursing staff had completed/noted the order at 3:00 PM on 11/7/11. Review of the October/November 2011 Treatment Record/Medication Administration Record, Frequent Checks"" sheet revealed there were 8 shifts from 10/27/11 through 11/7/11 that the O2 saturation for Resident #3 had not been documented. The missing documentation was for the 3-11 shift on 10/27, 10/31, 11/1, 11/2, 11/3, and 11/4; the 11-7 shift on 11/2; and the 7-3 shift on 11/7. During an interview on 11/9/11 at 12:15 PM, RN #1 was asked to review the order which said to ""Check O2 Saturation q shift + PRN"" and asked if she would expect the nursing staff to document the Oxygen saturation somewhere in the record. She answered ""Yes"". After reviewing the above documentation, she verified the above findings of missing documentation related to the Oxygen Saturation for Resident #3. She stated that there was no other place the nursing staff would document this information. Continued review revealed a Physician's Telephone Order dated 11/7/11 to ""D/C (Discontinue) O2"".",2014-06-01
10112,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,309,D,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide care and services to maintain the highest practicable physical well being possible for one of one residents reviewed with incisional care. The nurse did not provide care for a right knee incision as ordered for Resident #4. The findings included: The facility admitted Resident #4 on 2/1/99 and readmitted her on 9/14/11 with diagnoses, including, but not limited to, Postoperative Right Knee Infection, status [REDACTED]. Observation on 11/8/11 at 4:32 PM revealed Licensed Practical Nurse (LPN) #1 preparing to provide an ordered treatment to the right knee of Resident #4. A Chux covered a bedside table on which was observed [MEDICATION NAME] Spray, (3) Cosmopore Dressings, Hand Sanitizer, and gloves. The nurse applied her gloves after washing her hands. She removed the top of the [MEDICATION NAME] Spray, opened the three Cosmopore dressings and placed them on the table. She pulled back the residents blanket that was draping her right leg and removed three dressings from resident's leg and placed them in the trash. She removed her gloves, used the hand sanitizer, and applied a new pair of gloves. She then sprayed the [MEDICATION NAME] onto the suture line of the right leg, waited for it to dry, and then placed three Cosmopore dressing along the suture line up the resident's leg. Review of Physician's Telephone Orders on 11/9/11 revealed an order dated 10/29/11 which stated ""...Cleanse R(ight) knee incisions (with) wound cleanser, pat dry. Apply skin prep to periwound skin. Spray small amount [MEDICATION NAME] to incision line, allow to dry, cover (with) non adherent dsg (dressing) daily & PRN (As needed)"". Review of the November 2011 Treatment Record revealed an entry for the above ordered wound care to be done. This entry had been initialed as having been done daily from 11/1/11 through 11/9/11. During an interview on 11/10/11 at 7:50 AM, the November 2011 Treatment Record was reviewed with Registered Nurse (RN) #1. She was told that the nurse doing the treatment on 11/8/11 had not cleaned the right knee incisions with wound cleanser, had not patted the area dry, and did not apply skin prep to the periwound skin. When asked, RN #1 stated she would have expected the nurse to do the treatment as ordered by the physician.",2014-06-01
10113,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,323,E,0,1,HXLZ11,"On the days of the survey, based on observation and interview, the facility failed to assure the environment was as free as possible from accident hazards as evidenced by unsecured doors to the laundry, soiled utility room, supply room, and bathing area which all contained chemical and/or physical hazards. The findings included: Observations on 11/8/11 at approximately 10:40am during initial tour revealed the following concerns: The laundry room door on the resident hall was propped open with a brick. The washer was running and there was a 64 ounce (oz) bottle of ""Tide"" laundry detergent sitting on the counter next to the washer. The Soiled Utility room door was also propped open with a brick. On the counter was an aerosol can of ""Febreze"" air freshener. The Bathing Room across from the library was unsecured. A notice on the door stated ""Construction Area"" ""Do Not Enter"". Inside the room, the sink had been removed from the wall and was sitting on the floor. The whirlpool tube was detached from the wall and was in two sections. The toilet was removed from its base on the floor exposing the drain and the tank was missing. Electrical outlets were removed and in one cavity there were two exposed wires. There were two 1 gallon bottles of Whirlpool Disinfectant (Material Safety Data Sheet (MSDS) states ""Health Hazards (Acute and Chronic) EYES: Irritating and may cause chemical burns. SKIN: Prolonged or repeated contact with skin may cause irritation. If ingested: May be harmful or fatal"") on the floor by the tub- one of which had been opened. In addition, there was a 1 gallon bottle of MasterCare Skin Conditioner and Defoamer (MSDS states ""Health Hazards: May cause mild eye irritation with exposure to concentrate. Can be harmful if swallowed."")on the floor. The Supply room door was unsecured. Inside were approximately 45 Kendall Monoject Magellan 3ml (milliliter) syringes with safety needle. 2 boxes (100 per box) of B-D 1ml Safety Lock Syringe with precision glide needle, 2 Suture Removal Kits, A Disinfectant Spray labeled Keep Out of Reach of Children, 6 oz bottle of finger nail polish remover, 7 bottles of finger nail polish, 2 disposable razors, 3-12 oz bottles of Purell hand sanitizer, 6-8 oz bottles of body bath labeled Keep Out of Reach of Children, 6-8 oz bottles of Periwash labeled Keep Out of Reach of Children, 12-1.5 oz container of Antiperspirant labeled Keep Out of Reach of Children among other items. Observations at 11:45am with another surveyor revealed: The Bathing room remained unsecured. Further inspection of this room revealed the call light system was not working from this location. Additional chemicals were found in a cabinet above were the toilet had been. A key was in the cabinet's lock but it was in the unlocked position. In the cabinet was Cen Sol II Bath Oil (MSDS states ""KEEP OUT OF REACH CHILDREN. CAUTION. EFFECTS OF OVEREXPOSURE: INGESTION: Nausea, Laxative Effect EYES: irritation"") and a gallon bottle of Dispersing Bath Oil (MSDS states ""Health Hazards: May cause mild eye irritation with exposure to concentrate. Can be harmful if swallowed.""). The Supply room door was locked, the bricks had been removed from the Laundry and Soiled Utility doors but the doors were unsecured. Observations and interview at 12:00 noon: the Administrator was shown the status of the Bathing room. The Administrator immediately noticed the unsecured chemicals, that construction had begun in the room and that the door had not been secured. The Administrator stated that the room was not safe for residents and immediately had the area secured. Observations at 12:45pm revealed that the Bathing room and Supply room continued to be secured and that the Laundry and Soiled Utility rooms were now secured. At no time during the survey of the facility were there observations of residents wandering the hallways of the facility alone. Interview at 3:00pm with the Administrator indicated that there was only 1 resident identified as being cognitively impaired and mobile with the stipulation that the resident had just achieved mobility 2 days earlier in therapy were he had begun to walk with a walker. At this time the resident was not walking with the walker without staff assistance. Interview at 3:50pm with the Administrator indicated that the Licensed Nursing staff had a key to the Supply room door which is passed shift to shift. In addition, the Licensed Nursing staff had a key to the Laundry and Soiled Utility rooms. The Certified Nursing Staff had one key among the shift to the Laundry and Soiled Utility rooms. The key was passed shift to shift. During an interview on 11/8/2011 at 3:25 PM with Certified Nursing Assistant (CNA) #4, the surveyor questioned if the soiled utility and laundry room doors were locked. The CNA stated that they are locked ""all the time"". The surveyor questioned the use of bricks that were observed in use to prop these doors open. CNA #4 stated that the CNAs did not prop the doors open and that it must have been something "" maintenance had done.""",2014-06-01
10114,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,431,D,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview, and review of the policy provided by the facility entitled ""Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles"" revised 5/10/10, the facility failed to ensure that 3 medications observed at a resident's bedside were securely stored and inaccessible to residents and visitors. The findings included: Observation during Initial Tour on 11/8/11 at approximately 10:00 AM revealed three medications sitting on a bedside table in room [ROOM NUMBER]. The three medications included a bottle of Brimonidine Tartrate Ophthalmic Solution, 1.25 ounces of Tineacide Antifungal Cream, and 1 bottle of Fluticasone Nasal Spray. Observations on 11/8/11 at 12:01 PM and 12:32 PM revealed the medications remained on the resident's bedside table. According to the resident, she had brought these medications from home and used to take them herself. When asked if she currently took those herself now, she stated no, that staff now administer these medications to her. During the observations there were no cognitively impaired self mobile residents observed. During an interview on 11/8/11 at 12:39 PM, Registered Nurse (RN) #1 opened the medicine cart and showed the surveyor a bottle of Flonase Nasal Spray and Brimonidine Tartrate eye drops labeled for the resident's use. She stated these medications were ordered and given to the resident by the nursing staff. When asked if there was an order for [REDACTED]. Review on 11/10/11 of the policy provided by the facility entitled ""Storage ...of Medications...""revealed under ""General Storage Procedures"" that the ""Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.",2014-06-01
10115,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,225,D,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to ensure that all injuries of unknown source were reported immediately to the administrator of the facility and to other officials in accordance with State law, including the State Survey and Certification Agency. Resident #6 was documented as having a bruise of unknown origin which was not investigated nor reported. (1 of 7 residents reviewed for injuries of unknown origin). The findings included: The facility admitted Resident #6 on 9/11/2009 with [DIAGNOSES REDACTED]. On 11/9/2011 review of Resident #6's Nurses' Notes revealed on 10/17/11, the resident had bruising to the upper and lower right arm and that the resident was unable to tell the staff how the bruising occurred. The notes contained no descriptive documentation related to the bruises. On 11/9/2011 at 5:00 PM, review of the facility's Incident Log revealed that Resident #6 was documented as having had ""bruising to RUE (right upper extremity) on 10/17/11."" The log also indicated that the bruise was not reported (to the State Agency) and that there was no follow up needed to be done. At 5:15 PM on 11/9/2011, during an interview with the facility's Administrator, the surveyor questioned how the facility determined the incident of bruising was not reportable with no description of the bruises and the resident unable to verbalize how the injury occurred? The Administrator stated they did not report the incident because there were no signs of distress documented in the Nurses' Notes.",2014-06-01
10116,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,241,E,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and review of the facility's policy entitled Incontinent Care, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity. The facility failed to drape and provide privacy for Residents #1 and #3, (2 of 2 residents observed for Perineal/Incontinent Care.) The findings included: The facility admitted Resident #1 on 1/07/10 and readmitted her on 4/27/10 with [DIAGNOSES REDACTED]. On 11/08/2011 at 3:00 PM, during observation of Perineal/Incontinent Care for the resident, Certified Nursing Assistants (CNAs) #1 and #3 failed to drape the resident. The resident was exposed from the abdomen to her feet while the procedure was completed. The resident was in a private room with no privacy curtain. During the provision of care, a sitter was present in the room. The sitter was positioned sitting to the resident's left at the bottom of the bed and able to view the procedure as it was completed. On 11/9/2011, during an interview with Registered Nurse (RN) #1, she stated that the resident should have been draped and that the sitter should not have been in the room during the care. The facility admitted Resident #3 on 10/24/2011 with [DIAGNOSES REDACTED]. On 11/9/2011 at 3:45 PM, during observation of Incontinent/Perineal Care for the Resident, CNA #2 draped the resident from his lower chest area to the pubic bone area leaving him exposed from the pubic area to his feet. The resident was in a private room with no privacy curtain. On 11/9/2011 at 4:20 PM, during an interview with CNA #2, the surveyor reviewed her observations with the CNA. CNA #2 did not dispute the surveyors observations that the resident had been unnecessarily exposed. . Review of the facility's policy entitled Incontinent Care stated: .""Policy:..To provide care in a manner that preserves patient/resident dignity...Procedure:...4. Uncover the patient/resident, preserving as much dignity as possible...""",2014-06-01
10117,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,315,E,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent Urinary Tract Infections for Resident #1 and Resident #3. Resident # 1 received inadequate cleansing. Concerns with handwashing, glove use and cleansing technique were identified during the observation of incontinence care for Resident # 3 (2 of 2 residents observed for Incontinent Care.) The findings included: The facility admitted Resident #1 on 1/07/10 and readmitted her on 4/27/10 with [DIAGNOSES REDACTED]. On 11.08/2011 at 3:00 PM, during observation of Incontinence/Perineal Care for Resident # 1, Certified Nursing Assistant (CNA) #1 was observed to wipe the center of the labia one time. CNA #1 did not spread the labia to cleanse each inner side of the labia. She then cleansed the area at the top of the left and right thigh. On 11/9/2011, during an interview with Registered Nurse (RN) #1, she verified the CNA should have spread the labia to allow the area to be adequately cleaned. The facility admitted Resident #3 on 10/24/2011 with [DIAGNOSES REDACTED]. On 11/9/2011 at 3:45 PM, during observation of Incontinence/Perineal Care for the resident, (Certified Nursing Assistant) CNA #2 with gloved hands, moved a waste basket from beside the closet area, raised the bed, and removed the resident's pants and brief. The CNA began incontinence care without washing her hands or changing her gloves. During the observation, CNA #2 cleaned the Glans Penis area, wiping 4 times with the same area of the wipe. Using a clean wipe, CNA # 2 cleaned the shaft of the penis by wiping 4-5 times with the same area of the wipe. She then cleaned the left and right side of the scrotal area with a new wipe for each side but wiped each side 2 times with the same area of the wipe. The resident was then positioned to his right side. The CNA again cleaned the left and right side of the scrotal area, wiping multiple times on each side with the same area of the wipe while continuing onto the buttock area. The anal area was also cleansed, using four wipes but wiping multiple times with the same wipe. Stool was noted on the wipes as the CNA cleansed the resident. The CNA removed her gloves, washed her hands, donned clean gloves and applied a cream to the resident's buttocks. Continuing to wear the soiled gloves, she then replaced the resident's brief and clothes without changing gloves or washing her hands. On 11/9/2011 at 4:20 PM, during an interview with CNA #2, the surveyor reviewed her observations with the CNA. CNA #2 did not dispute the surveyors observations.",2014-06-01
10118,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,441,E,0,1,HXLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interviews, record reviews and review of the facility's policy entitled Infection Control Policies and Procedures, the facility failed to establish an infection control program under which it prevented infections in the facility and failed to maintain a record of incidents and corrective actions related to infections. While performing incontinence care for Resident #1 and Resident #3, facility staff members failed to maintain appropriate infection control precautions. The Certified Nursing Assistants performing care touched the residents and multiple areas wearing contaminated gloves. The facility failed to complete and monitor a line listing of each infection or a list of MDROs.(Multidrug Resistant Organisms) (Resident # 4) The findings included: On 11/9/2011, the facility's Infection Control Log which listed infections treated and diagnosed by the physician and MDROs (Multidrug Resistant Organisms) was reviewed. The facility admitted Resident #4 on 2/1/99 and readmitted her on 9/14/11 with [DIAGNOSES REDACTED]. Record review on 11/9/11 at approximately 2:15 PM revealed a hospital Transfer Summary dated 9/12/11, which stated Resident #4 recently had ""recurrent infection secondary to Methicillin Resistant Staph (MRSA)""...and ""underwent explant of her hardware with placement of antibiotic spacers..."". Discharge Medications included [MEDICATION NAME], and [MEDICATION NAME]. Review of the History and Physical dated 9/14/11 for Admission revealed the resident was admitted to the facility for skilled nursing care with a Hickman catheter for intra-articular antibiotics. Under the "" Assessment/Plan"", the Physician documented ""1) Knee Replacement (Secondary) MRSA infection. Review of the Medication Administration Record for September 2011 revealed the medications [MEDICATION NAME] and [MEDICATION NAME] had been administered. There was no tracking of this resident by the facility. In an interview with the facility's Administrator on 11/9/2011, she stated that the facility completes a graft each month of infection rates but does not complete a line listing of each infection or a list of MDROs. The facility admitted Resident #1 on 1/07/10 and readmitted her on 4/27/10 with [DIAGNOSES REDACTED]. On 11.08/2011 at 3:00 PM, during observation of Perineal Care for the resident, Certified Nursing Assistant (CNA) #1 repositioned the resident, touching her clothing and skin while wearing soiled gloves. She then removed the soiled gloves and without washing her hands wiped the resident's mouth and eyes with a wipe. . The facility admitted Resident #3 on 10/24/2011 with [DIAGNOSES REDACTED]. On 11/9/2011 at 3:45 PM, after an observation of Perineal Care for the resident, CNA #2 applied a cream to the resident's buttocks and replaced his clothing and linens while wearing soiled gloves.",2014-06-01
10119,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,152,D,0,1,HXLZ11,"**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 allow Resident #2 to exercise her right to sign the ""Do Not Resuscitate Order"". Resident #2 was 1 of 7 sampled residents, who had not been declared incapacitated by two Physicians, reviewed for advance directives. The findings included: Resident #2 was admitted with [DIAGNOSES REDACTED]. Record review on 11/8/11 at approximately 4:40pm revealed a ""Do Not Resuscitate Order"" was signed by the resident's Power of Attorney on 8/12/10. Further review revealed there was no documentation by two physicians stating the resident was incapacitated as required by State Law. Interview with the Administrator on 11/9/11 at approximately 4:30pm indicated that after review of the resident's records, a statement signed by two physicians of the resident's incapacity could not be found.",2014-06-01
10120,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,167,C,0,1,HXLZ11,"On the days of the survey, based on observation and interview, the results of the most recent survey of the facility was not posted in a place readily accessible to the residents per regulatory requirement. The most recent survey result was located behind a locked door and not accessible to resident's without knowledge of a code to unlock the door. The findings included: On 11/8/11 during initial tour of the facility, the most recent survey results were not seen. Interview on 11/9/11 at approximately 9:10AM with the Administrator indicated that the survey results were on a table by the main entrance to the Certified unit. The surveyor went to the main entrance to verify the Administrator's statement. To access the main entrance, the surveyor had to enter a code to unlock a door to enter the area were the survey results were available. On 11/10/11 at approximately 8:50AM, the Administrator was asked to show the surveyor where the survey results were posted. The Administrator showed surveyor were the survey results were kept by entering a code to unlock the door. When the surveyor asked how the residents could gain access to the survey results if they do not have a code to unlock the door, the Administrator stated the survey results needed to be on the other side of the locked door.",2014-06-01
10121,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,371,F,0,1,HXLZ11,"On the days of the survey based on observation and interview, the facility failed to prepare and serve food under sanitary conditions as evidenced by: staff chewing gum, food debris, spills on shelving throughout the main kitchen. In the satellite kitchen, dust build up on the grill of the ice dispenser, food debris, and spills in the refrigerator. During preparation of the lunch meal there was no verification that ""to order"" meats were cooked to the proper internal temperature before plating. The findings included: Observations on 11/8/11 at approximately 10:00am revealed the Director of Food Service chewing gum while touring with the surveyor. There was food debris and dried spills on the shelving under the table by the steam table used for pureed food and on shelving throughout the food prep area. Observations at approximately 10:55am in the satellite kitchen revealed heavy accumulation of dust on the grill of the ice dispenser. In the white refrigerator there was food debris on the floor of the refrigerator and dried spills on the shelving and floor of the refrigerator. Observations on 11/9/11 at approximately 2:10pm in the main kitchen revealed there continued to be food debris and spills on the shelving throughout the food prep area. In the satellite kitchen there continued to be an heavy accumulation of dust on the grill of the ice dispenser. In the white refrigerator there continued to be food debris on the floor of the refrigerator and dried spills on the shelving and floor of the refrigerator. Interview with the Director of Food Service at that time confirmed all of the above findings. During observations on 11/9/11 at approximately 11:15am of the plating of food revealed a Cook heating a serving of ham. Interview with the Director of Food Service at that time indicated that the facility practices a cook ""to order ""food preparation system. The ham was being prepared based on a resident request. The Director of Food Service explained the system: A resident indicates on the menu which items they would like for a meal. When the tray is prepared the meat item is cooked to order. Thus, the ham was being heated for plating. When asked if the temperature of the meat was checked before serving, he stated no, the ham was a precooked item. When asked if they checked the temperature of an item like fried chicken, the Director stated that no they do not. It was further explained that they follow a recipe that states at what temperature the fryer is to be and for how long to cook the item. The cooks uses a timer to assure the meat is cooked for the correct length of time.",2014-06-01
10122,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,280,D,0,1,HXLZ11,"**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 the plan of care for Resident # 3 who was found on the floor on 10/29/11. The resident's care plan was not revised to reflect interventions to prevent reoccurance of similar incidents. (1 of 5 sampled residents reviewed for revisions of the plan of care.) The findings included: The facility admitted Resident #3 on 10/24/11 with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 11/8/11 revealed an entry dated 10/29/11 at 5:30 PM which stated ""CNA (Certified Nursing Assistant) called nurse to room. Found Resident sitting on floor. Resident stated he was ""trying to get up to scan his barcode"". No injuries noted. Neurochecks started at this time. Resident's VS (Vital Signs) WNL (Within Normal Limits). Blood Sugar 100. 02 @ 2L (Liters)/min(ute) via nc (nasal cannula). Helped Resident back to bed..."". Review of the Comprehensive Care Plan dated 11/3/11 revealed ""I am at risk for further falls r/t (related to) hx (history) of falls, fatigues easily, [MEDICAL CONDITIONS], DM (Diabetes Mellitus), dementia, some decrease in hearing/vision, decreased safety awareness and advanced age."" The Start Date was listed as 10/24/11 with the goal being ""I would like to have no additional falls over the next quarter"". The Approaches listed included ""Please complete a fall risk assessment on me quarterly. Keep my room clutter free and well lit. My call light within reach. My bed in low locked position. Use- I prefer to use half bed rails for my bed mobility. I will need assistance to wear non skid footwear. Please remind me to lock my wheelchair brakes and to ring for assistance when I need to transfer. Please bring me to the nursing area when I am out of bed. Please remind me to wear and assist me if needed with wearing my glasses every day while I am awake. Please remind my family to notify the staff when they bring me back to my home or room. I need assist x 1-2 staff for transfers at times. OT/PT (Occupational Therapy/Physical Therapy) as ordered. Please ensure my pain needs are met daily"". Review of the Admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ""5"" for Resident #3. During an interview on 11/10/11 at 7:15 AM, Registered Nurse (RN) #1 was asked about the fall. She was asked if an incident report was done for the fall, and stated ""No"" after reviewing the Nurse's Note for 10/29/11. When asked if any interventions had been put into place to prevent future incidents or injury, she stated that the resident no longer had the tube feeding on from 6:00 AM to 3:00 PM, and that he may have been trying to ""mess"" with his pump at the time of the fall. She stated that the bed is as low to the floor as possible and they asked him to push his call light. When asked if they had implemented a low bed for the resident, she said no; and when asked stated that they had kept the bed as low as possible before the resident had fallen. She verified the resident had been found on the floor and the incident had been unwitnessed. She stated that is why neurochecks had been implemented, since no one saw the resident fall and they were unsure if the resident had hit his head. She stated that the resident had been working with PT and OT (therapy) since admission and knows that he should only walk or transfer with staff assistance and use his walker. She also stated that the resident had no previous falls prior to this incident. The incident was not noted on the plan of care and there were no additions or changes to the plan of care since it was developed on 10/24/11.",2014-06-01
10022,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-03-17,323,G,1,0,DB3J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, interviews, and review of facility documents, the facility failed to ensure residents received appropriate assistance devices to maintain a resident environment as free of accident hazards as possible for 1 of 2 residents reviewed who had bruising from a known source (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessments of 4/5/10 and 9/20/10 revealed the resident had memory and communication impairment. The resident did not ambulate and required total care from the staff for transfer, dressing, hygiene, and bathing. When out of bed, the resident used a tray top on her wheelchair for positioning due to leaning. She received anticoagulant therapy with the drug Coumadin. On 11/4/10, the 7:40 AM Nurse's Note stated the nurse was called to the resident's room. ""... Nurse noted resident to have a bruise from sternum, over the (L) (left) side of chest, around to the back. ..."" The nurse notified the nurse practitioner and the resident's daughter. At 1:45 PM on 11/4/10 (sic), the Nurse's Note said the bruise was ""... from sternum to waist area on (L) side and goes around to back. According to the nurse's note, the nurse practitioner ordered An x-ray of the abdomen on right and left side. The note also stated ""... resident appears to be in pain leans to (R) (right) side."" The facility determined the wheelchair tray top was responsible for the band of bruising around the resident's left side. Review of the resident's blood levels related to her anticoagulant therapy showed elevated PT (prothrombin time) and INR (international normalized ratio) on 11/1/10. The resident's tests were in therapeutic range on 11/4/10 but elevated again on 11/8/10. The physician and nurse practitioner monitored the resident's test results and adjusted the Coumadin dose as necessary, however, the likelihood of continued injury or new bruising remained high for this resident. Review of the Rehabilitation Screen dated 9/9/09 revealed the resident needed positioning in the wheelchair with the lap tray, right side supports, and calf pads. Review of the medical record and an interview with one of the resident's direct caregivers, Certified Nursing Assistant #1, revealed no evidence the side support was in use in November 2010. Review of the medical record showed no interventions put in place to protect the resident from further potential injury from the tray table.",2014-07-01
10023,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-03-17,514,D,1,0,DB3J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, the facility failed to maintain an accurately documented medical record in accordance to accepted professional standards for 1 of 2 resident's reviewed who sustained bruises of known origin (#1). The findings included: On 11/4/10, nursing staff found a bruise on Resident #1's left side. Review of the documentation failed to show specific details of the bruising, such as measured size, exact location and extent, and color. The medical record also showed conflicting information related to the x-ray ordered related to the bruising. Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessments of 4/5/10 and 9/20/10 revealed the resident had memory and communication impairment. The resident did not ambulate and required total care from the staff for transfer, dressing, hygiene, and bathing. When out of bed, the resident used a tray top on her wheelchair for positioning due to leaning. She received anticoagulant therapy with the drug [MEDICATION NAME]. Entries into the medical record related to the bruising included the following documentation in the Nurse's Notes: 11/4/10, 7:40 AM, ""... bruise from sternum, over (L) (left) side of chest, around to the back..."" 11/4/10 (sic), 1:45 PM, ""...bruise from sternum to waist area on (L) side and goes around to back..."" (no documentation on 11/5/10) 11/6/10, ""... mid chest area remains bluish/yellow discoloration chest..."" 11/6/10, 3 PM, ""...discoloration side bluish/black in color..."" 11/6/10, 2200 (10 PM), "" (L) chest and abd (abdominal) area remains discolored black & blueish (sic) discoloration..."" 11/7/10, 2400, ""chest area remains bluish/yellow discoloration..."" 11/7/10, 11:00 AM, ""... chest area remains blue/yellow ..."" Documentation on the facility's investigation worksheet dated 11/4/10 revealed ""... bruising from sternum around left side to resident's back."" Review of the nurse practitioner's progress note dated 11/9/10 revealed the resident had a ""... large bruise noted across patient's chest..."" Review of the C.N.A. (Certified Nursing Assistant) Daily Skin Inspection Record showed a body form, front and back to the right side of the record. A line was drawn completely across the front of the body under the breasts, and on the left side of the back to the spine. The drawing corresponded to CNA documentation on 11/5, 11/6, and 11/7. Review of the medical record showed conflicting information related to the x-ray done on 11/5/10. The Nurse's Note on 11/4/10 (sic) at 1:45 PM revealed the nurse practitioner gave an order for [REDACTED]."" Review of the x-ray report, initialed by the nurse practitioner, showed ""Exam: Abdomen 1V/ KUB (kidney, ureter, bladder)"" This x-ray report showed findings of ""The bowel gas pattern is unremarkable without large or small bowel dilation. There is no soft tissue mass or pathologic calcification. Conclusion: Unremarkable abdomen examination.""",2014-07-01
10024,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2011-03-23,281,G,1,1,IWIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of the South Carolina Board of Nursing Advisory Option #9 the facility failed to provide care and services that met professional standards of practice for; one of one newly admitted resident reviewed, Resident #22, with a [DIAGNOSES REDACTED]. sugars. On 10/23/2010, at 2 AM, when noted with a change in mental status and a blood sugar of 82, Resident # 22 was sent to the emergency room . The resident on transfer was found to have a blood sugar of 34; one of three residents reviewed with a Peripheral Inserted Central Catheter (PICC) Line. Resident #14 was administered PICC Line flushes that were not per physician order, Licensed Practical Nurses (LPN) administered PICC Line medications with no documentation of advanced training and there were numerous occasions when a Registered Nurse (RN) was not on site when the LPN's administered the medications via the PICC Line; the facility failed to obtain a physician order before placing Resident # 21 on oxygen for one of three resident's reviewed for oxygen use. The findings included: The facility admitted Resident #22 on 10/22/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the Resident was admitted to the facility on [DATE] at 4:30 PM. Review of the Nurse's Notes dated 10/22/2010 at 6:00 PM indicated the resident fed himself supper and a poor appetite was documented. The family was observed at the bedside. Nursing documentation on 10/23/2010 at 0200 AM stated, ""Resident only responsive to painful stimulation. Pt. (patient) sticks out tongue consistently. Eyes with a stare. Was yelling but yelling stopped. V/S (vital signs) T (temperature) 96 P (pulse) 79 R (respirations) 20 BP (blood pressure) 143/63, Sats (oxygen saturations) 96% 3 LNC (liters nasal cannula). BS (blood sugar) 82. MD (medical doctor) notified N. O. (new orders) obtained. Left message for (wife) about transfer to (hospital) for evaluation... 0313 Regional Ambulance employees at bedside for pickup. Report given. Pt transported via stretcher..."" 10/23/2010 at 0645 AM stated, ""Resident returned to facility via stretcher via ambulance. ...RN (registered nurse) at hospital states BS (blood sugar) was 34 on arrival to ER (emergency room ). MD wants BS checks before meals, and make sure resident eats..."" The Nurse's Notes failed to show that Resident #22's vital signs or blood sugars were monitored after the 10/23/2010 entry at 0200. Review of the hospital Transfer Summary dated 10/20/2010 included transfer diagnosis #8 as ""Type 2 diabetes mellitus, insulin dependent with fluctuations..."" The summary stated under the Hospital Course: ...In regards to his diabetes, he has had fluctuant levels requiring changing of his insulin regimen. He did require IV (intravenous) insulin drip while in ICU (intensive care unit)..."" Review of the Physician's admission orders [REDACTED]. Review of the Physician's Admission History and Physical, assessment date 10/25/2010 stated under the heading ""... Overall Medical Assessment... Is there any other worthy things about this individual, from a physician's perspective? He went to ...(hospital) ER (emergency room ) 10/23/10 due to mental status changes BS 34..."" Review of the Medication Administration indicated the 4:30 PM blood sugar and the 8:30 PM blood sugar on 10/22/10 were not obtained. There was no explanation as to why the order was not followed. In an interview with the surveyor on 03/22/2011 at approximately 2:30 PM the Director of Nursing confirmed there was no documentation that the blood sugars were obtained on 10/22/2010. The facility admitted Resident #14 on 10/20/10, with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the January 2011 Medication Administration Records (MARS) showed the resident received [MEDICATION NAME] via a PICC line at 4 AM and 4 PM on 1/1/11 through 4 AM on 1/12/11. The [MEDICATION NAME] was not given at 4 PM on 1/12/11 per order, as the facility was waiting for the medication to arrive from the pharmacy. It was re-started on 1/12/11 at 4 AM and continued through the end of the month. The resident was also noted to be receiving [MEDICATION NAME] (an additional antibiotic) intravenously every day at 9 AM. Documentation related to flushing the resident's PICC with 5 cc's (cubic centimeters) of normal saline before/after the antibiotic was signed as administered at 9 AM and 9 PM from 1/1/11 through 1/5/11. It was then documented on the medication administration record that the PICC line to right upper arm was flushed with 5 cc's of NS (normal saline) before and after IV abt. (antibiotic)- followed by 5 ML (milliliters) of a [MEDICATION NAME] flush solution. This was signed as being done on the 11 PM -7 AM shift and the 7 AM - 3 PM shift from 1/7- 1/31/11. The January 2011 medication administration record also listed documentation that the PICC line was flushed with an additional 5 cc's of NS (normal saline) every shift and it was signed off as being done for the entire month. Review of the facility staffing sheets and time clock punches for the month of January 2011 showed that there were nine shifts when a Registered Nurse (RN) was not in the building as required while the medication and flushes were being done via a PICC line per documentation on the medication administration record. Further record review showed that Resident #14 received [MEDICATION NAME] via PICC line every day at 9 AM from 2/1/11 through 2/22/11 and [MEDICATION NAME] at 4 AM and 4 PM from 2/1/11 through 4 AM on 2/23/11. The medication administration record for February 2011 (2/1/11 - 2/23/11) documented- Flush PICC line to right upper arm with 5 cc of NS before and after IV antibiotic followed by 5 ml [MEDICATION NAME] flush solution and it was signed as done on the 11 PM - 7 AM shift, 3 PM - 11 PM shift and the 7 AM - 3 PM shift. Also on the MARS was a notation to 'Flush PICC line with 5 cc's of NS every shift'. This was also signed as being done on all three shifts. The physician orders for the resident's re-admission on 2/25/11 through 2/28/11 stated the resident was to receive [MEDICATION NAME] at 5 AM and 5 PM via IV. The medication was later changed to be given at 9 PM via IV. The order to flush the PICC line was not obtained until 2/26/11 and it read as follows: 1) Flush PICC line with 5 cc's of NS before and after IV abt. 2) Flush PICC line with 5 cc's of NS q shift. There were three nursing shifts for the month of February where there were no RN's in the building as required during the IV medication administration or the PICC line flushes. The March 2011 physician orders stated [MEDICATION NAME] was to be given at 9 PM via PICC line and the [MEDICATION NAME] was to be given at 5 AM and 5 PM via PICC line. The orders also contained the following directions for the flushes: 'Normal Saline flush 0.9% disp (dispense) syringe. Flush PICC line as directed.' It was documented to be done on the 7 AM - 3 PM shift, the 3 PM - 11 PM shift and the 11 PM - 7 AM shift. The March MARS showed that the [MEDICATION NAME] was given at 5 AM on 3/1 and 3/2 and at 5 PM on 3/1. The MARS later showed a time change to give the [MEDICATION NAME] at 4 AM and 4 PM and it then was signed off as being given at those times. [MEDICATION NAME] was given via the PICC line at 9 PM on 3/1, 3/2 and 3/3. The administration time for the [MEDICATION NAME] was then changed to 9 AM and was signed off as being given at that time. The March MARS also showed that the PICC line flush was signed off as being done every shift from 3/1/11 through 3/21/11 for the 7 AM - 3 PM shift. A new order obtained on 3/21/11 was written as follows: ' 1) D/C (discontinue) flush PICC line flush with 5 cc NS q shift 2) flush with 5 cc NS pre and post IV ABT (for [MEDICATION NAME] and [MEDICATION NAME] ABT IV).' This was changed on the March MARS on 3/21/11 with the flushes to be done at 4 AM, 4 PM and 9 AM. The first NS flush was at 4 PM on 3/21/11. There was one shift found to be without RN coverage during 3/1/11 - 3/21/11. Review of the March 2011 MARS revealed that the PICC line medication and the PICC line flushes were administered by six Licensed Practical Nurses (LPN) who had no proof of having been trained to work with PICC lines per state regulations as confirmed by the Director of Nurses and the Administrator on 3/23/11 at approximately 12:15 PM. Per the South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion # 9B) states: ""The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central cenous access devices/lines that includes didactic and supervised clinical competency training with return demonstration.... The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter sire (port A cath). The Agency must have specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN."" Section 40-33-20 defines supervision as meaning "" the process of critically observing, directing, and evaluating another's performance."" The facility admitted Resident #21 on 11/15/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed a Physician's Progress Note dated 11/17/2010 that stated, ""11/17/2010 Medicine Late entry Nurse informed me yesterday evening when in facility that pt (patient) had been on O2 it was removed not ordered. When signing rehab orders of 11/16/10 it was also noted that pt was to be cont (continued) on O2 - this was crossed out since pt was not on O2. When passing room last nt (night) - pt was not on O2. He appeared comfortable. Wife left facility shortly after that time. No expressed concerns to me."" Review of the Physician Orders Occupational Therapy dated 11/16/10 showed under Precautions: "" Falls, cont. O2 2 L(continue oxygen at 2 liters per minute) - cannula (not ordered)..."" The order for "" O2 2 L - cannula"" was marked out. Review of the Physical Therapy Evaluation dated 11/16/2010 indicated under Other Related Medical, Rehab, Social Hx (history) ...""Says he wears O2 when needed and [MEDICAL CONDITION] (breathing machine) at night."" ...Additional Tests: Pt (patient) on 2L O2 via NC (nasal cannula) during eval(uation)..."" In an interview with the surveyor on 03/22/2011 at 11:40 AM Physical Therapist #1 stated that Resident #21 was seated in a wheelchair, at the nurse's station around 2:00 PM on 11/16/2010, wearing oxygen when she went to do his initial evaluation. She stated that she assisted the resident from the wheelchair to his bed and hooked the oxygen to the concentrator, which was already set at 2 liters for his [MEDICAL CONDITION]. Review of the November 2010 Physician's Orders indicated ""O2 @ 2 LPM (liters per minute) hs (hours of sleep) with [MEDICAL CONDITION]."" Review of the Nurse's Notes from 11/15/2010 through 11/17/2010 revealed no documentation related to the resident receiving oxygen on 11/16/2010. Review of the Statement of Witness (Occupational Therapist #1) dated 11/16/10 stated, ""Went into patient room @ 11:00 AM and helped patient get dressed. Patient was found with O2 concentrator on and [MEDICAL CONDITION] mask next to his head... Patient said he wanted a cannula for O2. OT went to nurse and asked for cannula. The nurse asked who it was for and OT told nurse the patient name. Nurse gave him a cannula..."" In an interview with the surveyor on 03/22/2011 at approximately 3:20 PM LPN #1 confirmed she gave OT #1 a cannula for a resident but she was not sure who the resident was who needed the cannula. Review of the facility policy for Oxygen Administration stated, ""Purpose: To describe method for delivering oxygen in order to improve tissue oxygenation, reduce risk for [MEDICAL CONDITION], decrease work of breathing and reduce shortness of breath with activity. During a respiratory emergency it is appropriate for nursing to administer oxygen immediately and obtain physician's order after patient is stabilized or transferred... Procedure: 1. Verify Physician's order..."" There was no documentation noted that Resident #21 was short of breath or had an emergency arise which necessitated the use of oxygen at 2 liters.",2014-07-01
10025,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2011-03-23,514,E,1,1,IWIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews, the facility failed to maintain accurately documented clinical records for 3 of 16 records reviewed . Resident #5's x-ray done on [DATE] and the results were not available in the medical record. Resident #21's oxygen saturation levels were not documented on [DATE] for the 7 - 3 shift; [MEDICATION NAME] was not documented [DATE]; there was no documentation as to why [MEDICATION NAME] was not given as ordered on [DATE]. Resident #7's record revealed conflicting and incomplete documentation related to his elopement and there was inaccurate and incomplete documentation related to notification of the responsible party. The findings included: The facility admitted Resident #7 on [DATE] with the [DIAGNOSES REDACTED]. The resident was identified on entry to the facility as an ""exit seeker"" and a wanderguard was placed on him on [DATE]. It was being checked for placement and function. A record review on [DATE] at 11:30 AM revealed a nursing note dated [DATE] at 11:30 AM written by Licensed Practical Nurse (LPN) #1 which documented the resident's elopement from the facility. The note stated that an audible alarm was sounding at the entrance doors of the facility and after the nurse made an assessment of the surrounding area, she observed the resident ambulating with his walker a short distance from the facility. She returned him without difficulty and the wanderguard was checked and it was found to be functioning properly. During an interview with LPN #1 on [DATE] at 5:00 PM about the elopement incident, she stated that another LPN came outside with her on that date and that she saw the resident across the street (Highway 378) in front of Burger King. LPN #1 stated that she retrieved the resident. A review of the Incident Report for the elopement dated [DATE] at 11:00 AM was conducted and the description of the event read: ""Resident was seen sitting in the front lobby by 1st floor nurse. She went to assist another resident and when she returned approximately 5 minutes later the resident was no longer in lobby. Nurses went outside and found resident across street walking. Nurses redirected resident to facility, and assessed, no injury noted to resident."" In further review of the facility's investigation of the incident on [DATE], the Director of Nurse's (DON) signed investigative report documented the resident was ""walking on the sidewalk near Burger King. "" During an interview with the DON on [DATE] at 9:35 AM she stated that during the investigation she got 3 different accounts from 3 different nurses. She agreed the report needed to be more specific. In an interview with the resident's Responsible Party on [DATE] at 5:00 PM, she revealed that she had been notified about the incident, but heard varying accounts of the Resident's elopement and was unsure where he was found at the time of the elopement and which nurses found him. Further record review for Resident #7 revealed that a social work entry documented on [DATE] (with no time included) which stated, ""Reported by staff that res. (resident) states he will blow his brains out if his dtr.(daughter) doesn't get him OOF (out of facility). SSD(Social Services Director) met with res. Res. denies making comment. Res. denies plan to harm himself. Nursing made aware. Referral made to psychiatry. SS(Social Services) to assist as needed."" The note failed to name who informed the Social Services Director of the threat, or name the nurse who was notified, or if the responsible party was notified. In an interview with the Social Services Director on [DATE] at 3:00 PM, she stated that a Certified Nurses Assistant had informed her of the resident's threat, confirmed she had made nursing aware of the threat, but did not recall the nurse's name. She stated that she did not notify the Responsible Party because she assumed nursing would make the call. The Psychiatry referral was made that same day and the resident was seen by the Psychiatrist. In reviewing the nurse's notes for [DATE] there was no mention of the resident's threatening statement or if the Responsible Party was contacted. In further review of the nurses notes for [DATE] there is no mention of the incident on [DATE]. On [DATE] at 5:15 PM the Social Services Director provided a Late Entry note written on [DATE] for [DATE] written by RN #1 which stated, ""Resident PR (sic) called r/t Mr.-'s-statement, 'If I had a gun I blow my brains out...I'm sick of having people looking over my shoulder' ."" ""They appreciated the call-Dr.... was requested to see pt. while on rounds today. "" ""Verbalized he would. Dr....saw resident and it was determined resident was not a threat to himself or others."" ""P/R(sic) ...notified of Dr. ...'s visit and conclusions. ""In an interview with RN #1 on [DATE] at 9:35 AM pertaining to the Late Entry note she confirmed that she had contacted the resident's Responsible Party on [DATE] related to the resident's threat and failed to write the note. In an interview with Resident #7's Responsible Party on [DATE] at 5:00 PM, she stated she had never been notified of an incident involving Resident #7's behavior or threatening comments made on the [DATE] date. The facility admitted Resident #5 on [DATE], with [DIAGNOSES REDACTED]. Review of the current medical record revealed a Nurse's Note dated [DATE] at 5:30 PM that stated, ""Message left on responsible party's A.M. (answering machine) re (regarding): results of bilat (bilateral) hip, knee and femur Xray that were (-) (negative)."" Review of the medical record revealed no x-ray results for an x-ray obtained [DATE]. Review of the Physician's Progress Notes and the Nurse's Notes revealed no documentation regarding the physician's acknowledgement of the [DATE] x-ray findings. The facility admitted Resident #21 on [DATE], with [DIAGNOSES REDACTED]. Review of the closed medical record revealed a Physician's Progress Note dated [DATE] that stated, ""[DATE] Medicine Late entry Nurse informed me yesterday evening when in facility that pt (patient) had been on O2 it was removed not ordered. When signing rehab orders of [DATE] it was also noted that pt was to be cont (continued) on O2 (this was crossed out since pt. (patient/resident) was not on O2.) When passing room last nt (night) - pt was not on O2. He appeared comfortable. Wife left facility shortly after that time. No expressed concerns to me."" Review of the Medication Administration Record (MAR) revealed no documentation on [DATE] for the 7 - 3 shift that the physician ordered, ""check O2 sat (saturations) q (every) shift and PRN (as needed)"" was done as ordered. Further review of the MAR indicated that [MEDICATION NAME] 75 milligrams twice a day was not administered per physician orders [REDACTED]. There was no documentation as to why it was omitted. [MEDICATION NAME] 20 milligrams daily at 6:00 AM was documented on the MAR as having been administered on [DATE]. However, the resident expired at 4:30 AM on [DATE].",2014-07-01
10026,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2011-03-23,329,G,1,1,IWIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview the facility failed to provide adequate monitoring of prescribed medication for a newly admitted resident. Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. On 10/23/2010, at 2 AM, when noted with a change in mental status and a blood sugar of 82, Resident # 22 was sent to the emergency room . The findings included: The facility admitted Resident #22 on 10/22/2010, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed the Resident was admitted to the facility on [DATE] at 4:30 PM. Review of the Nurse's Notes dated 10/22/2010 at 6:00 PM indicated the resident fed himself supper and a poor appetite was documented. The family was observed at the bedside. Nursing documentation on 10/23/2010 at 0200 AM stated, ""Resident only responsive to painful stimulation. Pt. (patient) sticks out tongue consistently. Eyes with a stare. Was yelling but yelling stopped. V/S (vital signs) T (temperature) 96 P (pulse) 79 R (respirations) 20 BP (blood pressure) 143/63, Sats (oxygen saturations) 96% 3 LNC (liters nasal cannula). BS (blood sugar) 82. MD (medical doctor) notified N. O. (new orders) obtained. Left message for (wife) about transfer to (hospital) for evaluation..."" 10/23/2010 at 0645 AM stated, ""Resident returned to facility via stretcher via ambulance. ...RN (registered nurse) at hospital states BS (blood sugar) was 34 on arrival to ER (emergency room ). MD wants BS checks before meals, and make sure resident eats..."" Review of the Physician's admission orders [REDACTED]. Review of the Medication Administration indicated the 4:30 PM blood sugar and the 8:30 PM blood sugar on 10/22/10 were not obtained. There was no explanation as to why the order was not followed. In an interview with the surveyor on 03/22/2011 at approximately 2:30 PM the Director of Nursing confirmed there was no documentation that the blood sugars were obtained on 10/22/2010. Cross Refer to F281 as it relates to the failure of the facility staff to assess and monitor the resident's blood sugar and possible need for intervention.",2014-07-01
10027,HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2011-03-23,425,D,1,1,IWIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to provide pharmaceutical services to meet the needs of Resident #21 who failed to receive Lyrica at 9:00 AM and 5:00 AM on 11/16/2010, as ordered by the physician. The findings included: The facility admitted Resident #21 on 11/15/2010, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The back of the MAR indicated [REDACTED]. In an interview with the surveyor on 03/24/2011 the Director of Nursing stated that the physician failed to call the pharmacy to order the Lyrica and that was why it was not administered.",2014-07-01
10028,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,497,E,0,1,HKFQ11,"On the days of the survey, based on review of personnel files, the facility failed to ensure that seven of ten Certified Nursing Assistants (CNAs) reviewed had completed the required twelve hours of inservice education per year to ensure continued competence. The findings included: On 1-16-11 at 6 PM, personnel files of ten CNAs chosen at random by the facility were reviewed as part of the Extended survey process. Seven of the ten failed to complete the required 12 hours of continuing education per year based on review of the individual CNA inservice records and review of additional unlogged inservice records and sign-in sheets with the Director (DON) and Assistant Director of Nursing (ADON). CNA #a was hired on 5-27-96 and rehired on 4-11-01. Calculations based on use of either hire date resulted in a total of 4.75 hours for the full year from 2009 to 2010 based on hire date. CNA #b (date of hire (DOH) = 5/2/08) had a total of 5.25 hours from 5-2-09 through 5-1-10. CNA #c with a DOH of 10-4-92 had a total of 8 hours 10 minutes from 10-4-09 through 10-3-10. One additional 8-19-10 untimed ""read and sign"" inservice that was not logged on the individual CNA's record was provided by the DON and ADON at 6:45 PM on 1-26-11. CNA #d with a DOH of 8-19-08 had a total of 7 hours 40 minutes from 8-19-09 through 8-18-10. One additional 8-19-10 untimed ""read and sign"" inservice that was not logged on the individual CNA's record was provided by the DON and ADON at 6:45 PM on 1-26-11. CNA #e had two DOHs listed as 6-26-98 and 3-10-06. From 6-26-09 through 6-25-10, the CNA had a total of 6 hours 20 minutes. From 3-10-09 through 3-9-10, there was a total of 7.5 hours. CNA #f with a DOH of 7-19-04 had a total of 10 hours 35 minutes from 7-19-09 through 7-18-10. CNA #g with a DOH of 9-26-02 had a total of 5 hours from 9-26-09 through 9-25-10.",2014-07-01
10029,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,281,K,0,1,HKFQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that standards of clinical practice related to drug storage and administration established by the pharmaceutical company FDA (Food and Drug Administration) approved package inserts, Lexi-Comp Drug Information for Nursing and the facilities' policy and procedures on drug storage were followed on 1 of 2 nursing units. The finding included: During inspection of the West Medication Room on 1/25/11 at approximately 9:50 AM, 20 vials of Insulin Injection, 2 vials of [MEDICATION NAME] Injection, 1 syringe of [MEDICATION NAME] Injection, 2 vials of [MEDICATION NAME] B Adult P/F (preservative- free) Injection, 1 vial of [MEDICATION NAME] Injection, 9 -[MEDICATION NAME] Suppositories, 2 -Bisac-Evac Suppositories, 8- [MEDICATION NAME] Suppositories, 32 -[MEDICATION NAME] Suppositories and 41- Tucks [MEDICATION NAME] Suppositories were stored in the medication room refrigerator at a temperature of 20 degrees F (Fahrenheit). Two of the Insulin vials were frozen. During an interview on 1/25/11 at approximately 10:50 AM, LPN (Licensed Practical Nurse) # 1 stated that if she observed a refrigerator temperature of less than 36 degrees F, that she would turn up the refrigerator temperature and take the insulin to be administered out of the refrigerator to warm to room temperature prior to administering. During an interview on 1/25/11 at approximately 3:10 PM LPN # 1 and LPN # 2 stated that if the thermometer was observed to be less than 36 degrees F they would let the DON (Director of Nursing ) know and that the DON or Pharmacy would tell them what to do in terms of administering the drug, They stated that the DON usually tells them to let it warm to room temperature and then administer. They stated that the medication refrigerator temperature checks are usually made and recorded on first shift, but are sometimes done on third shift and that this responsibility is not assigned to any one person. According to pharmaceutical manufacturer standards (package inserts and manufacturer's labelling), Lexi-Comp Drug Information for Nursing and the facilities' policy and procedures the Insulin, [MEDICATION NAME] B, [MEDICATION NAME] and [MEDICATION NAME] Suppositories should be stored between 36-47 degrees F in order to ensure integrity of the drug. Bisac-Evac and [MEDICATION NAME] Suppositories should be stored at 59-86 degrees F and Tucks [MEDICATION NAME] Suppositories should be stored 68-77 degrees F. Based on observation, record reviews and interviews, facility nurses failed to seek guidance from the Pharmacy and or Physician as to the safety of administering medications improperly stored. Nursing staff when interviewed, stated that they had been instructed by the Director of Nursing to continue to administer medication known to have been improperly stored. There was no documentation that this directive was questioned. This action resulted in the potential for harm for residents who were ordered by their physicians to receive the medications which were improperly stored and subsequently administered. Medications which are improperly stored may lose efficacy or potency, therefore compromising the desired effect. It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility was first notified in writing by the Pharmacy of improper temperature controls. The Immediate Jeopardy at F281 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of ""E"".",2014-07-01
10030,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,425,K,0,1,HKFQ11,"On the days of the survey based on observations, record reviews and interviews the pharmacy failed to ensure that medications were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labelling and the Facility's Policy and Procedures of drug storage. The findings included: Inspection of the West Medication Room medication refrigerator on 1/25/11 at approximately 9:50 AM revealed a temperature reading of 20 degrees F (Fahrenheit). The refrigerator contained, on the top shelf, in a plastic basket ,2 opened vials of Novolin R Insulin 100 U (units)/ml (milliliter) which were frozen, 5 opened vials of Lantus Insulin 100 U/ml. Contained in a plastic bin on the second shelf were 2 vials of Procrit Injection 20,000 U/ml, 1 syringe of Aranesp Injection 40 mcg (micrograms)/ml, 2 vials of Engerix B Adult P/F (preservative- free) Injection 20 mg (1 was opened) and 1 opened vial of Tubersol Injection. Stored on the bottom of the refrigerator, in a plastic bin, were 9 Acephen 650 mg Suppositories, 2-Bisac-Evac 10 mg Suppositories, 8 Bisacodyl 10 mg Suppositories, 32 Phenadoz 25 mg Suppositories and 41 Tucks Hemorrhoidal Suppositories. The refrigerator door contained 1 vial of Lantus Insulin 100 U/ml and 10 vials of Novolin R Insulin 100 U/ml. A review of the FDA approved manufacturer's package inserts and manufacturer package labelling conducted on 1/25/11 at approximately 10:15 AM showed that the Insulin, Procrit, Aranesp, Engerix-B, Tubersol and Phenadoz Suppositories should be stored at 36-46 degrees F. The Acephen, Bisac-Evac and Bisacodyl Suppositories should be stored 59-86 degrees F and the Tuck Hemorrhoidal Suppositories should be stored 68-77 degrees F. On 1/25/11 at approximately 4:45 PM the Consultant Pharmacist, during a telephone interview, stated that medications should be stored according to specified standards by the manufacturer and that in December, 2010 she had concerns about the type of thermometer being used in the West Medication room refrigerator and that she told the nurse on duty. She was unable to identify the name of the nurse, stated that this was the first time she was aware of the problem and did not acknowledge review of the daily recordings of medication refrigerator temperatures. On 1/25/11 at approximately 5:00 PM a review of the ""MED ROOM INSPECTION NURSING STATION INSPECTION REPORT"" dated 1/21/11 revealed that CPhT # 1 had written ""Temp was very low - like 12 degrees - suggest adjusting"". Further review of ""MED ROOM INSPECTION NURSING STATION INSPECTION REPORT"" dated 11/2/10 revealed that CPhT # 2 had written ""Ref too cold 25 degree F"". There was no inspection done in December and neither the DON or Pharmacy could provide proof of inspection during October, 2010. On 1/26/11 at approximately 12:03 PM a telephone interview with the Medical /Director revealed that he was unaware of a problem with medication refrigerator temperatures and commented that ""It sounds like the person didn't recognize there was a problem. Good news is that they were checking"". He agreed that the observed temperature of 20 degrees F (Fahrenheit) and previously recorded temperatures were too low, but was unaware of any problems with patient sugars being too low or too high. He stated that the staff should have reported this as a problem months ago and that the Pharmacy Consultant should have been notified. He did not remember this concern being discussed at the Quality Assurance Committee. On 1/26/11 at approximately 2:30 PM a review of the October-December, 2010 and January 1-25, 2011 ""REFRIGERATOR/FREEZER TEMPERATURE CHECK"" logs for the West Wing medication refrigerator revealed a total of 116 daily temperatures recorded (a recording for January 17, 2011 was missing). Of these there were 8 recordings (6.9 % (percent)) of temperatures 36-46 degrees F, 56 (48.3%) at 30-35 degrees F, 45 (38.8%) at 20-29 degrees F (of which 7 or 6% were at 20 degrees F), 7 (6.0%) at 10 - 19 degrees F. On 1/26/11 at approximately 3:05 PM, during a telephone interview, CPhT # 1 stated that she discussed refrigerator temperature concerns with the DON on 1/21/11. There was discussion about where the temperature dial should be set (1-7) and where the thermometer should be placed and this resulted in the dial being set to ""1"" and the thermometer being placed on the second shelf. She was asked to clarify the temperature recorded (12 degrees or 20 degrees?) on the 1/21/11 inspection report, but could not recall the temperature. She agreed to pull the record at her home and advise on 1/27/11. As of 1/27/11 at approximately 11:30 AM contact with CPhT # 1 was unsuccessful. On 1/26/11 at approximately 4:00 PM a review of the Quality Assurance Committee attendance records October-December, 2010 failed to show attendance by the Consultant Pharmacist. The minutes did not reflect any discussion of medication refrigerator temperature concerns. Based on record review and interviews, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications. There was no immediate action documented which indicated the Pharmacy assessed the improperly stored medications at the time of discovery, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure the concern was immediately corrected. It was determined that the Immediate Jeopardy existed starting 11/2/2010. The Immediate Jeopardy at F425 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of ""E"".",2014-07-01
10031,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,431,K,0,1,HKFQ11,"On the days of the survey based on observations, record reviews and interviews the facility failed to ensure that medication were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labelling and the Facilities Policy and Procedures of drug storage. The findings included: Inspection of the West Medication Room medication refrigerator on 1/25/11 at approximately 9:50AM revealed a temperature reading of 20 degrees F (Fahrenheit). The refrigerator contained, on the top shelf, in a plastic basket ,2 opened vials of Novolin R Insulin 100 U (units)/ml (milliliter) which were frozen, 5 opened vials of Lantus Insulin 100 U/ml. Contained in a plastic bin on the second shelf were 2 vials of Procrit Injection 20,000U/ml, 1 syringe of Aranesp Injection 40 mcg (micrograms)/ml, 2 vials of Engerix B Adult P/F (preservative- free) Injection 20 mg (1 was opened) and 1 opened vial of Tubersol Injection. Stored on the bottom of the refrigerator, in a plastic bin, were 9 Acephen 650 mg Suppositories, 2-Bisac-Evac 10 mg Suppositories, 8 Bisacodyl 10 mg Suppositories, 32 Phenadoz 25 mg Suppositories and 41 Tucks Hemorrhoidal Suppositories. The refrigerator door contained 1 vial of Lantus Insulin 100 U/ml and 10 vials of Novolin R Insulin 100 U/ml. This finding was verified by LPN (Licensed Practical Nurse) # 1 on 1/25/11 at approximately 9:55 AM. LPN # 1 stated that the temperature dial was set on ""1"", but she was unsure as to whether that was the lowest of highest temperature setting. On 1/25/11 at approximately 10:00 AM the DON (Director of Nursing stated that she and CPhT (Certified Pharmacy Technician) # 1 discussed the low refrigerator temperature on 1/21/11 during a pharmacy inspection and that the temperature dial was set to ""1"". The DON stated that she was first aware that there could be a temperature problem about one month ago and that a problem found during inspection was supposed to be discussed with her, but that she was not always there. A review of the FDA approved manufacturer package inserts and manufacturer package labelling conducted on 1/25/11 at approximately 10:15AM show that the Insulinm, Procrit, Aranesp, Engerix-B, Tubersol and Phaenadoz Suppositories should be stored 36-46 degrees F. The Acephen, Bisac-Evac and Bisacodyl Suppositories should be stored 59-86 degrees F and the Tuck Hemorrhoidal Suppositories should be stored 68-77 degrees F. On 1/25/11 at approximately 4:45 PM the Consultant Pharmacist, during a telephone interview, stated that medications should be stored according to specified standards by the manufacturer and that in December, 2010 she had concerns about the type of thermometer being used in the West Medication room refrigerator and that she told the nurse on duty. She was unable to identify the name of the nurse and stated that this was the first time she was aware of the problem. On 1/25/11 at approximately 5:00 PM a review of the ""MED ROOM INSPECTION NURSING STATION INSPECTION REPORT"" dated 1/21/11 revealed that CPhT # 1 had written ""Temp was very low - like 12 degrees - suggest adjusting"". Further review of ""MED ROOM INSPECTION NURSING STATION INSPECTION REPORT"" dated 1/2/10 revealed that CPhT # 2 had written ""Ref too cold 25 degree F"". There was no inspection done in December and neither the DON or Pharmacy could provide proof of inspection during October, 2010. On 1/26/11 at approximately 2:30 PM a review of the October-December, 2010 and January 1-25, 2011 ""REFRIGERATOR/FREEZER TEMPERATURE CHECK"" logs for the West Wing medication refrigerator revealed a total of 116 daily temperatures recorded (a recording for January 17, 2011 was missing). Of these there were 8 recordings (6.9 % (percent)) of temperatures 36-46 degrees F, 56 (48.3%) at 30-35 degrees F, 45 (38.8%) at 20-29 degrees F (of which 7 or 6% were at 20 degrees F), 7 (6.0%) at 10 - 19 degrees F. On 1/26/11 at approximately 2:55 PM a review of the Maintenance Logs for the past year did not show any work requests or repairs for the West Wing Medication Refrigerator. On 1/26/11 at approximately 3:05 PM during a telephone interview CPhT # 1 stated that she discussed refrigerator temperature concerns with the DON on 1/21/11. There was discussion about where the temperature dial should be set (1-7) and where the thermometer should be placed and this resulted in the dial being set to ""1"" and the thermometer being placed on the second shelf. She was asked to clarify the temperature recorded (12 degrees or 20 degrees) on the 1/21/11 inspection report, but could not recall the temperature. She was to pull the record at her home and advise on 1/27/11. As of 1/27/11 at approximately 11:00 AM contact with CPhT # 1 was unsuccessful. Based on record reviews and interviews, the failure of Administration to correct a known concern related to medication storage and to have directed staff to continue to administer the medications placed residents at risk for serious harm. The standard for medication storage per the code of Federal Regulations states: ""All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF). It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. The Immediate Jeopardy at F431 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of ""E"".",2014-07-01
10032,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,490,K,0,1,HKFQ11,"On the days of the survey, based on observation, record reviews and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facility Admininstration failed to take immediate action when notified of improper medication refrigerator temperatures. Nursing Administration failed to educate and instruct facility staff on the appropriate use of medications which were known to have been improperly stored. The findings included: On 11/2/2010 a 'Med Room Inspection Nursing Station Inspection Report' (completed by the Consulting Pharmacy Technician) and submitted to the facility identified the West Nursing Station refrigerator as being ""too cold"" at 25 degrees Farenheit. A subsequent 'Med Room Inspection Nursing Station Inspection Report' dated 1/21/11 also documented ""Temp was very low - like 12 degrees - suggest adjusting"". The facility failed to initiate a plan of action which assured correction of the identified concern. Additionally, nursing staff when interviewed, stated that they had been instructed by the Director of Nursing to continue to administer medication known to have been improperly stored. The failure of Administration to correct a known concern related to medication storage and to have directed staff to continue to administer the medications placed residents at risk for serious harm. The standard for medication storage per the code of Federal Regulations states: ""All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF). It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. The Immediate Jeopardy at F490 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of ""E"".",2014-07-01
10033,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,441,E,0,1,HKFQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the facility's infection control logs, and review of the facility's policy on contact precautions, the facility failed to post signage for visitors/ volunteers to ""see nurse"" for Resident #5, one of one resident on contact precautions. The findings included: The facility admitted Resident #5 on 06/09/10. [DIAGNOSES REDACTED]. difficile. Observation of the resident and room during Initial Tour on 01/24/2011 revealed no report of the resident being on contact precautions and no signage was posted in the resident's room or on the door. The facility provided a list of residents currently on contact precautions during entrance on 01/24/2011 which included Resident #5. Review of the facility policy on ""Infection Prevention and Control"" revealed the following; Policy: Contact Precautions will be instituted on resident's that have been determined to have epidemiologically significant diseases with potential transmissibility to other residents. This includes but is not limited to those patients infected with multiple drug resistant organisms that are not treatable with the usual antibiotics. It also includes patients infected or colonized with an organism that is potentially hazardous to others (C. difficile)....... Equipment/Material: 2. Sign for reporting to nurse prior to entering room for room door if applicable. Visitors: 2. All visitors should be instructed on appropriate hand hygiene before and after visiting with the patient and personal protective equipment needed during their visit if the condition warrants..... In an interview with Licensed Practical Nurse (LPN) #2 on 01/24/2011 she indicated that the facility did not place any signage for the specific precaution due to HIPPA (Health Information Privacy and Protection Act) . When asked if signage which indicated ""See nurse before entering"" was used for residents on precautions, LPN #2 answered, ""No."" She then indicated that they (the staff) ""try"" to catch visitors before they enter the room of any resident on precautions. LPN #3 was also interviewed on 01/24/2011 and indicated they (the staff) ""try"" to catch them (the visitor) before they enter resident's rooms who are on precautions. Review of the medical record for Resident #5 revealed her gastrostomy tube site was positive for Methicillin Resistant Staph Aureus (MRSA) and that the resident had a history of [REDACTED]. The current physician's order included bilateral hand mitts due to pulling out the gastrostomy tube, yet there was no signage present to direct visitors and volunteers to the nurse for instructions to implement to prevent possible spread of any germs.",2014-07-01
10034,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2011-01-27,520,K,0,1,HKFQ11,"On the days of the survey, based on observations, interviews, record reviews, and review of facility policies, the facility failed to maintain a Quality Assessment and Assurance Committee which fully identified quality deficiencies related to medication storage at improper temperature ranges. The facility failed to address the concern and implement corrective action to ensure medications were stored within the appropriate temperature range to prevent compromising the integrity of the medications. The findings included: During an interview on 1/27/11 at approximately 10:30 AM, the Director of Nursing (DON) was asked how the facility identified issues which would require quality assessment and assurance action. At that time, the DON was asked if the Quality Assessment and Assurance Committee had identified medication refrigerator temperatures as a concern. The DON indicated during the interview that this concern had not been identified and taken to the committee for review. On 1/26/11 at approximately 12:03 PM a telephone interview with the Medical /Director revealed that he was unaware of a problem with medication refrigerator temperatures and commented that ""It sounds like the person didn't recognize there was a problem. Good news is that they were checking"". He agreed that the observed temperature of 20 degrees F (Fahrenheit) and previously recorded temperatures were too low, but was unaware of any problems with patient sugars being too low or too high. He stated that the staff should have reported this as a problem months ago and that the Pharmacy Consultant should have been notified. He did not remember this concern being discussed at the Quality Assurance Committee. It was determined that Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. Notification of the concern was provided to the facility but the concern was not addressed and the temperature readings logged in by staff continued to be consistently below acceptable parameters. The Immediate Jeopardy at F520 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of ""E"".",2014-07-01
10035,LAUREL BAYE HEALTHCARE OF ORANGEBURG,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2010-08-18,156,C,0,1,G5LE11,"On the days of the survey, based on record reviews and interview, the facility failed to complete 3 of 3 mandated Liability Notices. The findings included: During review of resident funds on 8/18/10, three of three mandated Liability Notices were not completed by the business office. During an interview following the review, the Business Manager confirmed that the Liability Notices were not completed.",2014-07-01
10036,LAUREL BAYE HEALTHCARE OF ORANGEBURG,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2010-08-18,315,D,0,1,G5LE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, facility policy, and interview, the facility failed to provide appropriate catheter care for 1 of 3 sampled residents with observed catheter care. Resident #3 received catheter care without appropriate cleansing of the area surrounding the meatus and releasing the labia between attempts to clean the perineal area. The findings included: The facility admitted Resident #3 on 11/14/08 with [DIAGNOSES REDACTED]. Observation of catheter care on 8/17/10 at 3:40 PM revealed that after donning gloves, Certified Nursing Assistant(CNA)#2 attempted to spread the resident's labia and with a peri-wipe cleansed down the center. Releasing the labia, CNA #2 obtained a second wipe and placing her right hand on the mons pubis, cleansed down the center of the perineal area. Resident #3 was turned to his/her right side and using different periwipes, cleansed down the left buttock, cleansed down the right buttock, and cleansed the rectal area in an upward motion. Resident #3 was turned onto his/her back. CNA #2 removed his/her gloves, washed his/her hands, and donned gloves. The catheter was grasped at the insertion site and cleansed approximately four inches down the catheter tubing. CNA #2 removed his/her gloves, washed his/her hands, gathered the trash and disposed of the trash in an appropriate container. Review of the facility policy titled ""Urinary Catheter Care"", states in section IIb - 'Cleanse area of catheter insertion well using soap and water or peri-wipes and being careful not to pull on catheter or advance it further into the urethra. The facility had conducted several inservice trainings on Urinary Tract Infections during the month of March 2010 in which CNA #2 attended at least one inservice. The above observation was shared with the Director of Nursing on 8/18/10.",2014-07-01
10037,LAUREL BAYE HEALTHCARE OF ORANGEBURG,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2010-08-18,441,D,0,1,G5LE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations and interviews, the facility presented with a soiled utility room on the North hall with the hand washing sink unaccessible due to a box of trash can liners placed on the sink and multiple over filled barrels of soiled linen which crowded the room. Soiled gloves were used to complete supra pubic catheter care for Resident #5 which was one of four catheter treatments observed. The findings include: The facility admitted Resident #5 on 03/19/09 with [DIAGNOSES REDACTED]. On 08/17/2010 at 11:30 AM Certified Nurses Assistant (CNA) #1 completed peri care and, with the same gloves on, completed supra pubic catheter care for Resident #5. After CNA #1 removed the soiled gloves and was washing her/his hands, she/he confirmed that normally the soiled gloves are removed and hands are washed, then the catheter care completed with clean gloves. During an interview with the Staff Development staff, they indicated that the catheter care and the peri-care was fine. She/ He verbalized that the gloves needed to be removed and the hands washed between peri-care and the supra pubic catheter care. After performing pressure sore treatment on 8/17/10 at 12:10 PM, Licensed Practical Nurse(LPN)#4 disposed of trash/linen in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into the room with three barrels not completely covered. LPN #4 left the soiled utility room and entered an employees' only room which appeared to be a nourishment area. After performing a tube flush on 8/17/10 at 12:57 PM, LPN #2 disposed of trash in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into room with several barrels partially covered. LPN #2 leaned over a barrel to reach the handwash sink. After performing pressure sore treatment on 8/17/10 at 4:42 PM, LPN #3 disposed of trash in the North soiled utility room. A box of trash liners was noted on the sink. LPN #3 entered an employees' only room which appeared to be a nourishment area. On 3/18/10 at 3:15 PM, the North soiled utility room was observed with LPN #1. He/she confirmed that two red barrels were partially covered and a box of trash liners on the handwash sink.",2014-07-01
10038,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-03-01,281,J,1,0,58ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Expanded Inspection based on record reviews, interviews, observations, review of a March 4, 2009 HCR ManorCare memo related to the use of hot pack treatments, and review of the South Carolina Licensing, Labor and Regulation Code of Ethics for Physical Therapy Assistants 101-14, the facility failed to ensure that one of four residents reviewed for specialized rehab received the appropriate standards of care related to the use of a hot pack. Resident #1 sustained a third degree burn to her mid [MEDICATION NAME] region when a hot pack made from a tube sock filled with an unknown amount of rice, was heated in the microwave for an undetermined amount of time and then placed on her mid [MEDICATION NAME] region. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. Review of the ""Physician Orders Physical Therapy"" dated 12/8/2010 revealed ""cold packs"" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy ""Consultation Evaluation"" indicated under treatment approaches, ""hot/cold"" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, ""patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..."" No other documentation was located related to the use of a hot pack. Review of the Nurse's Notes revealed the following entries: On 12/14/2010 at 10:00 PM ""Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..."" On 12/15/2010 at 8:30 AM, ""Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse."" Further review of the notes revealed the resident complained of pain to her back. The physician ordered [MEDICATION NAME] for the pain along with the scheduled Tylenol. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was ""very hot"" and on for a ""long time."" She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she had informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was ""held in place"" by her leaning back in the wheelchair. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used in the facility. PTA #1 stated that in order to use heat as a modality a physician's order must be written. He stated that the Rehab Director ""encouraged"" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was ""not a burn."" He stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made of socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. The three therapists stated that a physician's order must be written prior to using heat and all stated that they would not heat the sock in the microwave for more than 1 minute. All three stated that using the rice socks was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the make shift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was ""ok"" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have ""hot packs"" or ""heat"" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid [MEDICATION NAME] region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. The Medical Director stated that it ""wouldn't be a good thing to use."" He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR Manor Cares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was ""not aware"" of the memo and the memo should have been communicated to her. However, she stated, ""accountability was not clear."" Review of the memo sent March 4, 2009 from the Vice President, for Rehabilitation Services, HCR ManorCare, addressed to Directors of Rehabilitation, Rehab Services, ADNS (Director of Nursing), and Administrators stated, ""Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments. With the increasing acuity of the patients entering our centers, many patients present with contraindications to superficial moist heat. Our Rehabilitation Departments have other effective methods of deep tissue heating, such as diathermy and ultrasound. The Director of Rehabilitation should unplug, drain and dispose of [MEDICATION NAME] units and hot packs in your department effective immediately. The [MEDICATION NAME] units should be placed in a dumpster, rather than put in storage. Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..."" Review of the LLR 101-14 Code of Ethics for Physical Therapy Assistants revealed the following: Standard 1: Physical Therapist Assistants provide services under the supervision of a physical therapist. Standard 2: Physical Therapist Assistants respect the rights and dignity of all individuals. Standard 3: Physical Therapist Assistants maintain and promote high standards in the provision of services, giving the welfare of patients their highest regard. Standard 4: Physical Therapist Assistants provide services within the limits of the law. Standard 5: Physical Therapist Assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. Standard 6: Physical Therapist Assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross Refers to F-323 as it relates to the facility failure to provide an environment free of hazards as is possible and the facility failure to provide adequate supervision to prevent accidents for Resident #1 who sustained a third degree burn as a result of the use of a make shift hot pack. Cross Refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-281 at a scope and severity level of ""J"" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-281 was lowered to a scope and severity level of a ""D"" as of 3/1/2011 at 11:30AM.",2014-07-01
10039,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-03-01,323,J,1,0,58ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Inspection based on observations, record reviews and interviews, the facility failed to ensure the safety for one of four residents reviewed for specialized rehab. Resident #1 received hot pack therapy via a makeshift rice sock that resulted in a third degree burn to her mid thoracic region. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set ((MDS) dated [DATE] coded the resident as having no short-term or long-term memory problems and as not needing assistance in daily decision-making. No behaviors were coded for the assessment period. Review of the Quarterly MDS dated [DATE] indicated that the resident was not experiencing pain. The Quarterly MDS coded Resident #1 as having a burn. Review of Resident #1's Care Plan revealed no care plan for therapy services, however at the time of the survey the resident was not currently on therapy's caseload. No old care plans were produced at the time. Further review revealed the resident's Care Plan updated on 12/15/2010 to reflect the burn on her back as a result of a hot pack. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid thoracic region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. Review of the Nurses Notes revealed the following entries: On 12/14/2010 at 10:00 PM ""Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..."" On 12/15/2010 at 8:30 AM, ""Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse."" Further review of the notes revealed the resident complained of pain to her back. The physician ordered Tramadol for the pain along with the scheduled Tylenol. Review of the Skin Alteration Record initiated on 12/15/2010 measured the burn as 2.5 cm x 3.0 cm, reddened in color with no drainage. The record indicated that the burned area was decreasing in size. On 2/11/2011, the burn measured 2 cm x 1.5 cm with scant amount of serosanguinous drainage. On 2/17/2011, the burn was 1 cm x 1 cm with serous drainage. On 2/26/2011 the burn was recorded as measuring 0.5 cm x 0.5 cm with no drainage. Review of the Wound Notes revealed the ""burn was healing well."" Review of the Physician's Orders revealed the following: On 12/15/2010 a telephone order was written for ""Silverdeen (sic) to area on back q (every) day and cover c (with) border gauze."" On 1/5/2011 a telephone order was written for ""1. D/C (discontinue) Silverdene (sic) and border gauze to area on back q day. 2. Cleanse area to back c NS (normal saline), pat dry c 4 x 4, apply Santyl and cover c border gauze q day and PRN."" The order was clarified on 1/20/2011, ""D/C previous tx (treatment) to back wound start on 1/21: clean area c NS, pat dry c 4 x 4, apply Santyl, cover c Border Gause. change daily and prn (as needed) x 14 days, then reevaluate."" There was no documentation located as to why the dressing order was changed and Santyl was ordered. The following telephone order written on 1/21/2011 indicated, ""D/C previous to back: start 1/21 clean area c NS pat dry c 4 x 4, apply hydrogel and cover c Border Gause change daily and PRN until healed."" Review of the ""Physician Orders Physical Therapy"" dated 12/8/2010 revealed ""cold packs"" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy ""Consultation Evaluation"" indicated under treatment approaches, ""hot/cold"" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, ""patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..."" No other documentation was located related to the use of a hot pack. Review of the Physician's Progress Notes revealed an entry dated 12/15/2010 by the Attending Physician that documented, ""I was asked to evaluate a lesion on her back that is attributed to a burn from a heating pad. This appears shallow. I estimate its maximum dimensions at 2 cm or less. These usually heal in 7-14 days. A bandage for comfort is my only suggestion. Antibiotic creams or bland ointments are optional."" An entry dated 1/16/2011 documented, ""Burned area on back has not completely healed. Appropriately tx (treated) c protective bandage, which is all that she needs..."" During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was ""very hot"" and on a ""long time."" She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was ""held in place"" by her leaning back in the wheelchair. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used. PTA #1 stated that in order to use heat as a modality a physicians order must be written. He stated that the Rehab Director ""encouraged"" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was ""not a burn."" He stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made from socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. They stated that a physician's order must be written prior to using heat. All stated that they would not heat the sock in the microwave for more than 1 minute. All three stated that using the rice socks was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the makeshift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was ""ok"" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have ""hot packs"" or ""heat"" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid thoracic region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. He stated that it ""wouldn't be a good thing to use."" He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR ManorCares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was ""not aware"" of the memo and the memo should have been communicated to her. However, she stated, ""accountability was not clear."" Review of the Memo dated 3/4/2009 and sent to ""Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators."" The memo documented: ""Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the hydrocollator unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..."" Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-323 at a scope and severity level of ""J"" and existed in the facility as of 12/14/2010. Following a review of the facility Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-323 was lowered to a scope and severity level of a ""D"" as of 3/1/2011 at 11:30AM.",2014-07-01
10040,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-03-01,407,J,1,0,58ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Expanded Inspection based on observations, record reviews, interviews, review of the South Carolina Licensing, Labor and Regulation Code of Ethics for Physical Therapy Assistants 101-14, and review of the facility's Corporate Memo dated 3/4/2009, the facility failed to provide the appropriate rehabilitation services in accordance with facility policy, standards of practice for therapists, and as prescribed by the physician. Resident #1 sustained a third degree burn to her mid [MEDICATION NAME] region from a makeshift hot pack made from a tube sock and an undetermined amount of rice. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was ""very hot"" and on a ""long time."" She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was ""held in place"" by her leaning back in the wheelchair. Review of the Nurse's Notes revealed the following entries: On 12/14/2010 at 10:00 PM ""Resident is noted to have a redden (sic) area on back, slightly raised. When asked how it happened, resident stated when she was in therapy today, will continue to monitor..."" On 12/15/2010 at 8:30 AM, ""Resident is noted to have a burn area to back, area is noted to be 2.5 cm x 3.0 cm with serous drainage family is notified and MD, new orders are written for Silvedeen (sic), incident report will be completed by primary nurse."" Further review of the notes revealed the resident complained of pain to her back. The physician ordered [MEDICATION NAME] for the pain along with the scheduled Tylenol. Review of the ""Physician Orders Physical Therapy"" dated 12/8/2010 revealed ""cold packs"" were checked as a treatment. Nowhere on the form were hot packs listed as a modality. Review of the Therapy ""Consultation Evaluation"" indicated under treatment approaches, ""hot/cold"" pack was listed as a modality. Review of the Rehabilitation Summary form revealed a weekly status update dated 12/15/2010 that stated, ""patient on 12-14-10 reported low back pain @ +10, after treatment no pain; ...patient received heat to low back x 12 minutes f/b (followed by) rub down of pain relieving cream to low back region..."" No other documentation was located related to the use of a hot pack. Review of the Physician's Progress Notes revealed an entry dated 12/15/2010 by the Attending Physician that documented, ""I was asked to evaluate a lesion on her back that is attributed to a burn from a heating pad. This appears shallow. I estimate its maximum dimensions at 2 cm or less. These usually heal in 7-14 days. A bandage for comfort is my only suggestion. Antibiotic creams or bland ointments are optional."" An entry dated 1/16/2011 documented, ""Burned area on back has not completely healed. Appropriately tx (treated) c protective bandage, which is all that she needs..."" During an interview on 2/28/2011, the Attending Physician stated that the burn sustained on Resident #1's mid [MEDICATION NAME] region was a third degree burn. He stated that he was not aware the burn was sustained while using a makeshift rice sock that was heated in the microwave. During an interview on 2/28/2011, the Medical Director stated that he was aware of the Corporate Policy related to not using hot packs or heat as a modality. He stated that he was not aware that heat was being used in the facility. He stated that he was not aware the makeshift hot packs that were in use were made from tube socks and rice. He stated that it ""wouldn't' t be a good thing to use."" He further stated that in order to use the product it must be standardized, reproducible and predictable in order to establish safety. He confirmed that the makeshift rice socks were none of the above. During an interview on 2/28/2011, the Physical Therapy Assistant (PTA) #1 stated that he placed the hot pack on Resident #1. He stated that the hot pack was placed on her lower back region not her shoulder. He stated that he used the makeshift rice sock because that was what was used in the facility. PTA #1 stated that in order to use heat as a modality a physicians order must be written. He stated that the Rehab Director ""encouraged"" the use of makeshift hot packs. PTA #1 stated that he placed the makeshift hot pack into the microwave for 3-5 minutes then placed the hot pack in towels and placed the pack on Resident #1. PTA #1 stated that the nursing department reported the burn the next day. He stated that he assessed the wound and that it was ""not a burn."" PTA #1 stated that the Rehab Director destroyed the hot packs and stated that they were not to be in use. He then stated that the Rehab Director stated that the hot packs were not even supposed to be in the building due to a Corporate Policy. Three therapists were interviewed on 2/28/2011, all three stated that the makeshift hot packs made of socks and rice were in use in the building prior to 12/15/2010. All three stated that the Rehab Director was aware of the use. They stated that a physician's order must be written prior to using heat. All stated that they would not heat the sock in the microwave for more than 1 minute and that using the rice sock was a routine practice; however none could remember specific patients the rice socks were used on. During an interview on 2/28/2011, the Rehab Director stated that she was aware the makeshift hot packs were in use prior to 12/15/2010. She stated that they had been in use prior to her position as the manager in November 2009. The Rehab Director stated that she supported the use of all modalities and did not encourage the use of one over another and was ""ok"" with the use of the hot packs. The Rehab Director stated that she was not aware of the Corporate Policy related to the use of heat and hot packs. The Rehab Director confirmed the Physician's Order did not have ""hot packs"" or ""heat"" as a modality ordered. She stated that since hot/cold pack was on the evaluation form and signed by the physician that it was the therapist's discretion as to which modality to use. During an interview on 2/28/2011, the Regional Rehab Director stated that it was the policy of HCR Manor Cares that heat was not to be used as a modality. She stated that the policy went into effect 3/4/2009. She further stated that a memo was sent to all Administrators, Directors of Nursing and Rehab Directors. She stated that heat should not have been used in the facility. She also stated that the Rehab Director at this facility was ""not aware"" of the memo and the memo should have been communicated to her. However, she stated, ""accountability was not clear."" Review of the Memo dated 3/4/2009 and sent to ""Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators."" The memo documented: ""Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..."" Review of the LLR 101-14 Code of Ethics for Physical Therapy Assistants revealed the following: Standard 1: Physical Therapist Assistants provide services under the supervision of a physical therapist. Standard 2: Physical Therapist Assistants respect the rights and dignity of all individuals. Standard 3: Physical Therapist Assistants maintain and promote high standards in the provision of services, giving the welfare of patients their highest regard. Standard 4: Physical Therapist Assistants provide services within the limits of the law. Standard 5: Physical Therapist Assistants make those judgments that are commensurate with their qualifications as physical therapist assistants. Standard 6: Physical Therapist Assistants accept the responsibility to protect the public and the profession from unethical, incompetent, or illegal acts. Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-323 as it relates to the facility' s failure to provide an environment free of hazards as is possible and the facility' s failure to provide adequate supervision to prevent accidents for Resident #1''s third degree burn sustained as a result of the use of a makeshift hot pack. Cross Refers to F-520 as it relates to the failure of the Quality Assessment and Assurance Committee to appropriately act on an identified concern related to a third degree burn sustained by Resident #1 as a result of the use of a makeshift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-407 at a scope and severity level of ""J"" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-407 was lowered to a scope and severity level of ""D"" as of 3/1/2011 at 11:30AM.",2014-07-01
10041,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-03-01,520,J,1,0,58ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Expanded Inspection based on observations, record reviews, interviews and review of the facility's Quality Assurance (QA) committee meeting minutes, the facility failed to appropriately act upon a known deficiency. A Corporate policy implemented in 2009 mandated that heat would not be a part of therapy utilized in the facility. The facility Rehab Director was aware that makeshift rice socks were in use to provide heat packs as a part of therapy. A Plan of Action was put in place when a resident was burned on 12/14/10 but the QA meeting minutes revealed the facility was aware the plan of action put into place on 12/15/2010 had not been completed. The findings included: The facility admitted Resident #1 on 6/16/2010 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 2/28/2011 revealed a dark red colored, burned area, approximately 5 centimeters by 2.5 centimeters (cm) to the mid [MEDICATION NAME] region of the back. The center of the burn was a small area of friable tissue measuring approximately 0.5 cm by 0.5 cm. The center area skin was intact but extremely fragile in appearance. During an interview on 2/28/2011, Resident #1 stated that the burn occurred during therapy. Resident #1 stated that the therapist placed a hot pack on her shoulder and it fell over. She stated that it was ""very hot"" and on a ""long time."" She also stated that she did not tell anyone in the therapy department that the hot pack was too hot. Resident #1 stated that she informed the nurses that evening of what happened. Resident #1 was asked, on three separate occasions to show the surveyor exactly where the hot pack was placed. Each time Resident #1 pointed to the right shoulder, mid shoulder blade region and said that the hot pack fell down towards the left shoulder. She stated that the hot pack was ""held in place"" by her leaning back in the wheelchair. Review of a Memo dated 3/4/2009 and sent to ""Directors of Rehabilitation, Rehab Services, ADNS (Directors of Nurses) and Administrators."" The memo documented: ""Effective immediately, the Skilled Nursing Center Rehabilitation Departments will no longer be providing hot pack treatments... Do not substitute the [MEDICATION NAME] unit and hot packs with any type of electric, microwaveable, or chemically activated heating pads..."" After Resident #1 received the burn, a Plan of Action was put in place that included inservicing all staff of the facility policy related to ""no heat therapy"". Review of the Inservice Sign in sheet for the inservice conducted on 12/15 and 12/16/2010 as a result of the burn Resident #1 sustained revealed that not all of the therapy and licensed nursing staff attended the inservice. Review of the facility's QA meeting minutes dated 1/28/2011 revealed ""DHEC reports- (Resident #1) therapy to complete inservices."" During an interview on 3/1/2011, the Director of Nursing confirmed the inservice sign in sheets showed that all of the therapy staff and licensed nursing staff had not completed the inservice related to the plan of correction put in place following a burn to Resident #1 on 12/14/2010. The DON confirmed that the plan of correction submitted to the Bureau of Certification on 12/15/2010 included staff inservicing. The DON also confirmed that the Memo sent on 3/4/2009 was sent to the Administrator. She stated, however that she was not the DON at the time and the Rehab Director was not the Director at the time the memo was sent. The DON stated that the nursing staff was aware that heat was not to be used as a modality. She further stated that the therapy department ""should have known"" not to use the hot packs. Cross Refers to F-281 as it relates to the failure of the facility to provide specialized rehab services that met professional standards of practice. Cross Refers to F-407 as it relates to providing specialized rehabilitative services by qualified personnel to Resident #1 and the failure of the facility to provide rehabilitative services as prescribed by a physician. Cross Refers to F-323 as it relates to the facility failure to provide an environment as free of hazards as possible and the facility failure to provide adequate supervision to prevent accidents for Resident #1 who sustained a third degree burn due to the use of a make shift hot pack. On 2/28/2011 at 2:15 PM the Administrator was notified that Immediate Jeopardy was identified at F-520 at a scope and severity level of ""J"" and existed in the facility as of 12/14/2010. Following a review of the Allegation of Compliance documentation, inservice content and staff inservice completion sign off sheets, staff interviews, and record review of residents with therapy orders, the Immediate Jeopardy was removed and the citation at F-520 was lowered to a scope and severity level of a ""D"" as of 3/1/2011 at 11:30AM.",2014-07-01
10042,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-03-16,225,D,1,0,VX0B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, interviews, record reviews and review of the facility's Abuse/Neglect Policy and Procedure, the facility failed to assure one of two sampled resident's injury of unknown origin was thoroughly investigated. Resident #1 sustained a hematoma to her left calf on 12/19/2010; the injury was not fully investigated. The findings included: The facility admitted Resident #1 on 12/1/2008 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having short and long term memory problems and as moderately impaired in daily decision making abilities. Review of the Monthly Summary dated 12/21/2010 coded Resident #1 has having short and long term memory problems and as rarely making decisions. Resident #1 was coded as having hallucinations. The resident was also coded as requiring a mechanical lift for transfers and used a wheelchair as the primary mode of locomotion. Review of the Care Plan revealed a problem area of abnormal bleeding tendencies was identified related to the use of anticoagulants with approaches including "" observe for any bruising during daily care and bathing or dressing. "" Another problem area of "" risk for skin breakdown "" was identified with approaches including "" monitor skin for redness during the provision of care and comprehensive weekly body audits, report changes as soon as noticed for timely intervention. The care plan had been updated on 1/1/2011 to reflect the hematoma on the left calf. No new interventions were added. Review of the physician's orders [REDACTED].#1 was receiving [MEDICATION NAME]. Review of Resident #1's INR (International Normalizing Ratio) laboratory results, revealed on 12/3/2010 the resident was therapeutic at 2.3 and was on 2 mg of [MEDICATION NAME]. Review of the Nurses Progress Notes revealed on 12/19/2010, "" CNA (Certified Nursing Assistant) came to this writer and reported a discoloration/hematoma to L(eft) (lower) leg (calf area). Resident states to this writer "" it happened in the beauty shop. "" "" There was no other documentation prior to 12/19/2010 of an injury to the left lower leg. Review of the Body Audits revealed on 12/1/2010, a "" discolored area "" was observed to the left lateral calf area. On 12/8/2010, a "" discolored area "" was noted to the left lower calf area. On 12/15/2010, a "" lemon sized discoloration to outer lower shin "" was noted. On 12/30/2010 no discoloration was to the lateral calf area was documented even though the resident was known to have a hematoma to that area at the time. Review of the treatment record revealed Resident #1 received a dressing change to the left lower calf injury daily. Review of the 24 Hour report sent to the State Certification Agency, revealed the incident was reported to the Director of Nurses (DON) on 12/19/2010 at 6:30 AM. The report indicated that Resident #1 sustained a "" hematoma to her left lower leg area. Resident stated it happened in the beauty shop. Unsure of how injury occurred, investigation pending. "" Review of the 5 Day Report revealed a summary of events, which documented "" injury actually occurred 2 weeks ago in beauty shop and is not an injury of unknown origin. "" Review of the Narrative Summary sent to the State Certification Agency revealed the resident reported "" bumping "" her left leg during transfer to the beautician's chair on 12/7/2010. The report documented that the resident was on [MEDICATION NAME] and was predisposed to bruising. The report revealed that two witness statements were obtained from the Unit Manager and the nurse on duty 12/19/2010. Review of the Beauty Shop schedule revealed Resident #1 did receive services on 12/7/2010. Review of the facility obtained witness statement from Licensed Practical Nurse #1, the nurse on duty 12/19/2010, revealed the statement was dated 1/4/2011, and documented "" when asked about res(ident) leg, Res stated "" I bumped it on the chair in the beauty shop when getting out of my wheelchair. "" "" Review of the facility obtained statement from the Unit Manager, the statement was dated 12/22/2010 and documented that the injury occurred two weeks prior. No other facility obtained witness statements were completed at the time of the complaint survey. During an interview on 3/16/2011, the Unit Manager stated that the resident had bumped her leg during a transfer in the beauty shop. He stated that he was notified after 12/19/2010 and had assessed the resident's leg and noted a large dark purple hematoma that "" might be starting to fade. "" The Unit Manager stated that he was unsure of why there was a long delay in the time the bruise was noticed and when the injury was alleged to have taken place. He confirmed the resident was on [MEDICATION NAME] and was therapeutic. He also confirmed that the resident bruised easily and the confirmed that a resident on [MEDICATION NAME] would bruise quickly and the bruise would be visible quickly. The Unit Manager confirmed the resident was not "" interviewable. "" During an interview on 3/16/2011, Certified Nursing Assistant #1 stated that she routinely cared for Resident #1 and stated that she was unsure how the bruise occurred. She stated that the resident transferred with a two person assist to the beauty shop chair but normally transferred with the assist of a mechanical lift. She stated that she was aware of the bruise to Resident #1's left calf. CNA#1 stated that she knew to report injuries and changes in condition immediately to the nurse. During a telephone interview on 3/16/2011, LPN #2 stated that the hematoma was reported to him by a CNA#. He stated that he was not aware of the bruise prior to 12/19/2010 nor did he see the bruise prior to 12/19/2010. He stated that he assessed the left leg and found a hematoma that was "" barely raised "" and dark purple in color. He stated that the hematoma "" didn't look like it just happened. "" LPN #2 stated that there was no documentation or reports made regarding the injury prior to 12/19/2010. During the survey, 4 CNAs and 2 nurses were interviewed regarding identifying, reporting and investigating injuries of unknown origin and abuse/neglect. All answered appropriately and stated that the injury would be reported immediately to the nurse and the nurse supervisor. All 4 CNAs stated that they had transferred Resident #1 and none could recall the resident injuring herself during a transfer. Neither nurse could recall Resident #1 bumping her leg during a transfer. During an interview on 3/16/2011, the Director of Nurses (DON) stated that LPN #2 on 12/19/2010 first reported the bruise on a weekend shift. She confirmed that the resident had been at the beauty shop on 12/7/2010, 2 weeks prior to the discovery of the injury. The DON confirmed that Resident #1 was on [MEDICATION NAME] and stated that the bruising would have occurred right away and not 2 weeks later. The DON also confirmed that Resident #1 was not oriented. The DON stated that only 2 witness statements were recorded. The DON confirmed that she did not have witness statements from the staff that worked the shifts of and prior to the incident on 12/19/2010. She confirmed the investigation was not thorough. Review of the facility's policy on Abuse/Neglect revealed the following: "" Investigating: The Administrator or designee will be responsible for completing an accurate and timely investigation. Once a complaint or situation is identified involving alleged mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: Investigation documentation will include but not be limited to the following: signed statements from pertinent parties, cognitive status of resident (are they alert, oriented and able to answer questions appropriately-this would help in determining if they would be a credible witness), information gathered from the investigation. "" "" Under the SNF Federal Requirement tag F225, the healthcare agency must investigate all injuries of unknown origin... "" "" If it appears to a reasonable person that injury of unknown cause has occurred, interviews will be conducted. Signed statements will be gathered from staff that cared for the resident just prior to and just after the injury. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source can be identified... """,2014-07-01
10043,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-03-09,225,D,1,0,EMRG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on review of facility documentation and interview with the Director of Nurses, the facility failed to ensure that injuries of unknown origin were reported to the State survey and certification agency within the allowed time frames for 1 of 1 injury of unknown origin reviewed (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessments of 6/10/10 and 12/9/10 showed the resident had short and long term memory problems with severely impaired decision making ability. She was independent with transfer and required supervision with ambulation. The resident displayed behavioral symptoms of wandering, physical abuse, and resisting care. Assessment notes revealed the resident wandered into other resident rooms and plundered their belongings. She would get physically abusive when redirected. Review of the medical record revealed that at 5 PM on 2/2/11, the resident was found on the floor of another resident's room. Diagnostic studies on 2/3/11 revealed a fractured right femur. The facility made an initial report of the injury to the State survey and certification agency and investigated the injury. However, the facility failed to file a five day follow-up report with the results of their investigation. An interview with the Director of Nurses revealed she thought she had ten days to file the report. She believed the report was sent, but she was unable to produce any evidence to show the five day report was filed.",2014-07-01
10044,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,492,D,0,1,9IUK11,"On the days of the survey, based on record review and interviews, the facility failed to obtain the necessary background checks as required by State Law for 1 of 5 employees reviewed for background checks. The findings include: On 4/25/11 at approximately 4:30 PM, review of employee files revealed that LPN (Licensed Practical Nurse) #1 had worked in South Carolina for 5 months and in North Carolina for 4 months preceding the date of her employment application. There was no documented employment for 3 months, from 10/2009 to 2/2010. Further review revealed LPN #1 listed her address at the time of her application as North Carolina. At the time of hire, 8/26/10, LPN #1 still listed her address as being in North Carolina. The facility obtained South Carolina Law Enforcement Division (SLED) criminal records check and a criminal history search from North Carolina. There was no evidence of a FBI (Federal Bureau of Investigation) check as she had not resided in South Carolina for 12 consecutive months prior to employment as required by the South Carolina Code of Laws, Article 23, Section 44-7-2910, (C)(2). At approximately 9:30 AM on 4/26/11, the Business Office Manager confirmed that there had been no FBI criminal background check done for LPN #1. She further verified that LPN #1 listed her address as being in North Carolina and that there was no verification of residency for the full 12 months preceding her application.",2014-07-01
10045,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,425,D,0,1,9IUK11,"On the days of the survey, based on observations, interview, and the Drug Facts and Comparisons book (updated monthly), the facility failed to follow a procedure to ensure that expired medications were removed from storage with other medications available for resident use. Aplisol was stored beyond the recommended storage timeframe after opening. The findings included: On 4/25/11 at 2:18 PM, observation of the facility's Medication Room refrigerator revealed one 1 ml (10 test) Tuberculin Purified Protein Derivative (PPD), Aplisol, with a puncture date of 3/22/11. The Drug Facts and Comparisons book (Updated Monthly), page 2001, states (in reference to Storage/Stability of Tuberculin Purified Protein Derivative): ""Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency."" During an interview on 4/25/11 at 3:22 PM, Registered Nurse (RN) #1 revealed that the Medication Nurses were to check the medication room and medication refrigerator for expired products. They were supposed to check the medication refrigerator every day. No one person was designated as responsible to monitor the expiration dates for the other products stored in the medication room.",2014-07-01
10046,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,441,D,0,1,9IUK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired resident care products were removed from storage with other resident care products, available for resident use, in the facility's medication room. The findings included: On [DATE] at 2:18 PM, observation of the facility's Medication Room revealed the following: -two Smallbore Extension Sets with male luer slip and female luer lock adapter and slip clamp, Sterile Non-pyrogenic, by B/Braum, expired ,[DATE] -one BD Insyte Autoguard Shielded I.V. Catheter, expired ,[DATE] -16 remaining, in a box of 50 pieces, Nipro Safelet Catheters NIC - 22 G (gauge) X 1 inch, Sterile, Single Use, expired ,[DATE]. During an interview on [DATE] at 3:22 PM, Registered Nurse (RN) #1 revealed that the Medication Nurses check the medication room and medication refrigerator for expired products. However, no one person was responsible for the other products in the medication room.",2014-07-01
10047,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,309,D,0,1,9IUK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to develop and coordinate a plan of care with Hospice to delineate frequency of visits and provision of services by all levels of personnel for one of one sampled residents reviewed for Hospice services. There was no Hospice plan of care on the record for Resident #1 and no evidence of Hospice visitation to meet end of life needs. The findings included: The facility admitted Resident #1 on 3-20-10. Record review on 4-25-11 at 4:40 PM revealed that, subsequent to admission, the resident suffered significant weight loss and was diagnosed with [REDACTED]. A physician referral was made to Hospice on 3-21-11 and an order was written following Hospice election on 3-28-11. Further review revealed that the facility had no copy of the Hospice Care Plan and there was no evidence that Hospice had reviewed the facility plan to ensure coordination of services. There was only one Hospice note by a Registered Nurse in the record, dated 4-13-11. There was no evidence that any other services were being provided to this resident by Hospice personnel (Social Services, Chaplain, Hospice Aide). During an interview at this time, the Director of Nurses reviewed the record and confirmed that Hospice records of services were not available for review at the facility.",2014-07-01
10048,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,323,E,0,1,9IUK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations and interviews, the facility failed to implement adequate fall prevention measures as ordered/care planned for two of three residents reviewed for falls. The facility failed to assess Resident #4 following each fall for changes in interventions in the care plan to prevent reoccurrence. Resident #3, admitted with a history of falls, did not have a bed alarm in place as per the care plan. The facility also failed to secure hazardous chemicals from residents' access. Chemicals were accessible in an unattended, unlocked laundry room. A twelve ounce bottle of hand sanitizer was found in a resident's room. In addition, the facility failed to maintain assistive devices in safe condition. Four toilet risers had missing and/or loose grab bars. The findings included: The facility admitted Resident #4 on 10-14-10 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a history of [REDACTED]. Review of the Nurse's Notes, Comprehensive Care Plan, and Resident Incident/Accident Investigation Worksheets revealed that the resident had sustained falls on 11-03-10, 11-07-10, 11-17-10, 12-26-10, 4-19-11, all related to the resident attempting to toilet himself without calling for assistance. Review of the Comprehensive Plan of Care dated 11-04-10 revealed the interventions implemented on admission included: (1)""Encourage resident to ask for assistance of staff, (2) Ensure call light is in reach, Answer promptly, (3) PT (Physical Therapy) to eval(uate) and treat per orders, (4) Anticipate needs, Provide prompt assistance, (5) Assure lighting is adequate and areas are free of clutter, (6) Encourage socialization and activity attendance as tolerated."" The fall interventions added after the fall on 11-03-11 included: (7) ""PT as ordered, (8) Remind resident to lock w/c (wheelchair) with transfer."" Because review of the MDS revealed Resident #4 was moderately cognitively impaired, and he was already receiving Physical Therapy at the time of this fall, no new interventions were implemented to prevent another fall. The interventions after the fall of 11-07-10 included: (9)"" Inform PT of fall, (10) Remind resident to call for assistance with rising, (11) Canary alarm placement on w/c, (12) Grab bar near bed."" Again, this resident was moderately cognitively impaired, and not all interventions were appropriate to prevent reoccurrence. The intervention for the fall on 11-17-10 was: (13) ""Notify PT."" The resident was already receiving Physical Therapy at the time of this fall and therefore there were no changes in interventions to prevent further falls. The intervention for the 12-26-10 fall was: (14) ""Toileting every 2 hours."" Interview with the Director of Nursing on 4-26-11 at 12 PM revealed that the resident toileted himself as frequently as every 30 minutes related to prostate problems and therefore, this intervention was not appropriate. The interventions for the fall on 04-19-11 included: (15) ""Safety concerns discussed with resident, (16) Reminders to call for assistance, (17) Noncompliant to call for ass't (assistance) c (with) transfers. Res(ident) able to remove canary alarm, if res will not comply - may need to assess for physical restraint."" During an interview on 4-26-11 at 12 PM, the Director of Nursing stated that the resident removed the tab alarm and toileted himself without calling for assistance. She also stated that the process after a resident fell was to discuss it in a meeting held every morning with all Department Heads. The team made the determination of what interventions were to be implemented and the MDS Coordinator added it to the Comprehensive Care Plan. During an interview with the Assistant Director of Nursing on 4-26-10 at approximately 11:00 AM, she stated the resident toileted himself without asking for assistance and removed the tab alert himself. She also confirmed the discussion this surveyor had with the Director of Nursing regarding the process that the facility followed after a resident fall. On 4-25-11 at 3:30 PM this surveyor observed Resident #4 sitting in his wheel chair in his room with his tab alert attached to the chair but not to his person. On 4-26-11 during an interview with Resident #4, surveyors observed him excuse himself from the interview to go to the bathroom without asking for assistance of staff. His tab alert was observed attached to the back of the wheelchair but not to him. He stated that this was because he had toileted himself earlier and forgot to reattach it. He propelled himself to the bathroom and closed the door. When he returned, the tab alert was again not attached as ordered. During the Initial Tour with on 4-25-11 beginning at 11:30 AM, a partially used 12 ounce bottle of 62% alcohol-based hand sanitizer was noted in Room 101 on the bedside table. During an interview on 4-26-11, the Director of Nurses (DON) stated that the family must have brought the hand sanitizer because the facility did not provide that size bottles for use in resident rooms. The DON verified that there were several residents that wandered into other's rooms. She stated that chemicals had been secured following management's notification at the end of the day on 4-25-11. The facility admitted Resident #3 on 4-18-11 with [DIAGNOSES REDACTED]. Record review on 4-25-11 at 2:40 PM revealed information from the resident's hospitalization that indicated that the resident had a history of [REDACTED]. Review of Nurse's Notes revealed that the resident required limited assistance with transfers and had an unsteady gait. The resident scored ""12"" on the admission Falls Risk Evaluation, indicating that he was at risk for falls. Interventions on the Interim Plan of Care included a bed alarm. Observation on 4-25-11 at 2:40 PM revealed that the resident was in bed with the head of the bed elevated approximately 30 degrees. A pressure type alarm with a small sensor pad for use in chairs was located under the mattress at the level of the resident's upper torso. When the resident got out of bed and ambulated to the bathroom with a walker, the alarm failed to sound. On 4-26-11 at 9:15 AM, the resident was observed in bed with his head covered. No alarm could be located on the resident's bed. During an observation and interview on 4-26-11 at 11:35 AM, Certified Nursing Assistant (CNA) #1 verified that there was no alarm on Resident #3's bed. When asked how staff were made aware of special care items needed by the residents, she stated that they received a ""verbal report from the nurses"" and that ""each PCR (Patient Care Record) Book has a list of special care items"", including alarms. When the PCR Book was reviewed with CNA #1, she confirmed that Resident #3 was not on the list of residents who required an alarm. During the Initial Tour with the Assistant Director of Nursing on 4-25-11 beginning at 11:30 AM, the laundry area, opening onto a resident care corridor, was found to be unlocked and unattended. Five gallon containers of Flexilite and Laundri Destainer (bleach) were noted on the floor next to the washers. There were also two 32 ounce screw-top spray bottles of chemicals between the washers, one of Fresh Breeze TB Detergent and Disinfectant and one of U-1 Germicidal Cleaner. All containers were marked to ""Keep out of the reach of children."" During an interview while observing the laundry process on 4-26-11 at approximately 9 AM, a Regional Corporate Housekeeping/Laundry Representative confirmed that the laundry area had been unlocked the previous day prior to the management staff notification at 7 PM. Chemicals had been accessible to any of the wandering residents at the facility. On 4-26-11 at 11:15 AM, the Material Safety Data Sheets (MSDS) for the accessible chemicals were provided by the Housekeeping/Laundry Supervisor. Review of the MSDS for U-1 revealed that it was both an eye and skin irritant. If contact with eyes, ""Flush immediately with water for at least 15 minutes. Call a physician."" If contact with skin, ""Flush immediately with water for at least 15 minutes. If irritation persists, call a physician."" If ingested, instructions were to ""Drink milk, egg whites, gelatin solution or if these are not available, drink large quantities of water. Call a physician."" Health hazards for Fresh Breeze also included irritation of skin and/or eyes. Handling information noted to ""avoid contact with skin, eyes, and clothing."" If ingested, instructions were to ""Drink large quantities of milk or water. Call a physician."" The MSDS for Flexilite noted that it ""May cause eye and skin irritation."" Acute health effects noted that the chemical was ""moderately irritating to eyes (and)...skin. May be harmful if swallowed."" Instructions for contact with eyes and skin were as above noted. For ingestion, ""Do not induce vomiting. Get medical attention immediately."" During the Initial Tour with the Assistant Director of Nursing on 4-25-11 beginning at 11:30 AM and during a tour with the Housekeeping/Laundry Supervisor and Maintenance Supervisor on 4-26-11 at 3:45 PM, the stool riser on the toilet in the Shower Room near Room 109 had one grab bar missing and the bolt holding the second bar in place was very loose, making the unit unstable for use. The missing grab bar was found on the seat of a chair with torn upholstery in the tub room. The bathrooms for residents in Rooms 101, 102, 103, 104, 113, and 115 also had stool risers in place. Each had loose and/or missing grab bars, making the units unstable for use. During an interview during the tour on 4-26-11, the Maintenance Supervisor stated that the first thing he did on a daily basis was to check his book for needed repairs and that he had received no work requests to repair the units. ,",2014-07-01
10049,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,367,D,0,1,9IUK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide diets as ordered for 2 of 4 sampled residents reviewed for therapeutic diets. Residents #1 and #7 did not receive foods per the planned menu for physician-ordered mechanically altered diets. The findings included: The facility admitted Resident #1 on 3-23-10 with [DIAGNOSES REDACTED]. Record review on 4-25-11 at 4:40 PM revealed that, subsequent to admission, the resident suffered significant weight loss (per 3-9-11 and 4-6-11 Minimum Data Set Assessments) and was diagnosed with [REDACTED]. Review of 4-11 physician's orders [REDACTED]. The resident was evaluated and treated by the Speech Therapist for Dysphagia from 3-23-10 to 4-13-10. Treatment was discontinued due to resident refusal/poor participation. A mechanical soft diet was ordered as the least restrictive diet due to oral tremors, poor labial strength, and decreased lingual sweep for oral clearance. During the evening meal on 4-25-11 at 6:15 PM, two surveyors observed that the resident was served a whole salmon patty, cole slaw, cornbread, strawberries and bananas, 4 ounces (oz) health shake, 8 oz milk, and 8 oz water. Observation revealed the resident ate approximately 25% and made no attempt to eat the salmon patty. Review of the planned menu and diet card with the Dietary Supervisor on 4-26-11 at 12:30 PM revealed that the resident should have received a ground salmon patty and pureed cole slaw instead of the regular texture that was served. In addition, the Dietary Supervisor stated that she should have received 1/2 cup ""fortified"" mashed potatoes for weight loss. The facility admitted Resident #7 on 2-20-04 with [DIAGNOSES REDACTED]. Record review on 4-25-11 at 6:30 PM revealed 4-11 physician's orders [REDACTED]. Observation of the evening meal by two surveyors on 4-25-11 at 6:30 PM revealed that the resident received a whole salmon patty, cole slaw, cornbread, strawberries and bananas, 8 oz milk, and 8 oz water. The diet card on the tray noted that the resident should have received a ""chopped meat salmon patty"". Resident #7 picked up the whole patty and made multiple attempts to bite it without success. No attempts were made by staff to cut up/chop it at the table after the tray was served. The resident ate none of this food item. During an interview on 4-26-11 at 12:45 PM, the Dietary Supervisor reviewed the diet card and stated that the resident should have received chopped salmon from the kitchen.",2014-07-01
10050,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2011-04-26,505,D,0,1,9IUK11,"**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 notify the physician when laboratory tests were not done as ordered for one of nine residents reviewed for provision of laboratory services. Resident #1 refused lab draws multiple times without evidence of physician notification. The findings included: The facility admitted Resident #1 on 3-20-10. Record review on 4-25-11 at 4:40 PM revealed that, subsequent to admission, the resident suffered significant weight loss and was diagnosed with [REDACTED]. Record review on 4-25-11 at 3:15 PM revealed physician's orders [REDACTED]. Blood Count), CMP,..."", and on 3-26-11 to ""Check pre-[MEDICATION NAME] level q (every) month X 2..."". No results could be located in the record. There was no evidence in the Nurse's Notes that the lab tests had been drawn as ordered or that the physician was aware that the lab tests had not been done. During an interview on 4-26-11 at 12:15 PM, the Assistant Director of Nurses (ADON) verified that the lab tests had not been done as ordered. She reviewed the Lab Book and noted that all the above lab draws were marked as ""refused"". After further review of the Lab Book and medical record, the ADON confirmed that there was no documentation of further attempts to redraw the tests or of physician notification that the tests had not been drawn as ordered.",2014-07-01
10051,"NHC HEALTH CARE,  CHARLESTON",425381,2230 ASHLEY CROSSING DRIVE,CHARLESTON,SC,29414,2010-08-31,371,E,0,1,SJ8211,"On the days of the survey, based on observation and interview, the facility failed to prepare food under sanitary conditions as evidenced by food service equipment and the floor with a build up of grease, dried food stains, and/or food debris on it. The findings included: Observations on 8/30/10 at approximately 6:15am revealed lids to the steam table had a build up of grease and food stains; drawers to the left of the sugar/flour bins had a build up of grease on the fronts and drawer pulls; a reach-in refrigerator to the right of the sugar/flour bins had dried spills on the front of the door; bakers racks at the end of the trayline had grease build up, dried spills, and food debris on the rails and uprights; a switch box at the prep sink had grease and dust on the top of the box; there was a wide strip of built up grime around the electric boxes on the floor under the prep and steam tables; and in the baking prep area there was a build up of grime at the juncture were the floor met the wall. Observations on 8/31/10 at approximately 10:55am with the Director of Food Service (DFS) confirmed that the above conditions were present. Interview at that time indicated that the kitchen had been pressure washed on 8/17/10 but had not cleaned closely around the electric boxes. S/he further indicated that there was a daily, weekly, and monthly cleaning schedule for the kitchen. Review of the daily cleaning schedule revealed ""Baking Prep area, both tables top and bottom shelves, Dry bins, inside drawers, refrigerator inside and out, cart cleaned, all items dated and labeled. COOKS AREA ALL AREAS USED BY COOKS WILL BE CLEANED DAILY. . . "" When surveyor asked to review the past week's completed daily cleaning schedule, the most recent completed schedule provided was 8/26/10. The DFS indicated that more recent completed schedules could not be found at that time.",2014-07-01
10052,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2014-03-27,279,E,0,1,G9QM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 3/25/14 of the physician orders [REDACTED]. On 1/21/14, a physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the resident's care plan revealed there was no care plan developed for Urinary Tract Infections or a history of Urinary Tract Infections. During an interview with the MDS (MInimum Data Set) Coordinator on 3/26/14, he/she confirmed a care plan for Urinary Tract Infections had not been developed. The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Record review on 3/26/14 of the physician orders [REDACTED]. During an interview with the MDS Coordinator on 3/26/14, he/she confirmed a care plan for [MEDICATION NAME] had not been developed. On the days of the survey, based on record reviews, interviews, review of the facility's Infection Control Log, and the facility policy titled ""Activity policy"", the facility failed to develop a Comprehensive Plan of Care to include measurable objectives and timetables to meet the needs of 5 of 13 sampled residents reviewed for a Comprehensive Plan of Care to reflect the resident's current status. The facility failed to develop a Comprehensive Plan of Care to reflect a Urinary Tract Infection for Resident #22 and Resident #18. The facility further failed to develop a Comprehensive Plan of Care related to Activities for Resident #28 and Resident #36 and failed to develop a Comprehensive Plan of Care for Resident #54 related to [MEDICATION NAME]. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 03-26-14 at approximately 10:45 AM of a Hospital Discharge [DIAGNOSES REDACTED].#3. Urinary Tract Infection."" Record review on 03-26-14 at approximately 10:45 AM of the Daily Skilled Nurse's Note dated 02-17-14 revealed the following, ""Resident on Levoquin that should take care of UTI..."" Record review on 03-26-14 at approximately 10:45 AM of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02-24-14 revealed in Section I. the following, ""Active [DIAGNOSES REDACTED].e.."" Record review on 03-26-14 at approximately 10:45 AM of the Comprehensive Plan of Care for Resident #22 dated 12-02-13 and updated on 02-28-14 did not reflect a Urinary Tract Infection. Review on 03-26-14 at approximately 4:00 PM of the facility's February 2014 Infection Control Log revealed the following, ""Resident #22: Infection Type: UTI, Antibiotic: [MEDICATION NAME], Start Date: 02-16-14, End Date: 2-23-14."" During an interview on 03-25-14 at approximately 3:56 PM with the MDS Coordinator, he/she stated ,""I would not expect to see a Care Plan for UTI as we have a handle on it and make sure the resident receives fluids. He/she hasn't had a UTI before."" During an additional interview on 03-26-14 at approximately 11:00 AM with the MDS Coordinator, he/she, after record review, verified a Comprehensive Plan of Care to reflect a Urinary Tract Infection for Resident #22 had not been developed. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review on 03-26-14 at approximately 11:30 AM of the Social Service Progress Note dated 10-10-13 revealed the following, ""...i.e...Resident could not follow conversations and gave non-sensical answers for the Brief Interview for Mental Status (BIMS) and Mood Interview....i.e.."" Record review on 03-26-14 at approximately 11:30 AM of the Social Service Progress Note dated 01-09-14 revealed the following, ""...i.e...Resident scored a 3 out of 15 on BIMS...i.e...Daily Skilled Nursing Notes document short term and long term memory problems...i.e..."" Record review of Resident #36's Comprehensive Care Plan with start date of 10-11-13 and updated on 01-09-14 revealed a Care Plan for Activities had not been developed. During an interview on 03-26-14 at approximately 11:30 AM with the Activity Director, he/she stated, ""a summary is made of the resident's activities in my notes but the resident does participate in activities. Resident #36's BIMS score in January 2014 was 3. The Minimum Data Set (MDS) Coordinator is responsible to develop the Care Plan."" During an interview on 03-26-14 at approximately 11:45 AM with the Minimum Data Set (MDS) Coordinator, he/she stated, ""the resident's family informed me of his/her activities but an Initial Comprehensive Care Plan was not developed. I will write one now."" Review on 03-27-14 at approximately 9:55 AM of the facility policy titled ""Activity Policy"" revealed the following, ""Policy Statement: ...i.e..#7. ""Residents both ambulatory and bedfast are encouraged but not forced to participate in planned activities appropriate to residents' needs and incorporated into the Resident Care Pan. The plan will identify and specify types of therapeutic recreational activities and will be developed in consultation with nursing personnel and qualified therapists."" The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Record review on 3/25/2014 at approximately 4:00 PM revealed a Plan of Care for Resident #28 which did not include activities. During an interview on 3/25/2014 at approximately 4:00 PM with the Activity Director, she/he stated, "" activities are not put on the care plan, they are listed in the Activity Progress Notes."" Review of the facilities ""Activity Policy,"" entitled, ""Responsibility,"" states, ""It is the responsibility of the Activities Assistant to plan activities, maintain adequate records and attend Resident Care Planning meetings, and conduct in-service programs."" During an interview on 3/26/2014 at approximately 9:20 AM with the Care Plan Coordinator, she/he stated, ""activities are not included on this resident's Care Plan because she/he is able to make her/his own decisions."" Further review of the current medical record revealed the resident lacked capacity to make his/her own healthcare decisions; monthly summaries documented the resident as having little interest or pleasure in doing things; memory problems and dependence of staff for needs and care.",2014-07-01
10053,PRESBYTERIAN HOME OF SC - CLINTON,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2011-04-05,164,D,0,1,1GP411,"**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 provide full visual privacy for two of two sampled residents observed for privacy during wound care and personal care. Blinds were not closed during wound care for Resident #3 leaving her exposed to any possible passers-by. Blinds were not closed during incontinent care for Resident #7 leaving her exposed to any possible passers-by. The findings included: The facility admitted Resident #3 on 3/23/11 with [DIAGNOSES REDACTED]. Observation of a Pressure Ulcer treatment on 4/5/11 at 11:35 AM revealed Resident #3 sitting next to the bed in her wheelchair. A large window with blinds opened to the parking lot revealed a car parked near the window. The nurses did not close the blinds before starting the wound care. RN #2 assisted the resident to stand and pull her pants down. RN #2 then assisted the resident to bend over and held the resident, while RN #1 performed the wound care to her coccyx area. After cleaning the wound, RN #1 went to the sink to wash her hands while RN #2 continued to hold the resident in a bent over position with her pants down exposed to the window. RN #1 returned from handwashing, applied gloves and dabbed ointment over the wound. RN #2 then assisted the resident in pulling up her pants. The resident had been left exposed from her waist down to her lower extremities to any possible passers-by. During an interview on 4/5/11 at 4:35 PM, RN #1 verified the privacy blinds had not been closed and the resident had been left uncovered during the treatment. The facility admitted Resident #7 on 3/17/11 with [DIAGNOSES REDACTED]. Observation of Incontinent Care on 4/5/11 at 3:10 PM revealed Resident #7 lying in bed. A large window near the bed had blinds open to a grassy area. The Certified Nursing Assistants (CNAs) did not close the blinds before starting incontinent care. CNAs #1 and #2 both unfastened and removed the brief on Resident #7. CNA #2 turned the resident to her left side while CNA #1 wiped the resident's back side. CNA #1 removed her gloves, left the bedside, and washed her hands leaving the resident exposed to window. CNA #1 returned with a tube of cream from the resident's drawer. She then cleaned the resident again, removed her gloves and washed her hands. CNA #2 also removed her gloves and went to wash her hands leaving the resident exposed from her abdomen to her knees. CNA #1 placed a new brief under the resident and applied the cream to her backside. She then removed her gloves and went to wash her hands. CNA #2 applied gloves while the resident tried to pull up her pants. CNA #2 pulled the brief through the resident's legs and applied the fasteners and then pulled up the resident's pants. During an interview on 4/5/11 at approximately 3:30 PM, CNA #1 was asked if they closed blinds during care for residents? She stated that they would close the blinds if they were getting the residents dressed.",2014-07-01
10054,PRESBYTERIAN HOME OF SC - CLINTON,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2011-04-05,323,D,0,1,1GP411,"On the days of the survey, based on observations and interview, the facility failed to ensure that resident care areas remained as free of accident hazards as is possible. The findings included: Observations during Initial Tour on 4/4/11 at approximately 6:00 PM revealed multiple hazards. A circular saw with the blade exposed was lying in an area off the main hallway near the Nurse's Station. There were also 5 tubes of caulking, (5) 4 gallon buckets of carpet seam adhesive (one of which had been opened with yellow adhesive spills on the sides and top near the lid) on the floor next to the saw. The door to the soiled utility room and laundry area were unlocked. During an interview on 4/4/11 at approximately 6:10 PM, the Maintenance Director verified the above hazards and stated that workers had been laying flooring on the unit that day and were scheduled to come back that evening to finish. He stated that he would have the hazards locked immediately to ensure safety of the residents. He verified the doors to the laundry room and soiled utility room were unlocked and locked them as well. Further observations revealed the door to a storage room in the hallway in front of the Nurse's Station was wide open with a drill sitting on the floor. A treatment cart in the room was also unlocked. The treatment cart contained hazards such as medicated ointment, 3 pairs of scissors, 2 bottles of iodine, 1 bottle of hydrogen peroxide and 1 bottle of rubbing alcohol. During an interview on 4/4/11 at approximately 6:10 PM, Licensed Practical Nurse (LPN) #1 verified the treatment cart was unlocked and locked it.",2014-07-01
10055,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-06-14,309,D,0,1,ZT5Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to provide care and services related to resident # 4's pacemaker/ICD (Internal Cardiac Defibrillator). There was no documentation in the Physicians orders or a Care Plan related to the residents pacemaker/ICD. The findings included: The facility admitted resident #4 on 5/31/11 with the following Diagnosis: [REDACTED]. During the record review on 6/13 and 6/14/11 no documentation was found related to the residents pacemaker/ICD. On 6/14/11 at 9:00 AM the DON (Director of Nursing) was ask where to find documentation on pacemakers, she stated- "" We don't have anyone now with a pacemaker"". When ask about Resident #4's pacemaker, she stated ""Oh, it must be on the thinned record, I will get it"". The DON came back at 9:30 AM and stated the information on the nurse's admission assessment should have been carried over to the orders and the care plan. The thinned record was a previous admission in which the nurse had documented the pacemaker/ICD on the admission assessment. The information included the last pacemaker check and next scheduled check to be done. The DON stated ""this should have been brought forward or the information should have been obtained again, placed on the chart and care planned. I don't know what happened.""",2014-07-01
10056,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-06-14,502,D,0,1,ZT5Y11,"**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 obtain laboratory services as order on residents #1 and 9, and failed to discard expired laboratory supplies. The findings included: The facility admitted resident #1 on [DATE] with the following Diagnosis: [REDACTED]. The record review on [DATE] revealed an order for FeSo4, Ferritin and TIBC (Total Iron Binding Capacity) which was ordered on [DATE] to be done now and every 6 months. The blood work was drawn and reported on [DATE], further record review did not reveal any other blood work for Iron since then. There has been no order to discontinue the lab work. The DON (Director of Nursing) confirmed that it should have been repeated in [DATE]. The facility admitted resident # 9 on [DATE] with the following Diagnosis: [REDACTED]. The record review on [DATE] revealed an order for [REDACTED]. During a interview with the DON on [DATE] at 11:00 AM she stated "" they should have drawn one then for a baseline , then every six months after that."" On [DATE] at 3:30 PM, observation of the medication room revealed the following: -47 Becton Dickinson Vacutainer Eclipse Blood Collection Needles with pre-attached holders, expired ,[DATE]. -16 Becton Dickinson Vacutainer Push Button Blood Collection Sets, expired ,[DATE]. During an interview on [DATE] at 4:02 PM, Licensed Practical Nurse #1 stated, ""The pharmacy and all the nurses were responsible for checking the medication room for expired products.""",2014-07-01
10057,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-06-14,371,F,0,1,ZT5Y11,"On the days of the survey, based on observation, record review, interviews and review of the facility's policy entitled ""Standards & Guidelines, Section: Dining Services"", the facility failed to follow procedures for dating and labeling food items in the freezer and cooler and failed to date items in the dry storage area. The facility also failed to date opened containers or to reseal opened containers tightly to prevent contamination. The findings included: Initial tour of the kitchen was conducted on 6/13/11 beginning at 1:25 PM with the Director of Dining Services. Tour of the freezer revealed packages of ground meat without a date or label. Tour of the cooler revealed 2 trays of unlabeled, undated pork loins. In the dry food storage area, 7 boxes of muffin mix with the code KB1101G and 4 boxes of pancake and waffle mix with the code 1 KFD were found without dates. In addition, there were 4 bags of previously opened pasta that were undated and not tightly sealed tightly. In a food prep area, on the lower shelf of a stainless steel prep table, four 20 pound containers were opened and not dated were found. Stored in the containers were raspberry filling, caramel glaze, strawberry glaze and apricot jam. On the raspberry filling container was the statement ""Keep refrigerated at all times"" and on the caramel glaze was the statement ""Keep Refrigerated."" Additionally, the apricot jam and a 20 pound container of chocolate donut icing were found to not be completely sealed . The Director of Dining Services confirmed these findings and stated they had been there approximately 30 days. Review of the facility's policy entitled Standards & Guidelines, Section: Dining Services, Storage Guidelines revealed: DRY STORAGE ... 5. Opened packages are to be stored in closed containers, labeled and dated. ...7. Stock should be dated and rotated so that the oldest items are used first. REFRIGERATION ... 7. All meats should be ... wrapped in freezer wrap, and labeled for meals before storage. ... 12. All foods in the freezer ... They are to be labeled and dated. During the tour, the Director of Dining Services confirmed all findings. He stated, after a dietary employee researched the products online, that the codes on the bottom of the muffin mix and the pancake/ waffle mix were the production dates. He also confirmed that prior to the day of the survey, he was not aware what the codes meant and that cooks would have no way of knowing if the products had exceeded their shelf life. During an interview on 6/14/11 at 4:10 PM, the Certified Dietary Manager stated she assumed that all the items that came in a case had expiration dates like grocery stores and did not know that these boxes did not have expiration dates. She also confirmed that the ground meat and pork loins should have been labeled and dated.",2014-07-01
10058,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-06-14,425,D,0,1,ZT5Y11,"On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were removed from storage with other medications, available for resident use, in the medication room. The findings included: On 06/13/2011 at 3:30 PM, observation of the medication room revealed the following: -one 1000 milliliter bag of 0.45% Normal Saline, expired May 2011. -one bottle of Good Sense Motionsickness (Dimenhydrate 50 milligrams), expired May 2011. During an interview on 06/13/2011 at 4:10 PM, the Director of Nursing confirmed expiration dates and stated, ""The pharmacy checks for expired medications.""",2014-07-01
10059,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,225,D,0,1,7PCF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review, and interviews, the facility failed to identify and report an injury of unknown origin to the State Survey and Certification agency until 5 days after the incident. Resident #16 was sent to the hospital with a right hip dislocation. (1 of 1 records reviewed for injury of unknown origin.) The findings included: The facility admitted Resident #16 on 5/9/11 with [DIAGNOSES REDACTED]. Nursing notes of 5/20/11 (no time) documented ""son states resident has increased pain this morning. Therapy in to check resident who states resident does have pain that is consistent with pain she had one week ago with bed mobility. Will X-ray R(ight) hip and L(eft) knee. Will continue to monitor pain."" Nursing notes of 5/20/11 PM at 5:30 PM documented ""X-ray results analyse (sic.) states that the impression show an dislocated femer (sic.)."" The resident was sent to the hospital for evaluation and treatment. The resident remained in the hospital during the days of the survey. The Director of Health Services (DHS) was interviewed on 5/24/11 at 11:50 AM about the incident report related to Resident #16's injury and she stated there was none. She also stated it was a witnessed injury and she was going to report it to State Licensing only. Review of the facility investigation related to the incident revealed the facility had not obtained any statements from the staff involved with the resident's care to document it was a witnessed injury. Based on documentation provided by the DHS at exit, the initial report to the State survey and certification agency was dated 5/25/11 which failed to meet regulatory requirement.",2014-07-01
10060,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,281,G,0,1,7PCF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, observation, interviews and review of the professional resource of Perry and Potter Clinical Nursing Skills and Techniques 7th Edition, the facility failed to provide services that met professional standards of quality. The clinical record for Resident # 1 lacked documentation that physician ordered treatments had been completed as ordered. Resident # 5's medication was administered without following physician ordered parameters and in the presence of potential significant side effects. Resident # 9's Medication Administration Record [REDACTED]. (3 of 16 sampled resident's reviewed for professional standards related to documentation of following physician orders) The findings included: The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. Review of Resident # 5's medical record revealed that three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER (extended release) 300 mg, and [MEDICATION NAME] 320 mg) used for the treatment of [REDACTED].< (less than) 110."" The instructions for administration were clearly identified on the MAR (Medication Administration Record). Further review of the medical record revealed that Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift using the following code: D (Day) E (Evening) N (Night) on a Vital Sign Record sheet. The readings from the Vital Sign Record sheets were brought forward onto the NN (Daily Skilled Nurses Notes), however, review revealed 5 of 6 NN were not fully completed. Additionally, it was unclear if the blood pressure was obtained immediately prior to the administration of the medications as the time was not documented. Comparison of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg were administered. The B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 96/56, E 93/58, N blank 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 75/48, E 72/46, N blank. It appeared that five different nurses had documented the medications were administered without following the physician ordered parameters for administration. The facility admitted Resident #9 on 12/25/10 with [DIAGNOSES REDACTED]. Review of the medical record on 5/25/11 revealed a current physician's orders [REDACTED]. Further review of the medical record indicated a telephone order dated 3/03/11 for Prostat 101 30 ml daily. Record review noted that Resident #9 had pressure ulcers to the sacrum and heel and continued to receive treatment for [REDACTED]. Review of the May 2011 Medication Record (MAR) revealed blanks on the MAR for 5/23/11 and 5/24/11 indicating Resident #9 did not receive Prostat on those dates. The scheduled time for Prostat administration was 9 AM, and all other 9 AM medications on 5/23/11 and 5/24/11 were documented by staff as administered per orders. Review of the back of the MAR indicated [REDACTED]. The above findings were shared with the Staff Development Coordinator on 5/25/11 at approximately 10:30 AM. The facility afterward provided a handwritten statement from staff indicating Resident #9 ""did receive Prostat on May 23 & 24. Medication administration was not documented on MAR."" Review of the professional resource of Perry and Potter Clinical Nursing Skills and Techniques 7th Edition, page 515 states: ""Standards are those actions that ensure safe nursing practice. To ensure safe medication administration, nurses follow the nursing standard called the six rights of medication administration consistently every time they administer medications. All medication errors are linked, in some way, to an inconsistency in adhering to the six rights."" The rights include:....""right documentation."" After administering the medication, documentation of the administration of the medication should occur as soon as possible. When preparing medications from bottles or containers, ""compare the label of the medication with the MAR indicated [REDACTED] Cross Refer to F 329 as it relates to failure of the facility to adequately monitor medications for Resident # 5. Medications were administered without following physician defined parameters and in the presence of potential side effects. Resident # 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Discontinue use and notify Occupational Therapy if redness / irritation persist greater than 30 minutes after taking off- remove for personal care"" ; Left knee orthotic to be worn 3-6 hours 7-3 shift every day- discontinue use and notify Physical Therapy if redness persists greater than 30 minutes after removing""; ""Cleanse peg tube site with normal saline pat dry and apply dry dressing change every day"". Review of the May Treatment Record showed a lack of documentation that the treatment(s) were completed to the elbow on 05/07/11, 05/08/11, and 05/17/11; the treatment to the Peg tube site for 05/14/11 and 05/15/11; the treatment to the left upper extremity for 05/08/11 and 05/17/11; and the treatment for [REDACTED].",2014-07-01
10061,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,333,E,0,1,7PCF11,"**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 ensure that 1 of 9 residents reviewed for medications, remained free from significant medication error. Resident # 5 repeatedly received medications that were administered without following the physician ordered parameters for administration. The findings included: The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. Review of Resident # 5's Medical Record revealed that three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER 300 mg, and [MEDICATION NAME] 320 mg) prescribed at admittance had the following requirements: ""Hold for SBP (Systolic Blood Pressure) < (less than) 110."" These instructions were clearly identified on the MAR (Medication Administration Record). Further review of the medical record revealed that Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift {D (Day) E (Evening) N (Night)}, on a Vital Sign Record sheet. The readings from the Vital Sign Record sheets were brought forward onto the NN (Daily Skilled Nurses Notes), however, review of 5 of 6 NN revealed they were not completely filled in. Comparison of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg, B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg, BP on NN were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg, BP on NN were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg, BP on NN were D 96/56, E 93/58, N blank 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg, BP on NN were D 75/48, E 72/46, N blank. It appeared that five different nurses signed off the medication given on the above entries. Observations of Resident # 5 over the course of the survey, revealed he was in bed sleeping during the initial tour at approximately 10:50 AM on 5-23-11. At 1:10 PM Resident # 5 was observed in bed with his meal on the over the bed table untouched. Resident # 5 replied slowly to questions asked and appeared lethargic. At 5:40 PM Resident # 5 was still in bed with eyes closed, but he responded to conversation talked slowly and appeared confused when asked simple questions. He stated that he had not eaten lunch and was not hungry. When asked if he needed help to eat, he stated ""yes"", then after a few minutes he said ""no, I don't want to eat now."" On 5-24-11 at approximately 11:00 AM, wound care was attempted, however Resident # 5 stated he was in pain, so mediation was given and wound care was delayed. Resident # 5 again seemed lethargic and was slow to respond to questions by the nursing staff. On 5-24-11 at approximately 11:20 AM, the Unit Manager confirmed that blood pressure medications were given when the Systolic Blood Pressure was below 110. On 5-24-11 at approximately 3:00 PM during a telephone interview with the Primary Physician, who is also the Medical Director of the facility, this surveyor conveyed concerns related to Resident # 5 displaying lethargic behavior and medications given to the resident when the Systolic Blood Pressure was below 110. The Medical Director stated that he was unaware that the blood pressure medications were being given when the Systolic Blood Pressures was below the parameters which he had ordered. On 5-25-11 at approximately 7:30 AM, the Medical Director assessed Resident # 5 and he was transferred to the local hospital for evaluation. This surveyor asked the facility Director of Health Services for information related to Resident # 5's condition at the hospital but none was supplied before the survey ended. Review of the Drug facts and Comparison which is updated monthly revealed the following statement about the [MEDICATION NAME] and [MEDICATION NAME] on page 438b: ""Carefully monitor blood pressure during initial administration. Closely observe patients already taking antihypertensives.""",2014-07-01
10062,UNIHEALTH POST ACUTE CARE - BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,496,E,0,1,7PCF11,"On the days of the survey, based on record review and interview, the facility failed to verify that 3 of 4 CNA's (Certified Nursing Assistants) had completed training or were certified prior to hiring. (CNA # 1, # 2, # 3.) The findings included: Review of the new hires for the facility revealed that 3 of 4 CNA's who were hired within the last four months did not have registry verification before they were hired: CNA # 1 hire date of 3-5-11, Registry verification dated 5-19-11, CNA # 2 hire date of 2-7-11, Registry verification dated 2-10-11, CNA # 3 hire date of 4-8-11, Registry verification dated 4-14-11. These findings were confirmed during a conversation with the Director of Health Services on 5-24-11 at approximately 4:30 PM.",2014-07-01
10063,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,157,D,0,1,JY8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Initial Certification Survey, based on interviews and record review, the facility failed to notify the legal representative when a significant change (decline) was noted in the resident's pressure ulcer or upon the emergence of six new pressure areas for Resident #2,. (One of four residents reviewed with a change in condition and reviewed for notification.) The findings included: The facility admitted Resident #2 on 7/6/11 receiving Hospice Services with [DIAGNOSES REDACTED]. Record review on 8/2/11 at 3:32 PM of the Body Audit Weekly Summary dated 7/7/11 revealed a narrative note that indicated the resident had a stage II pressure ulcer on the right hip and bruises on the right and left arm. On the reverse page of the body audit was another narrative note dated 7/15/11 indicating the pressure ulcer on the right hip had progressed to a Stage IV and that there were also Stage I pressure areas on both heels and on the Great Toe and 3rd toe of the right foot and a Stage II on the 2nd toe. On 7/14/11 at 11:00 AM, the nurse documented the wound on the right hip measured 5.0 cm (centimeters) L (length) X 3.0 cm W (width) with eschar in the center of the wound. The Nurse's Note dated 7/15/11 at 4:10 PM stated ""Also has Stage I on both heels & (and) on R(ight) great toe & 3rd toe & Stage II on second toe."" A Nurse's Note dated 7/16/11 at 6:00 PM stated the resident had a ""stage I 1.0 cm to coccyx."" Also on 8/2/11 at approximately 3:32 PM review of the Hospice Record revealed a Nursing Visit Note dated 7/15/11 with a Patient Hospice Eligibility Description that indicated ""New wounds noted on on R(ight) great toe, 1st toe & 2nd toe, both heels are pink and mushy."" The Wound Assessment portion of the Nursing Visit Note indicated ""New! R(ight) great toe &1st & 2nd toe State II both heals (sic) red stage I."" There was no evidence in any of the documentation that the family had been notified of the changes in the pressure ulcer on the resident's right hip or that she had developed 5 new areas on her right foot and one new area on the coccyx. During an interview at 4:20 PM the Director of Nursing reviewed the Nurse's Notes, Initial Nursing Assessment, Body Audit and Hospice Nursing Visit Notes. She confirmed there was no evidence that the family had been notified that the wound on the right hip had worsened or of the emergence of the 5 new areas on her right foot or the new area on the coccyx.",2014-07-01
10064,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,309,E,0,1,JY8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Initial survey, based on record review and interviews, the facility failed to ensure the provision of Hospice services for 3 of 4 residents reviewed for Hospice Care. Residents #1 and #2 received Hospice from the same agency. Resident #1 had no documentation of Hospice Certified Nursing Assistant(CNA) and Chaplain services since hospice was ordered. Resident #2 , who was admitted to the facility on hospice, had no documentation of Hospice CNA services since admission to the facility. Resident #3 received services from a different Hospice agency and had no documentation of ordered Chaplain, Medical Social Work, Skilled Nursing, and Certified Nursing Assistant (CNA) services. The findings included: The facility admitted Resident #3 on 09/03/10 with the following [DIAGNOSES REDACTED]. The record review on 8/2/11 at 10:55 AM revealed that the resident was certified for hospice on 1/28/11. The Hospice care plan revealed that the Skilled Nurse was to visit the resident 1-3 times per week and PRN (as needed), the Chaplain was to visit the resident 1-2 times per month and PRN, the Medical Social Worker was to visit 1-2 times per month and PRN, and the CNA was to visit 3-5 times per week and PRN. No documentation was found in the Resident's Hospice Notebook for the Initial Survey time frame (6/24/11-present) to detail what was done for the resident, how the resident responded, or to indicate care plan coordination. The only documentation found in the hospice record was a sign-in sheet which was not being used consistently by the professional hospice staff. In an interview with the Director of Nurses on 8/2/11 at 4:00 PM, she was unable to locate the documentation requested and stated that she had specifically talked to the Hospice providers about always signing in and printing all hospice notes to have for the resident's chart. The facility admitted Resident #2 on 7/6/11 under Hospice Services with [DIAGNOSES REDACTED]. On 8/2/11 at 2:45 PM, record review of the Hospice Chart revealed no documentation of Hospice Aide Visits. Further review of the Hospice Initial Plan of Care at 3:07 PM revealed the Hospice Aide was to provide services 2-5 times per week. During an interview on 8/2/11 at 3:20 PM, the Director of Nursing stated she ""knew the aide has been here"" but confirmed there was no documentation in the record of the Hospice Aide Visits. She further confirmed that she would have expected the documentation to be in the record. The facility admitted Resident # 1 on 11/17/2010 with [DIAGNOSES REDACTED]. Record review on 08/02/2011 at 1:00 PM revealed a physician's orders [REDACTED]. Review of the Hospice care plan revealed that the resident was certified for Hospice care on 07/11/2011. The Hospice care plan noted that the Certified Nursing Assistant (CNA) was to visit five times a week and as needed and the Chaplain was to visit one time a month and as needed. Review of the resident's Hospice chart revealed no documentation of CNA or Chaplain visits from initial certification for Hospice services to present. During an interview on 08/02/2011 at 6:45 PM, Licensed Practical Nurse #1 verified there was no documentation of CNA or Chaplain visits to substantiate the Hospice care plan.",2014-07-01
10065,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,314,E,0,1,JY8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Initial Certification Survey, based on observation, interview , record review, and review of the professional resource treatment of [REDACTED].#2 and #4, (2 of 2 residents reviewed with pressure ulcers.) Resident #2 had a Stage II pressure ulcer on the right hip upon admission to the facility that was measured one time in 28 days resulting in inadequate assessment for evaluation of the progression or regression of the wound. The facility also failed to accurately assess for the presence of pressure ulcers or provide consistent treatment to Resident #4. The findings included: The facility admitted Resident #2 on [DATE] receiving Hospice Services with [DIAGNOSES REDACTED]. Upon admission, the resident had a Stage II pressure ulcer to the right hip. Record review on [DATE] at 11:39 AM revealed the resident was assessed upon admission with a score of 7 on the Norton Scale and found to be at high risk (score of less than or equal to 10) for the development of pressure ulcers. The resident was also assessed as being at high risk for malnutrition on ,[DATE] with a score of 24 and on ,[DATE] with a score of 20 (high risk being a score less than 10.) Review of the Nurse's Notes on [DATE] at 1:35 PM revealed a note dated [DATE] at 5:45 PM that indicated the resident had ""a decubitus on her hip which this nurse will evaluate on [DATE]."" Record review on [DATE] at 3:32 PM of the Body Audit Weekly Summary dated [DATE] revealed a narrative note that indicated the resident had a stage II pressure ulcer on the right hip and bruises on the right and left arm. On the reverse page of the body audit was another narrative note dated [DATE] indicating the pressure ulcer on the right hip had progressed to a Stage IV and that there were also Stage I pressure areas on both heels and on the Great Toe and 3rd toe of the right foot and a Stage II on the 2nd toe. The diagram on the first page indicated all areas but there was no notation indicating that any of the areas were added to the diagram on [DATE]. Review of the Initial Nursing assessment dated [DATE] indicated on the diagram and in the narrative notes that Resident #2 had a Stage II on the right hip and bruises on the left and right arm. There was no indication that the resident had any pressure areas on the left or right heel or on the toes of the right foot. There was also no documentation of the wound measurements or a description of the wound bed in the Nurse's Notes, the Initial Nursing Assessment or the Body Audit Weekly Summary. On [DATE] at 11:00 AM, the nurse documented the wound on the right hip measured 5.0 cm (centimeters) L (length) X 3.0 cm W (width) with eschar in the center of the wound. The Nurse's Note dated [DATE] at 4:10 PM stated ""Also has Stage I on both heels & (and) on R(ight) great toe & 3rd toe & Stage II on second toe."" A Nurse's Note dated [DATE] at 6:00 PM stated the resident had a ""stage I 1.0 cm to coccyx."" There is no further documentation of wound measurements in the record. Also on [DATE] at approximately 3:32 PM review of the Hospice Record revealed a Nursing Visit Note dated [DATE] that indicated ""New wounds noted on on R(ight) great toe, 1st toe & 2nd toe, both heels are pink and mushy."" The Wound Assessment portion of the Nursing Visit Note indicated ""New! R(ight) great toe &1st & 2nd toe State II both heals (sic) red stage I."" The wound work sheet dated [DATE] indicated a measurement for the right hip wound and toes; the size of the wounds on the heels is stated as ""size of bottom of heel."" There was no documentation of any further measurements of the wounds after [DATE]. There was no evidence that the wounds were being consistently assessed for decrease or increase in size to evaluate the efficacy of the treatments. During an interview on [DATE] at approximately 3:55 PM, Registered Nurse #2 confirmed there was no documentation of the measurements of the wound on admission. She further stated that documenting wounds has been a problem since she started (working at the facility) and stated she had been there for 4 months. She also verified that without documentation of the wound measurements and description, it would be difficult to determine progression of wound healing. During an interview at 4:20 PM the Director of Nursing reviewed the Nurse's Notes, Initial Nursing Assessment, Body Audit and Hospice Nursing Visit Notes. She confirmed that it looked like the resident did not have pressure ulcers on the toes and heels of her right foot on admission. She verified that it appeared like the 5 new areas on the right foot were added to the diagram dated [DATE] when they were found on [DATE]. She further stated it ""would have been good practice"" to use a new form to document the wounds on [DATE]. She further stated she would expect the wounds to be measured weekly. Review of Bergstrom N, Bennett MA, Carlson CE, et al. treatment of [REDACTED]. 15 Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR (Agency for Health Care Policy and Research) Publication No. ,[DATE]. [DATE] revealed .....""7. Assessment of Ulcer Healing...Progress toward healing should be evaluated at least weekly. If signs of ulcer deterioration are observed sooner (e.g., during daily dressing changes), steps to reverse them should be taken immediately. If the patient's general condition deteriorates (e.g., signs [MEDICAL CONDITION]), the ulcer should be reassessed promptly. Healing should be evaluated using the same criteria discussed under initial assessment (Node 2), that is, size, depth, and the presence of exudate, [MEDICATION NAME], granulation tissue, and findings such as necrotic tissue, sinus tracts, undermining, tunneling, and purulent drainage or other signs of infection. A clean pressure ulcer with adequate innervation and blood supply should show progress toward healing in 2 to 4 weeks. "" The facility admitted Resident #4 on [DATE] with Hypertension and multiple comorbidities. On Initial Tour with Registered Nurse (RN) #1 on [DATE] at 9:20am, Resident #4 was identified as having chronic issues with pressure sores to the sacral area, however that the area was healed at the present time. Licensed Practical Nurse (LPN) #1 was notified of need to observe the resident during wound care treatment when scheduled. During observation on [DATE] at 1:30pm of the resident wound care, a small, pink in color, open area was noted on the sacral area. LPN #1 stated that the sore was not open that morning and was new. Measurements of the open area were obtained by LPN #1 as Stage II, 1.2 X 1cm. At 2:20pm, LPN #1 stated that a call was placed to the physician to notify him of the open areas. At 1:50pm, Body Audit Sheets were given to the surveyor by RN #1 for Resident #4 that revealed no weekly body audits had been performed since [DATE] as confirmed by RN #1. Record review of the Nurse's Progress Notes from [DATE] thru [DATE] stated skin condition as ""Skin Intact and Stage 2 resolved to coccyx"". Nurse's Progress Notes from [DATE] thru [DATE] stated skin condition as ""Skin Intact and Barrier cream as preventive measures and progress"". Further review of the document entitled ""Nurse's Notes: Skin Integrity"" revealed that for the weeks [DATE]-[DATE] that skin was not intact, however skin was intact on [DATE]. No weekly skin assessment was performed since [DATE] and this was confirmed by RN #2. The last Body Audit performed on [DATE] revealed in the Nurse's Notes that the ""Area remains the same size ,[DATE]cm X 1cm. Area is almost a Stage I. Will keep at a Stage II for 1 more week. No odor. No Drainage. Pink in color"". Review of the Nurse's Notes for [DATE] stated ""Has 2 small 0.5cm Stage II's One on coccyx and one in crease of buttocks"". Upon further Record Review at 5:00pm, a Physician Telephone Order noted for ""[MEDICATION NAME] to buttocks BID (twice a day)"" was discontinued due to area healed on [DATE]. However, the order ""Vasolix ointment ([MEDICATION NAME] generic) to open area on coccyx BID"" was carried over on the Treatment Record for June and [DATE]. During an interview on [DATE] at 5:00pm, LPN #1 confirmed after looking through the chart that no order was present for the continued use of [MEDICATION NAME] to coccyx area.",2014-07-01
10066,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,492,D,0,1,JY8H11,"On the days of the Initial Certification Survey, based on interviews and record review, the facility failed to obtain Nursing Licensure verification prior to the date of hire for 1 of 1 newly hired Registered Nurses reviewed for license verification. The findings included: On 8/2/11 at approximately 1:15 PM, record review for pre-employment screening revealed that Registered Nurse ""A's"" date of hire was 7/11/11. The facility verified her license on 8/2/11. Further review revealed that Registered Nurse ""B"" was also hired on 7/11/11. License verification was obtained by the facility on 8/2/11. Both license verifications were obtained after requested by the Surveyor. During an interview on 8/2/11 at 4:40 PM, the Business Office Coordinator confirmed that the facility just did the license verification for Registered Nurses A and B on 8/2/11. She also confirmed that the hire date for Registered Nurses A and B was 7/11/11.",2014-07-01
10067,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,496,D,0,1,JY8H11,"On the day of the Initial Certification Survey, based on interview and record review, the facility failed to obtain/review a registry verification for Certified Nursing Assistant ""A"", 1 of 3 newly hired Certified Nursing Assistants reviewed for registry verification. The findings included: On 8/2/11 at approximately 1:15 PM, record review of newly hired employees revealed that the facility did not review the registry verification for Certified Nursing Assistant ""A"" prior to the date of hire per regulatory requirement. Record review revealed Certified Nursing Assistant ""A"" was hired on 7/11/11. The facility obtained the registry verification on 7/12/11 as confirmed during an interview on 8/2/11 at 4:40 PM with the Business Office Coordinator.",2014-07-01
10068,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,241,D,0,1,JY8H11,"On the day of the initial survey, based on observation and interviews, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality during 2 of 3 treatments observed. During observation of treatments for Residents #2 and #4, staff knocked on the door and entered without waiting for a response. The findings included: During an observation with Registered Nurse (RN) #2 on 8/2/2011 at 11:20am of a wound care treatment performed by Licensed Practical Nurse (LPN) #1 on Resident #2, staff was noted knocking at the door and entering the room without obtaining permission to do so twice during the resident's wound care. During observation of wound care treatment done by LPN #1 on Resident #4 at 1:30pm with RN #2 present, staff was noted knocking at the door and entering the room without waiting for response during the resident's wound care. During an interview on 8/2/2011 at 3:30pm, when RN #2 was asked of any concerns during wound care treatments, she stated ""Interruptions at the door and staff not waiting for permission prior to entering the room"". RN #2 confirmed that it happened twice in each room during the wound care.",2014-07-01
10069,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,315,D,0,1,JY8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the initial survey, based on observation, interview, and review of the facility policy entitled, ""Suprapubic Catheter Care"", the facility failed to provide appropriate treatment and services to prevent urinary tract infection in 1 of 1 residents with indwelling catheters. During catheter care for Resident #1, Licensed Practical Nurse (LPN) #1 failed to clean the catheter tube and used the same area of the cloth to clean the stoma site repeatedly. The findings included: The facility admitted Resident #1 on 11/17/10 with [DIAGNOSES REDACTED]. During observation with Registered Nurse (RN) #1 present for Suprapubic Catheter care for Resident #1 on 8/2/11 at 11:05am, LPN #1 was observed repeatedly cleaning the stoma and catheter insertion site with the same area of the cloth. The nurse also failed to clean the catheter tubing during the catheter care. During an interview on 8/2/11 at 3:30pm, RN #2 confirmed that during her observation of the suprapubic catheter care, LPN #1 ""Did not clean the catheter and wiped in the same area"". Review of the facility policy for Suprapubic Catheter Care on 8/2/11 revealed the following items listed: ""Wash around the catheter site with soap and water.....Wash the outer part of the catheter tube with soap and water"".",2014-07-01
10070,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,328,D,0,1,JY8H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Initial Survey, based on observation and interview, the facility failed to ensure proper care of oxygen concentrators as evidenced by the random observation of 2 oxygen concentrators with excessive dust and debris on the filters. The findings included: During the Initial Tour of the 1800 Hall on 8/2/11 at 9:40 AM, oxygen concentrators in room [ROOM NUMBER] and 1813 were observed with filters covered with excessive dust and debris. In an interview with Registered Nurse (RN) #1 at that time, she confirmed the filters were dirty and should have been cleaned by the night shift. .",2014-07-01
10071,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,371,F,0,1,JY8H11,"On the day of the initial survey, based on observation and interview, the facility failed to store and prepare food under sanitary conditions as evidenced by dried food spills and debris on shelving and inside a hot box, grease build up on a grill, buffalo chopper, and tilt skillet, lid off a trash can, fans with excessive dust build up, a build up of dust on and around ceiling vents, food not labeled or dated in freezer, and use of the wrong test strip for the three-compartment sink sanitizer. The findings included: Observations on 8/2/11 at approximately 9:45am, with the Assistant Director of Dietary present, revealed: on the inside right wall and floor of the hot box was a dried food spill. There was no lid on the trash can in the pot sink area. Shelving under the prep table and rack storage for sheet pans and hotel pans had dried food spills and debris. The inside of the cover of the buffalo chopper had a film of grease. The grill had a grease build up to the point that one could not see between the rails on portions of the grill. In addition, the grease build up was on the outside of the grill and on the back of the range opposite of the grill. The tilt skillet had grease streaks on the outside right corner and grease build up around the outside edges. In the freezer was an open bag of breaded strips and an open bag of breaded meat which were not labeled or dated. In addition, there were 3 closed bags of what appeared to be meat that were not labeled or dated. Square ceiling vents, throughout the kitchen, had an accumulation of dust on and around them. Fans in use in the prep area and cooking area had a heavy accumulation of dust on the front and back grills as well as the blades of the fan. With the Assistant Director of Dietary (ADD) present, the request was made to test the level of sanitizing agent in the three-compartment sink. Using a test strip for the presence of chlorine, Food Service Aide (FSA) #1 place the strip in the sink containing sanitizer/water. The strip did not change color which indicates there was no chlorine present. The FSA was instructed by the ADD to repeat the test with another test strip. The strip did not change color. The ADD then instructed the FSA to empty the sink and refill it with fresh water and sanitizing agent. Using a test strip for chlorine, the FSA tested the newly refilled sink. The test strip did not change color. The surveyor then asked what type of sanitizing agent was being used. The ADD stated without hesitation ""a Quat"" (Quaternary). A quaternary solution does not contain chlorine. The FSA was directed to retest the sink with the chlorine test strip by the ADD. The test strip did not change color. The surveyor asked if the facility had another type of test strip. The ADD indicated they did and when it was retrieved and used, it registered the presence of approximately 200 ppm (parts per million) of Quat concentration which met requirements for proper sanitation. On 8/2/11 at approximately 10:20am the above equipment conditions were shown to the Director of Dietary who concurred with the findings. When told of the situation that occurred with the testing of the three-compartment sink, The Director of Dietary indicated that staff had used the wrong test strip and that the appropriate test strip should have been available at the sink and that staff should know which test strip should be used with each type of sanitizing agent.",2014-07-01
10072,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,503,C,0,1,JY8H11,"On the day of the initial survey, based on interview and review of Facility contracts, the facility failed to have on hand, at the time of the survey, a copy of the contract between the facility and the provider of laboratory services. The findings included: On 8/2/11 the surveyor requested to review the contract for laboratory services. The surveyor was informed by the Director of Nursing that the contract was held at the providing hospital and that the facility did not have a copy of the contract on hand. No additional information was received from the facility.",2014-07-01
9977,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-04-07,157,D,1,0,O72D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observations, record review and interviews, the facility failed to notify the family in a timely manner for Residents #1 who had a red skin irritation noted to the perineal and anal area. The findings included: The facility admitted Resident #1 on 12/08/2006 with [DIAGNOSES REDACTED]. Review of an Incident Investigation dated 03/12/2011 stated, ""Elder has bright red skin irritation noted to the perineal and anal area. ...5 cm (centimeter) area noted to R (right) groin area from brief irritation. Two small spots noted to be opened near anal area. Protective cream applied... Emailed...for order for Xanaderm, will continue to monitor."" Review of the Departmental Notes (nurse's notes) on 04/07/2011 at approximately 9:30 PM revealed an entry on 03/04/2011 the next entry dated 03/14/2011 stated, ""Perineal [MEDICAL CONDITION] noted. Assisted back to bed skin cleansed and Aloe Vista applied... Observe closely."" There was no entry for the 03/12/2011 assessment that resulted in the Incident Investigation and no mention of family notification. Review of the 24 Hour Report for 03/12/2011 showed no documentation regarding the skin irritation or concerns related to Resident #1. There was no evidence in the medical record that the family was notified at all, of the change in the resident's skin. During an interview with the surveyor on 04/07/2011 at 9:45 PM, Registered Nurse (RN) Supervisor #1 stated there was no Departmental Notes related to the change in Resident #1's skin and the information was not included on the 24 Hour Report for 03/12/2011. Observation of perineal care for Resident #1 on 04/07/2011 at approximately 10:20 PM revealed no open areas on the anal or perineal skin.",2014-08-01
9978,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-04-12,157,J,1,0,DO7W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews, the facility failed to ensure that the Physician was notified of a change in condition for 1 of 5 sampled residents with tracheostomies. Resident #3's physician was not notified of the resident's decannulation on the 11-7 shift until the later the following morning. The findings included: The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift (3/7-3/8/2011). On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the ""nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table........Notified physician and pt pulmonologist that [MEDICAL CONDITION] noted on bedside table,....... ."" During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's ""trach was out."" She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done ""medically"" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. Cross Refer to F328 related to the facility failure to promptly notify the physician and/or family related to a change in the resident's condition. On the days of the inspection, based on limited record reviews, observations, and interviews the facility failed to promptly notify Resident #3's physician and family when her [MEDICAL CONDITION] came out. On 03/28/2011 at 3:40 PM the Administrator was notified that Immediate Jeopardy was identified at F-157 and cited at a scope and severity level of ""J"" due to the facility failure to provide proper treatment and care for 1 of 5 residents with tracheostomies. On 03/08/2011 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube and the physician/family were not notified timely. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Immediate Jeopardy was removed and citation F-157 was lowered to a scope and severity level of ""D"" as of 03/29/2011 at 4:20 PM.",2014-08-01
9979,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-04-12,281,K,1,0,DO7W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review, interviews, review of the facility's policy and procedures for [MEDICAL CONDITION] Care and the Nurse Practice Act Section 40-33-20, the facility's Nursing staff failed to provide the appropriate and necessary treatment to 3 of 5 sampled resident with tracheostomies. Resident #1's [MEDICAL CONDITION] was not changed every 28 days per the physician's orders [REDACTED].#1 also did not receive appropriate [MEDICAL CONDITION] care. Resident #2's inner cannula was replaced with a size smaller due to the nursing staff's failure to obtain the correct size prior to performing [MEDICAL CONDITION] care. Resident #2 also had the [MEDICAL CONDITION] appliance changed out by a nurse that was not educated or trained. Facility staff failed to act when Resident #3's [MEDICAL CONDITION] came out and failed to follow up on the Pulmonologist's recommendations for a possible decannulation. The findings included: The facility admitted Resident #1 on 11/30/2010 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] coded the resident as alert and oriented and coded the resident as having no behaviors during the assessment period. Review of the Medication Administration Record [REDACTED]""Change #6 [MEDICAL CONDITION] (every) 28 days and prn (as needed) resident was receiving [MEDICAL CONDITION] every day. However, there was no documentation Resident #1'[MEDICAL CONDITION] changed every 28 days per the physician's orders [REDACTED]. Review of the nurses notes revealed an entry dated 3/8/2011 at 0545 AM that documented Resident #1 experienced problems [MEDICAL CONDITION] was completed and was transported to the ER. Review of the Transfer Summary dated 3/8/2011, revealed the primary [DIAGNOSES REDACTED]."" Review of the Physician's readmission orders [REDACTED]."" During an observation of the Unit 700, Supply Room, Licensed Practical Nurse #1 stated that there were no #6 [MEDICAL CONDITION] parts in the supply room. LPN #1 confirmed that Resident #1 only had a #4 Shiley complete appliance at the bedside and again stated that the facility had been out of #6 Shiley trachs and stated that they had been ordered. LPN #1 was asked what she used for Resident #1 [MEDICAL CONDITION]. LPN #1 picked up a size 4 ""spare inner cannula."" Visible on the size 4 packaging, was a Caution note that read ""Caution Temporary, Single Use Only. Ten (10) minutes is suggested as the time limit for continual usage. This inner cannula is shorter than the original custom fitted inner cannula and secretions may build up on the inside of the outer cannula if ten (10) minutes is exceeded. WARNING: Use only in Shiley [MEDICAL CONDITION] of the same size number."" LPN #1 stated that she used the ""spare inner cannula"" on Resident #1. LPN #1 stated that Resident #1 had a size 6 Shiley but stated again that there were no #6 Shiley [MEDICAL CONDITION] parts available. LPN #1 was again asked if she used the temporary spare inner cannula on Resident #1, LPN #1 stated, ""Yes."" LPN #1 then stated that she used the spare inner cannula for longer than ten minutes and stated that she knew the spare inner cannula was a size smaller than the resident's #6 Shiley. During an interview with the surveyor on 3/28/2011, LPN #1 and the DON confirmed the spare inner cannula warning and LPN #1 again stated that she used the spare inner cannula on Resident #1 and used it incorrectly. The DON also confirmed there was no documentation that Resident #1'[MEDICAL CONDITION] was changed every 28 days. The DON stated, ""If its not documented then it wasn't done."" The DON also stated that the nurses should initial on the MAR/TAR when any treatment was given. She stated that there was not an ""acceptable reason"" as to why there was no documentation. During an interview with the surveyor on 3/28/2011, the Medical Director and Attending Physician for Resident #1 stated that if a resident has a #6 [MEDICAL CONDITION] only #6 Shiley parts should be used. He further stated that he did would expect the nursing staff to not use different sizes for the trachs and not to use a temporary inner cannula. The Physician stated that he would expect the staff to call him and the pulmonologist if a smaller [MEDICAL CONDITION] or a temporary part needed to be used. During an interview with the surveyor on 3/29/2011, the Director of Respiratory Services stated that the Spare Inner Cannulas were only to be used if a resident was mechanically ventilated. The Spare Inner Cannulas should not be used on a resident that can spontaneously breath. Review of the [MEDICAL CONDITION] Care policy revealed the following: [MEDICAL CONDITION] Change outs: ""[MEDICAL CONDITION] change outs will be performed Q 29 Days and PRN unless otherwise ordered by the physician. Manufacturers guidelines are every 29 days and PRN... The following complications can occur within the first 48 hours [MEDICAL CONDITION] insertion/change out: Hemorrhage, bleeding causing airway obstruction, aspiration... Nursing Considerations: Keep appropriate equipment at the patient's bedside for immediate use in an emergency. Consult the physician about first aid measures you can use for your [MEDICAL CONDITION] should an emergency occur. Use extreme caution when attempting to insert an expelled [MEDICAL CONDITION] because of the risk of tracheal trauma, perforation, compression and asphyxiation..."" The facility admitted Resident #2 on 12/22/2009 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#2 had a #6 [MEDICAL CONDITION] a disposable inner cannula that was to be changed every day. Size 6 [MEDICAL CONDITION] out to be done every 28 days and PRN. Review of the nurses notes revealed on 3/7/2011 at 10 PM, ""Resident pulled out his outer cannula... reinserted cannula..."" On 3/8/2011 at 12 PM, ""Resident'[MEDICAL CONDITION] given, #4 inner cannula placed... Dr. called NNO (no new orders) thus far..."" On 3/8/2011 at 5 PM, ""received order form Dr. to [MEDICAL CONDITION] #8 Shiley now..."" At 5:10 PM, ""...Trach #8 Shiley replaced without difficulty."" During an interview with the surveyor, LPN #3 stated that she [MEDICAL CONDITION] on Resident #2 and placed a size 4 inner cannula into a size 6 Shiley Trach. She stated that she did not have all of her supplies when she went into the room. LPN #3 stated that she realized she did not have a #6 disposable inner cannula after she removed the old inner cannula. LPN #3 stated that she called for her supervisor to bring her a new disposable #6 Shiley inner cannula. The supervisor brought a Size 4 Disposable Inner Cannula and informed LPN #3 that there were no #6 Shiley's available. LPN #3 confirmed again that she did not have all the necessary supplies available prior to [MEDICAL CONDITION] for Resident #2. During an interview with the surveyor on 3/29/2011, LPN #4 stated that she changed out Resident #2'[MEDICAL CONDITION] the evening of 3/8/2011. Review of the Competencies for [MEDICAL CONDITION] Change Outs revealed 12 nurses completed the required training. All of the nurses were nurses that worked the 7-3 shift. LPN #4 did not have documentation of the necessary education and training required for [MEDICAL CONDITION] change outs. The DON and the Director of Respiratory Care Services confirmed that LPN #4 did not have the required education and training in place. Review of the Nurse Practice Act Section 40-33-20 revealed: ""Special Training. A nurse must successfully complete a course of ""special education and training"" acceptable to the board to perform additional acts."" The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Pulmonology Note dated 2/7/2011 revealed recommendations were as follows: ""1. Nighttime Pulse Ox on Room Air, 2. Wean O2 during day to room air-check pulse ox over 1-2 hours, 3. Cap [MEDICAL CONDITION] during day if room air pulse ox is >92%, 4. Possible decannulation next visit."" The next visit was scheduled for 3/7/2011. There was no documentation that the facility staff had followed up with the pulmonologist to clarify if he wanted his recommendations to be written as orders. None of the recommendations were acted upon. Review of the physician's orders [REDACTED]. There was no documentation that Speech Therapy began working with the resident on 2/22/2011. On 3/7/2011 an order was written for Speech Therapy to evaluate and treat 5 x/week for decannulation. Further review revealed Resident #3 ' s 3/7/2011 pulmonology appointment, was cancelled due to not having received the appropriate preparation for decannulation. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift. During an interview with the surveyor, Resident #3's husband stated he arrived to the facility on [DATE] at 10 AM and noticed the resident'[MEDICAL CONDITION] on the bedside table wrapped [MEDICAL CONDITION]. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. LPN #6 stated that the resident's oxygen saturations were normal and she was not in any distress. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's ""trach was out."" She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done ""medically"" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5 reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately assessed the resident and noted there was no respiratory distress. She then notified the Physician and the Pulmonologist. Cross Refer to F328 related to the facility failure to provide services according to acceptable standards of clinical practice. On the days of the inspection, based on limited record reviews, observations, interviews, and review of the [MEDICAL CONDITION] Care policy the facility failed to provide services, which met professional standards of quality. The facility staff failed to follow professional standards of practice related to the care of residents with tracheostomies. On 03/08/2001 Resident #2's [MEDICAL CONDITION] was changed by a nurse without the appropriate education and training; Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube; Resident #1's [MEDICAL CONDITION] was not changed as ordered. On 03/28/2011 at 3:40 PM the Administrator was notified that Immediate Jeopardy was identified at F-281 and cited at a scope and severity level of ""K"" due to the facility failure to provide proper treatment and care for 3 of 5 residents with tracheostomies. On 03/08/2011 Resident #2's [MEDICAL CONDITION] was changed by a nurse without the appropriate education and training; Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube; Resident #1's [MEDICAL CONDITION] was not changed as ordered. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Immediate Jeopardy was removed and citation F-281 was lowered to a scope and severity level of ""E"" as of 03/29/2011 at 4:20 PM.",2014-08-01
9980,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-04-12,328,K,1,0,DO7W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review, interviews, review of the facility's policy and procedures for [MEDICAL CONDITION] Care and the Nurse Practice Act Section 40-33-20, the facility's Nursing staff failed to provide the appropriate and necessary treatment to 3 of 5 sampled resident with tracheostomies. Resident #1's [MEDICAL CONDITION] was not changed every 28 days per the physician's orders [REDACTED].#1 also did not receive appropriate [MEDICAL CONDITION] care. Resident #2's inner cannula was replaced with a size smaller due to the nursing staff's failure to obtain the correct size prior to performing [MEDICAL CONDITION] care. Resident #2 also had the [MEDICAL CONDITION] appliance changed out by a nurse that was not educated or trained. Facility staff failed to act when Resident #3's [MEDICAL CONDITION] came out and failed to follow up on the Pulmonologist's recommendations for a possible decannulation. The findings included: The facility admitted Resident #1 on 11/30/2010 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] coded the resident as alert and oriented and coded the resident as having no behaviors during the assessment period. Review of the nurses notes revealed an entry dated 3/8/2011 at 0545 AM that documented ""trach care began - Resident began to cough up blood out [MEDICAL CONDITION] red in color. Resident inner cannula removed and cleaned - Resident began to vomit large amount of thick emesis, noted no milk. Cleaned mouth c (with) wash cloth. Resident began to make choking noises. Suction machine set up. Suctioned mouth small amount of frothy sputum obtained. [MEDICAL CONDITION]- bloody sputum obtained. HOB (head of bed) up O2 (oxygen) continued at 5 L (liters)/28%[MEDICAL CONDITION]. Sats (saturations) 97%. Supervisor notified and present. Doctor notified and new order obtained and noted. Regional called for transportation to ER at 6:40 AM."" Further review of the nurse's notes revealed documentation [MEDICAL CONDITION] was performed however, there was no documentation of the [MEDICAL CONDITION] appliance change out. Review of the Medication Administration Record [REDACTED]""Change #6 [MEDICAL CONDITION] (every) 28 days and prn (as needed) resident was receiving [MEDICAL CONDITION] every day. However, there was no documentation Resident #1'[MEDICAL CONDITION] changed every 28 days per the physician's orders [REDACTED]. Review of the Transfer Summary dated 3/8/2011, revealed the primary [DIAGNOSES REDACTED]."" Review of the Physician's readmission orders [REDACTED]."" During an interview with the surveyor on 3/28/2011, Resident #1 (who is unable to speak but communicates through writing) was asked what caused the bleeding to her [MEDICAL CONDITION] on 3/8 that resulted in her going to the hospital. Resident #1 wrote, ""Cause for bleeding was they took out my permanent piece that came [MEDICAL CONDITION] put some red piece which was not a replacement piece for my kind of trach."" During an observation of the Unit 700, Supply Room, Licensed Practical Nurse #1 stated that there were no #6 [MEDICAL CONDITION] parts in the supply room. LPN #1 confirmed that Resident #1 only had a #4 Shiley complete appliance at the bedside and again stated that the facility had been out of #6 Shiley trachs and stated that they had been ordered. LPN #1 was asked what she used for Resident #1 [MEDICAL CONDITION]. LPN #1 picked up a size 4 ""spare inner cannula."" Visible on the size 4 packaging, was a Caution note that read ""Caution Temporary, Single Use Only. Ten (10) minutes is suggested as the time limit for continual usage. This inner cannula is shorter than the original custom fitted inner cannula and secretions may build up on the inside of the outer cannula if ten (10) minutes is exceeded. WARNING: Use only in Shiley [MEDICAL CONDITION] of the same size number."" LPN #1 stated that she used the ""spare inner cannula"" on Resident #1. LPN #1 stated that Resident #1 had a size 6 Shiley but stated again that there were no #6 Shiley [MEDICAL CONDITION] parts available. LPN #1 was again asked if she used the temporary spare inner cannula on Resident #1, LPN #1 stated, ""Yes."" LPN #1 then stated that she used the spare inner cannula for longer than ten minutes and stated that she knew the spare inner cannula was a size smaller than the resident's #6 Shiley. Observation of the other three units supply rooms revealed one partial box of #6 [MEDICAL CONDITION] inner cannulas. Observation of the Main Supply Room revealed 2, #6 Shiley [MEDICAL CONDITION] complete appliances. During an interview with the surveyor on 3/28/2011 at 3:15 PM, the Director of Nurses, confirmed the #4 [MEDICAL CONDITION] bedside. During another interview at 4:30 PM, the DON presented a bag with Resident #1's name written on the outside that contained a #6 [MEDICAL CONDITION]. During an interview with the surveyor on 3/28/2011, LPN #1 and the DON confirmed the spare inner cannula warning and LPN #1 again stated that she used the spare inner cannula on Resident #1 and used it incorrectly. The DON also confirmed there was no documentation that Resident #1'[MEDICAL CONDITION] was changed every 28 days. The DON stated, ""If its not documented then it wasn't done."" The DON also stated that the nurses should initial on the MAR/TAR when any treatment was given. She stated that there was not an ""acceptable reason"" as to why there was no documentation. During an interview with the surveyor on 3/28/2011, the Medical Director and Attending Physician for Resident #1 stated that he expected that [MEDICAL CONDITION] care should be performed sterilely. The Physician also stated that if a resident has a #6 [MEDICAL CONDITION] only #6 Shiley parts should be used. He further stated that he did would expect the nursing staff to not use different sizes for the trachs and not to use a temporary inner cannula. The Physician stated that he would expect the staff to call him and the pulmonologist if a smaller [MEDICAL CONDITION] or a temporary part needed to be used. During an interview with the surveyor on 3/29/2011, the Director of Respiratory Services stated that the Spare Inner Cannulas were only to be used if a resident was mechanically ventilated. The Spare Inner Cannulas should not be used on a resident that can spontaneously breath. During an interview with the surveyor on 3/29/2011, the Administrator confirmed the presence of 2 size 6 Shiley trachs in the facility. One of which was at Resident #1's bedside and the other was temporarily in the administrator's office. Review of the General Ledger Spending Detail revealed on 3/24/2011, two Fenestrated Cuffless Size 6 Shiley trachs were ordered. No other entries for Size 6 Shiley trachs were located. During an interview with the surveyor on 3/29/2011, the Speech Therapist stated that Resident #1 did not tolerate occlusion of [MEDICAL CONDITION] long periods of time. She stated that she attempted ""finger occlusion"" to allow the resident to speak but if the resident needed to be suctioned or was congested, she could not tolerate any type of treatment. The Speech Therapist stated that a ""Decannulation Plug"" was never used on the resident, as she was not a candidate for decannulation due to her progressive disease process. During observation of [MEDICAL CONDITION] Care on 3/29/2011, LPN #2 washed her hands and applied disposable gloves. LPN #2 then placed her supplies on the bedside table where a urine filled bedpan had been placed. Liquid was observed on the bedside table. LPN #2 then placed a saturation monitor on the resident and auscultated the resident. LPN #2 opened the sterile gloves and proceeded to don them over the now soiled disposable gloves. LPN #2 then suctioned the resident again repeatedly touching the resident'[MEDICAL CONDITION] and outside of the cannula with her ""sterile"" hand. LPN #2 then removed the sterile gloves and proceeded to don another pair of sterile gloves without washing her hands or removing the other pair of disposable gloves. LPN #2 was observed to touch the resident's left bed rail. LPN #2 removed the inner cannula and placed it in the tray of sterile water, LPN #2 was observed to touch the underneath side of the tray that was not sterile with her right hand. LPN #2 picked up the inner cannula and touched the sterile portion of the cannula with her left hand. LPN #2 used her right hand to clean the inside portion. LPN #2 then used sterile gauze and cleaned the right and left side of the flange and under [MEDICAL CONDITION]. LPN #2 was not observed to clean around the stoma site. LPN #2 removed the sterile gloves and still with the disposable gloves applied [MEDICAL CONDITION] and put a new piece of gauze under the appliance. LPN #2 removed her gloves, ausculted, gathered the dirty supplies and then washed her hands and proceeded to the soiled utility room. LPN #2 returned to the resident room and was going to pour the liquid down the sink and stopped. She left the room and obtained a biohazard bag, she returned to the room, donned disposable gloves and disposed of the liquid in the biohazard bag. LPN #2 removed her gloves, set up the resident's bedside table and left the room with the biohazard bag. She picked up the phone and made a phone call with the bag in hand, and was observed to change hands multiple times. LPN #2 proceeded to the basement to dispose of the bag. LPN #2 returned to Unit 700 and was observed to rub the back of another resident and then began to chart. LPN #2 was asked if she was finished and she stated, ""Yes."" During an interview with the surveyor on 3/29/2011 LPN #2 and the DON were informed of the multiple breaks in sterile technique. Review of the facility's policy on [MEDICAL CONDITION] Care revealed the following: ""1. wash hands and assemble all supplies...4. Establish a sterile field near the resident's bed and place equipment and supplies on it...Procedure: Using sterile technique, suction the entire length of the [MEDICAL CONDITION] to clear the airway of any secretions that may hinder oxygenation. To clean a Stoma: 1. Put on sterile gloves...with dominate hand, saturate a sterile gauze pad with the cleaning solution... wipe the resident's neck under the [MEDICAL CONDITION] flanges and [MEDICATION NAME] tape...use additional pads or cotton tipped applicators to clean the stoma site and the tube's flanges. Remove and discard gloves. To clean a Non Disposable Inner Cannula: Put on Sterile Gloves, working quickly, use dominant hand to scrub the cannula with the sterile nylon brush..."" Further review of the policy revealed the following: [MEDICAL CONDITION] Change outs: ""[MEDICAL CONDITION] change outs will be performed Q 29 Days and PRN unless otherwise ordered by the physician. Manufacturers guidelines are every 29 days and PRN."" The following complications can occur within the first 48 hours [MEDICAL CONDITION] insertion/change out: Hemorrhage, bleeding causing airway obstruction, aspiration..."" Nursing Considerations: ""Keep appropriate equipment at the patient's bedside for immediate use in an emergency. Consult the physician about first aid measures you can use for your [MEDICAL CONDITION] should an emergency occur. Use extreme caution when attempting to insert an expelled [MEDICAL CONDITION] because of the risk of tracheal trauma, perforation, compression and asphyxiation."" The facility admitted Resident #2 on 12/22/2009 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#2 had a #6 [MEDICAL CONDITION] a disposable inner cannula that was to be changed every day. Size 6 [MEDICAL CONDITION] out to be done every 28 days and PRN. Review of the nurses notes revealed on 3/7/2011 at 10 PM, ""Resident pulled out his outer cannula... reinserted cannula..."" On 3/8/2011 at 12 PM, ""Resident'[MEDICAL CONDITION] given, #4 inner cannula placed."" On 3/8/2011 at 5 PM, ""received order form Dr. to [MEDICAL CONDITION] #8 Shiley now."" At 5:10 PM, ""Trach #8 Shiley replaced without difficulty."" During an interview with the surveyor, LPN #3 stated that she [MEDICAL CONDITION] on Resident #2 and placed a size 4 inner cannula into a size 6 Shiley Trach. She stated that she did not have all of her supplies when she went into the room. LPN #3 stated that she realized she did not have a #6 disposable inner cannula after she had removed the old inner cannula. LPN #3 stated that she called for her supervisor to bring her a new disposable #6 Shiley inner cannula. The supervisor brought a Size 4 Disposable Inner Cannula and informed LPN #3 that there were not any #6 available. LPN #3 confirmed again that she did not have all the necessary supplies available prior to [MEDICAL CONDITION] for Resident #2. During an interview with the surveyor on 3/29/2011, LPN #4 stated that she changed out Resident #2'[MEDICAL CONDITION] the evening of 3/8/2011. LPN #4 stated that the doctor was in the room with her and stated that ""he was not comfortable doing it"" and told LPN #4 to go ahead and change out [MEDICAL CONDITION] a size 8 Shiley. The DON and the Director of Respiratory Care Services confirmed that LPN #4 did not have the required education and training in place. Review of the Inservice Records revealed on 3/17/2011, the facility conducted a ""Skills Fair"" and [MEDICAL CONDITION] care was one of the topics taught; 31 nurses attended. The DON stated the inservice was not in relation to any event related to [MEDICAL CONDITION] care that occurred but was related to the annual skills fair. Review of the Competencies for [MEDICAL CONDITION] Change Outs revealed 12 nurses completed the required training. All of the nurses were nurses that worked the 7-3 shift. LPN #4 did not have documentation of the necessary education and training required for [MEDICAL CONDITION] change outs. The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation from the night shift. On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the ""nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table. Immediately assessed respiratory status, O2 sats 98-100% on RA (room air) resps even and unlabored, lungs clear to auscultation and greater than 10. Pt husband at bedside stated that pt was talking to him. Husband denies [MEDICAL CONDITION] stated that pt has decannulated herself ""several"" times in the past. Notified Dr. and pt pulmonologist that [MEDICAL CONDITION] noted on bedside table, pt O2 sat were 98-100% on RA, resps (respirations) 16 even and unlabored, lips and mucous membranes pink. Per Dr. Jones, pt to remain decannulated O2 sats every shift and PRN, O2 2 L per minute via NC (nasal cannula) for shortness of breath/O2 sats less than 92%, schedule follow up with pulmonology. Per pulmonologist, place dry gauze over stoma site, pt to come to Pulmonology Clinic 3/9/2011. ST (speech therapy) at bedside worked with pt for swallowing. Pt swallowing pudding and honey thick liquids. Husband at bedside, who was notified of new orders and appt in AM. Verbalized appreciation of our care and stated that he was happy [MEDICAL CONDITION] out."" Review of the Pulmonology Note dated 2/7/2011 revealed recommendations were as follows: ""1. Nighttime Pulse Ox on Room Air, 2. Wean O2 during day to room air-check pulse ox over 1-2 hours, 3. Cap [MEDICAL CONDITION] during day if room air pulse ox is >92%, 4. Possible decannulation next visit."" The next visit was scheduled for 3/7/2011. There was no documentation that the facility staff had followed up with the pulmonologist to clarify if he wanted his recommendations to be written as orders. None of the recommendations were acted upon. Review of the physician's orders [REDACTED]. There was no documentation that Speech Therapy began working with the resident on 2/22/2011. On 3/7/2011 an order was written for Speech Therapy to evaluate and treat 5 x/week for decannulation. Further review revealed Resident #3 ' s 3/7/2011 pulmonology appointment, was cancelled due to not having received the appropriate preparation for decannulation. During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5 reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately assessed the resident and noted there was no respiratory distress. She then notified the Physician and the Pulmonologist. The Nurse Supervisor stated that the husband was at the bedside and was questioned to see if he pulled [MEDICAL CONDITION]. The husband told the Nurse Supervisor that he did not pull [MEDICAL CONDITION]. During an interview with the surveyor, Resident #3's husband stated he arrived to the facility on [DATE] at 10 AM and noticed the resident'[MEDICAL CONDITION] on the bedside table wrapped [MEDICAL CONDITION]. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011. She was told that Resident #3's ""trach was out."" She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that during walking rounds she did not see [MEDICAL CONDITION] the resident's room. She also stated that the CNA performed AM care on the resident and did not notice [MEDICAL CONDITION] the resident's room. LPN #5 stated that she knew the resident was to be decannulated and assumed that it was done ""medically"" and not accidentally. LPN #5 returned to the resident's room and the husband asked her when [MEDICAL CONDITION] been removed. LPN #5 checked the chart and noted that there was no documentation of the decannulation. LPN #5 stated that she immediately notified the Supervisor. During a telephone interview with the surveyor on 4/7/2011, CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). She stated that the night shift of March 7th was the first and only time she had cared for the resident and stated that she did not know the resident. CNA #1 stated that she did not think the resident pulling out [MEDICAL CONDITION] an emergency situation. During a telephone interview with the surveyor on 4/12/2011, LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that the resident did not have [MEDICAL CONDITION] during his shift. He stated that he was aware the resident was to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident's trach. LPN #6 stated that he did not believe the situation was an emergency. LPN #6 stated that the resident's oxygen saturations were normal and she was not in any distress. He further stated that he did not think the resident accidentally decannulated herself because if she had then it would an emergency situation. On 03/28/2011 at 3:40 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-328 with a scope and severity level of ""K"" and existed in the facility as of 03/08/2011 due to the facility failure to provide proper treatment and care for 3 of 5 residents with tracheostomies. On 03/08/2011 a nurse without the appropriate education and training changed Resident #2's [MEDICAL CONDITION]. On the 11-7 shift on 3/7-3/8/2011 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. Resident #1's [MEDICAL CONDITION] was not changed as ordered. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Substandard Quality of Care and Immediate Jeopardy was removed and citation F-328 was lowered to a scope and severity level of ""E"" as of 03/29/2011 at 4:20 PM.",2014-08-01
9981,UNIHEALTH POST-ACUTE CARE - COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-04-12,224,J,1,0,DO7W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews, the facility failed to ensure Resident #3, 1 of 5 sampled residents with tracheostomies, was not neglected when she did not receive the necessary care and services (assessment and physician notification) that would have been appropriate at the time decannulization was first identified. Resident #3 accidentally decannulated on the 11-7 shift, 3/7-3/8/2011. The Certified Nurse Aide and the Licensed Practical Nurse providing care to Resident #3 on the 11-7 shift failed to notify the physician or provide the necessary care in a timely manner. The findings included: The facility admitted Resident #3 on 9/16/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/7/2011 at 10:30 PM the resident'[MEDICAL CONDITION] intact. There was no documentation of any resident concerns related to [MEDICAL CONDITION] the 11-7 shift (3/7-3/8/2011) staff. On 3/8/2011 at 11:45 AM, the nurse supervisor documented that the ""nurse reported to writer that pt (patient)[MEDICAL CONDITION] out. Upon entering the room noted [MEDICAL CONDITION] on napkin on bedside table."" During an interview with the surveyor on 4/4/2011, the Nurse Supervisor stated that LPN #5, working the morning shift 3/8/11, reported to her that Resident #3'[MEDICAL CONDITION] out. The Nurse Supervisor stated that she immediately went and assessed the resident and noted there was no respiratory distress. She then notified the physician and the pulmonologist. During an interview with the surveyor on 4/5/2011, LPN #5 stated that she received report at 7 AM on 3/8/2011 and it was reported that Resident #3's ""trach was out."" She stated that the night shift nurse did not report the decannulation as an emergency and did not indicate that the decannulation was accidental. LPN #5 stated that she knew the resident was scheduled to be decannulated and assumed that it was done ""medically"" and not accidentally. LPN #5 became concerned when questioned about [MEDICAL CONDITION] Resident #3's husband and could not find any evidence in the clinical record that the Resident was decannulated as scheduled. CNA #1 stated that she was bathing the resident around 4-4:30 AM and noticed [MEDICAL CONDITION] lying in the bed. She stated that she reported to the nurse immediately that [MEDICAL CONDITION] in the bed and handed [MEDICAL CONDITION] the nurse (LPN #6). LPN #6 stated that he was caring for Resident #3 on the night shift of March 7-March 8, 2011. He stated that he was aware the resident was scheduled to be decannulated and had assumed that was why Resident #3 did not have a trach. He stated that CNA #1 informed him at approximately 5 AM that she had found the resident'[MEDICAL CONDITION] stated that he did not believe the situation was an emergency. Cross refer to F-157 Related to the facility failure to promptly notify the physician and/or family related to a change in the resident's condition. Cross refer to F-281 Related to the facility failure to provide services according to acceptable standards of clinical practice. On 03/08/2001 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube Cross refer to F-328 Related to the facility failure to provide timely treatment and care for residents requiring [MEDICAL CONDITION] care. On 03/08/2001 Resident #3's [MEDICAL CONDITION] came out and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. On 03/28/2011 at 3:40 PM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-224 at a scope and severity level of ""J"" and existed in the facility as of 03/08/2011 due to the facility failure to provide appropriate and timely treatment and care for 3 of 5 residents with tracheostomies. Resident #3's [MEDICAL CONDITION] came out on the 11-7 shift, 3/7-3/8/2011 and was found in the resident's bed, no action was immediately taken regarding the decannulation of the tube. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, staff interviews, observation of staff [MEDICAL CONDITION] care and/or change out demonstration and record review of residents with tracheostomies, the Substandard Quality of Care and Immediate Jeopardy was removed and citation F-224 was lowered to a scope and severity level of ""D"" as of 03/29/2011 at 4:20 PM.",2014-08-01
9982,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,371,E,0,1,2B2D11,"On the days of the survey, based on observation and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions as evidenced by dietary staff not wearing hair restraints appropriately. The findings included: Observations on 7/19/10 at approximately 10:45am revealed 1 dietary aide whose hair restraint did not cover the front third of the head. Observations on 7/20/10 at approximately 12:05pm revealed the dietary aide, who was plating food on the trayline, the hair restraint did not cover the front half of the head. An aide who was placing the plates of food on the trays, the hair restraint did not cover the front third of the head. An aide who was a runner between the trayline in the main kitchen and the main dining room, the hair restraint did not cover the braids on the sides of the face. Interview with the Dietary Manager on 7/20/10 at approximately 12:25pm confirmed that the Aides were not wearing the hair restraints so that the restraints covered all the hair.",2014-08-01
9983,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,221,D,0,1,2B2D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to assure that one of two sampled residents reviewed for restraints was free from any physical restraint not required to treat the resident's medical symptoms. Resident # 20 was observed using a concave mattress. There was no evidence provided that a restraint assessment was completed, nor consent obtained for the use of the mattress. The findings included: The facility admitted Resident # 3 with [DIAGNOSES REDACTED]. During the initial tour of the building on 7/19/10, Resident # 3 was identified as using a concave mattress. A mattress with elevated sides was observed on the resident's bed. Record review conducted on 7/21/10 revealed a physician order [REDACTED]."" An Occupation Screen dated 7/6/09 stated: ""Resident suffered fall attempting to tx(transfer) out of bed. Res. (Resident) has low bed c (with) rails. Pt. (patient) would benefit from concave mattress as reminder to not attempt to tx. unassisted,..."" The Director of Rehabilitation also stated the resident fell again on 7/15, proving that the mattress did not ""prevent"" the resident from getting out of bed. However, s/he verified that the facility had not considered the concept that a concave mattress could meet the definition of a restraint and no initial or subsequent restraint evaluation or consent had been obtained for its use. After the resident fell on [DATE], no subsequent evaluation was conducted related to the safety of continuing the device. A general review of the resident's physical capabilities from 7/09- 7/10 revealed the resident's ability to transfer and ambulate had fluctuated during the past year. The resident's ambulation capability reached approximately 150 feet with minimum assist and rolling walker and the ability to transfer with minimum assist with contact guarding (8/22/09 therapy discharge notes). On 7/21/10 at 9:30AM, an interview with Certified Nursing Assistant (CNA) # 1 was conducted. The CNA verified s/he was assigned to the resident. The CNA stated s/he was a ""floater"" and did not always work the same unit but had cared for the resident previously. The CNA stated the resident stood and pivoted to transfer from the bed to the chair and was able to ambulate with a rolling walker. When asked if the resident napped in the afternoon, the CNA stated the resident usually ""stayed up."" S/he further explained if the resident was put back to bed and was not tired, s/he ""would attempt to get out of bed."" Review of the medical record revealed no restraint assessment nor consent for the use of the mattress. On 7/21/10 when the facility was asked for the policy and procedure for the use of restraints, the Director of Nursing stated there was no policy - ""We follow the regulation."" A copy of the last in-service on restraints was requested and revealed the staff was educated on 2/4/10 that the definition of a restraint was ""...any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.""",2014-08-01
9984,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,441,D,0,1,2B2D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility provided infection control policy for hand hygiene (8/7/09), a facility staff member was observed to not follow facility standards related to handwashing/gloves use during the completion of a tube flush for Resident # 3. The staff member donned gloves at the start of the procedure and contaminated clean areas by failing to change gloves and/or wash hands. (One of seven treatments observed for infection control compliance.) The findings included: The facility admitted Resident # 3 on 9/27/08 with [DIAGNOSES REDACTED]. Resident # 3 was located in a room with three additional resident beds, with one community sink. On 7/19/10 at 2:45PM, an observation was conducted of Licensed Practical Nurse (LPN) # 2 performing a gastric tube flush for Resident # 3. The LPN was observed to wash his/her hands and turn on the light above the resident's bed, partially pull the bedside curtain, and apply gloves. While wearing gloves, the LPN turned the faucet on/off three times to measure the water to be used for the flush. He/she pulled the bedside curtain closed, exposed the gastric tube site, raised the head of the bed, and checked for gastric tube residual. The LPN opened the bedside curtain, returned to the sink, still wearing the same pair of glove. He/she turned on the water and rinsed the syringe. Continuing to wear the same gloves, the bedside curtain was opened, and the nurse administered the tube flush via gravity. The resident was re-draped, the bedside curtain opened, and the syringe/plunger washed and returned to storage. The LPN then removed the gloves worn during the process and washed his/her hands. On 7/21/10, the observation was shared with the Director of Nursing and the concerns not disputed. Facility policy for infection control (8/7/09) stated: ""Gloves or the use of baby wipes are not a substitute for hand hygiene.""",2014-08-01
9985,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,253,E,0,1,2B2D11,"On the days of the survey, based on observations and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior. Throughout the facility there were observations of multiple wheelchairs and gerichairs with cracked and/or torn arm pads unable to be adequately cleaned or sanitized. On 3 of 5 units there were shower chairs coated with a reddish-brown and/or black filmy substance. The findings included: During general dining observations in the main dining room on 7/19/10 at 12:28 PM, three wheelchairs were noted with cracked or torn arm pads. Observations in the small dining room next to the 400 Unit Nurses Station on 7/19/10 at approximately 12:35 PM revealed 1 gerichair and 3 wheelchairs with cracked/torn arm pads. Based on these observations, a general tour of the facility was conducted on 7/20/10 beginning at 3:45 PM. Eight wheelchairs/gerichairs were noted with cracked/torn arm pads. - Outside Room 305 (Geri-chair with both arms torn). - In the small dining room next to the 300 Unit Nurses Station (3 residents sitting in wheelchairs with one or both arm pads cracked). - Between the Business Office and Room 501 (2 wheelchairs with torn arm pads) - Between the water fountain and Room 503 (1 wheelchair with cracked arm pads). - In Room 407 (1 resident sitting in a wheelchair with a cracked arm pad). During a walking tour of the facility on 7/21/10 between 8:37 AM and 9:15 AM, the following observations of wheelchairs and gerichairs with cracked or torn arm pads were verified by the Maintenance Supervisor, Housekeeping Supervisor, and the Regional Supervisor for the contracted Housekeeping Service: - There were 2 wheelchairs and 1 gerichair in the 300 Unit hall with cracked/torn arm pads. - In the small dining room next to the 400 Unit Nurses Station there were residents sitting in 2 wheelchairs with cracked/ torn arm pads. - There was one wheelchair outside room 408 and one wheelchair in room 505 with cracked/torn arm pads. - In the 500 Unit hall there were 2 wheelchairs with cracks in the arm pads, 1 wheelchair arm with exposed green stuffing, and 1 gerichair with torn arm pads. During a general tour of the facility on 7/20/10 at 3:50 PM, the following housekeeping concerns were noted: - A shower chair in the 100 Hall Shower Room was observed with a black filmy substance on the rear side of the back support and on the underside of the seat. The legs of the chair were coated with a reddish-brown substance. - Peeling paint was observed on the Grab Bars in 2 toilet areas and the sink and shower areas in the Men's shower room located across from Room 200. Inside the shower was a shower chair with a black substance on the back side of the chair and a brown-gray substance on the chair legs. - In the shower room across from room 304 a shower chair was observed with worn and torn netting on the back. On the chassis of the chair was a yellow substance. The above observations were verified by the Housekeeping Supervisor, Maintenance Supervisor, and the Regional Supervisor for the contracted Housekeeping Service during a walking tour of the facility on 7/21/10 starting at 8:37 AM. During an interview on 7/21/10 at 11:15 AM, the Director of Nursing (DON) stated that the Certified Nursing Assistants (CNAs) were responsible for cleaning the 'touch' surfaces of the shower chairs in between uses and that housekeeping was responsible for cleaning the chairs regularly on a set schedule. During an interview on 7/21/10 at 11:50 AM, the Housekeeping Supervisor stated shower chairs were cleaned weekly on Saturday by housekeeping staff based on the copy of the cleaning schedule provided on. When asked if he/she thought the shower chairs observed were cleaned the previous Saturday, the Housekeeping Supervisor stated that the schedule had not been followed. On 07/20/10 at 1:30 PM a Quality of Life Group Interview was conducted with 13 Interviewable residents in attendance. It was noted by the surveyor during the interview that 4 of the residents present had wheelchairs with cracked and torn armrests.",2014-08-01
9986,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,356,C,0,1,2B2D11,"On the days of the survey, based on observation and interview, the facility failed to post complete staffing data. The facility failed to post the number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the actual hours worked by category for each shift on the Staff Posting forms. The facility also failed to post the data in a prominent location readily accessible to visitors and residents as required. The findings included: Observation on 7/19/10 at approximately 5:20 PM and on 7/20/10 at approximately 10:50 AM revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting forms for the 7:00 AM - 3:00 PM shift, the 3:00 PM - 11:00 PM shift or the 11:00 PM - 7:00 AM shift on those dates but were posted as ""Licensed Nurses."" During observations throughout the survey, the Staff Posting forms were posted behind the nursing stations and not displayed in a prominent location readily accessible to visitors and residents. Copies of the Staff Posting forms for the last 30 days were requested on 7/20/10. Review of these forms revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting form on any of these dates as required but were posted as ""Licensed Nurses."" Review of the Staff Posting forms for the last 31 days revealed that on all of the last 31 days, the Staff Posting forms indicated 6 nurses for the 3:00 PM - 11:00 PM shift. Review of the 24 Hour Assignment sheets revealed that on 22 of the last 31 days, 6 nurses worked from 3:00 PM - 7:00 PM but only 5 nurses worked from 7:00 PM - 11:00 PM. During an interview on 7/21/10 at approximately 11:30 AM, the Director of Nursing (DON) confirmed that the posting did not list the Licensed Nurses by category or include the actual hours worked. The DON also confirmed that the Licensed Nurses worked 12 hour shifts and that the number of nurses that worked between 3:00 PM - 7:00 PM and 7:00 PM - 11:00 PM was different and was not reflected on the Staff Posting form. She/He also verified that the Staff Posting form was posted behind each of the nursing stations but not in a prominent area accessible to visitors and residents.",2014-08-01
9987,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,167,C,0,1,2B2D11,"On the days of the survey, based on observations and interview, the facility failed to place the most recent state survey results in a location readily accessible to residents and visitors, and there were no notices posted regarding the availability of the survey results. The findings included: Observation on 7/19/10 at approximately 12:45 PM revealed a white binder entitled ""DHEC (Department of Health and Environmental Control) Survey"" sitting on the receptionist's desk back behind a lamp. The survey results were not readily accessible to residents or visitors. Observation on 7/20/10 at 11:35 AM revealed the receptionist sitting at a desk near the entrance of the facility. The Director of Nursing (DON) was standing next to her/him. A white binder entitled ""DHEC Survey"" was sitting on the desk behind a lamp a couple feet away to the right and behind where the receptionist was sitting. When questioned by the surveyor if anyone had asked to see the survey results, the receptionist stated that sometimes residents or visitors would ask to see them. When questioned if the survey results were readily accessible where they were located if someone had to ask to see them, the DON moved the survey results to the front of the desk below the countertop. During a general tour of the facility on 7/20/10 from 3:45 PM to 4:45 PM, observations revealed there were no notices posted regarding availability of the most recent state survey results.",2014-08-01
9988,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,468,E,0,1,2B2D11,"On the days of the survey, based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side. The findings included: During a walk through of the facility on 7/20/10 beginning at 3:45 PM and during a tour with the Maintenance Supervisor on 7/21/10 at 8:37 AM, loose and/or missing handrails were observed and confirmed in the following areas: - Between the lobby and the 100 Hall Nursing Station there were no handrails on one side. The handrails on the other side were loose. The hall exiting to the courtyard had no handrails on either side. - Between Room 111 and the exit door, there was approximately 6 feet of handrail missing. - Between the Men and Women's Shower Room across from Room 200, there was a handrail missing. - There was a loose handrail outside of Room 208. - There was a loose handrail between the Men/Women's Restroom and Shower on the 300 Hall. - There was an 11 foot section of handrail that was missing in the breezeway near the 400 Hall Nursing Station. - There were several sections of handrail missing in the hall leading to the dining area between the 400 and 500 Halls (7 feet on one side, 4 feet on the other, and one full section of 11 feet on one side). - There were no handrails for approximately 3 feet outside the Social Services Office on the 500 Hall. - There were no handrails between Room 504 and the fire door for approximately 2 feet.",2014-08-01
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
9996,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2011-04-12,226,G,1,0,2BTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review, interviews and review of the facility Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, the facility failed to implement written policies and procedures to prevent neglect. Resident #1 was transferred inappropriately on 3/7/2011 resulting in injury. The incident was not reported or throughly investigated until 3/16/2011. The Certified Nursing Assistant (CNA) continued to work from the date of the incident until 3/16/2011. The findings included: The facility admitted Resident #1 on 4/20/2004 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed a problem area of falls with approaches including ""... 2 person transfer."" Review of the CNA Care Plan revealed ""... Transfer: Extensive x 2."" Review of the Nurse's Notes revealed on 3/8/2011 at 12 AM, ""Bruise noted to R (right) and L (left) lower legs... Denies pain or discomfort. Dr. notified."" Further review revealed the bruises remained to the bilateral lower legs through April 7 to April 9, 2011. Treatment continued to the resident's legs during that time. Review of the Incident Report dated 3/7/2011 and confirmed by the Director of Nurses documented bruising to legs. Under the ""describe what happened"" area only an asterisk was present. The DON stated that asterisk meant there was documentation however she was unable to obtain that documentation because the incident report was closed out and she did not have access. Under comments the CNA was counseled because Resident #1 was a 2 person transfer. Review of the 24 Hour Report dated 3/16/2011 revealed the incident occurred on 3/7/2011. The description of events stated, ""On 3/16/2011 the resident's family reported that the resident sustained [REDACTED]."" During an interview on 4/12/2011, CNA #1 stated that she was working on 3/7/2011 and was assigned to Resident #1. She stated that she transferred Resident #1 by herself. However, she stated on 3/7/2011 she asked for help from CNA #5. CNA #1 stated that on 3/18/2011 the Administrator informed her that she was ""let go"" because she transferred Resident #1 by herself. Review of the ""as worked schedule"" revealed CNA #1 was assigned to Resident #1 on 3/7/2011. CNA #1 was also assigned to work on 3/10, 3/14-3/16/2011, after the incident had been reported to administration on 3/7/2011. Review of the Time Card revealed CNA #1 worked from 7 AM to 3:03 PM on 3/7/2011. CNA #1 also worked 3/10 from 7 AM to 3 PM; 3/14 from 7 AM to 3 PM; 3/15 from 7 AM to 3 PM and 3/16 from 7:04 AM to 11:28 AM. Review of the 5 Day Report dated 3/23/2011 revealed corrective actions put in place were ""inservice all current staff on abuse and neglect. Coordinate an inservice for all caregivers with therapy on transfers."" The Summary was ""We feel that (Resident #1's) bruises were caused by a CNA (CNA #1) not following the CNA Care p\Plan for (Resident #1) and performed a transfer by herself."" An inservice was conducted on 3/28/2011 regarding Abuse/Neglect. The staff present in the building attended the inservice. No other staff members were inserviced. An inservice was conducted on 4/7/2011 regarding transfers. Eight staff members attended. During an interview on 4/12/2011, the Administrator and DON stated that the injury occurred on 3/7/2011. Both stated that they were aware of the injury and were aware that the injury was a result of CNA #1 improperly transferring Resident #1. The Administrator confirmed that the incident was not reported or investigated until 3/16/2011 when the family member stated that the injury was caused by abuse. The Administrator further stated that he did not think the fact that CNA #1 transferred the resident improperly and that the transfer caused injury to Resident #1 was neglect. The Administrator confirmed the inservice related to proper transfers only had 8 staff members in attendance. During an interview on 4/12/2011 at 5 PM, Resident #1's responsible party (RP) stated that the CNAs were rough with Resident #1. She also stated that on 3/7/2011 she reported the bruising to Resident #1's legs to the nurse. The RP stated that she was aware that CNA #1 transferred Resident #1 by herself. She then stated that the Administrator was aware of the incident on 3/8/2011. The RP stated that the Administrator informed her that he would investigate and suspend CNA #1. The RP stated that CNA #1 continued to care for Resident #1 after the Administrator assured her that he was investigating the incident. On 3/16/2011, the RP stated that Resident #1's legs looked bad and that she met with the Administrator immediately. She stated that the Administrator looked at the resident's legs and re-opened the investigation, terminated the CNA and reported the CNA to the registry. Review of the facility Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property revealed the following: ""Neglect: the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness."" ""Protection: Patients will be protected from harm during an investigation. Partners suspected of taking actions that would cause potential harm to a patient or other partners will be immediately placed on administrative leave pending the result of investigation."" ""Reporting: All allegations of possible abuse, neglect or misappropriation of patient property will be immediately assessed to determine the appropriate direction of the investigation. External reporting to the stated survey and certification agency and all other stated required agencies will follow Federal, individual State laws and licensing regulations."" ""Investigation: The investigation is conducted immediately under the following conditions: i. when it is identified that an alleged incident may have occurred, ii. as soon as any partner has knowledge and reports an alleged event.""",2014-08-01
9997,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2011-04-12,323,G,1,0,2BTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review, review of the facility Abuse Policy, and interviews, the facility failed to ensure one of four residents were transferred appropriately. Resident #1 transferred by a Certified Nursing Assistant (CNA) inappropriately resulting in injury to Resident #1's legs. The findings included: The facility admitted Resident # 1 on 4/20/2004 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 4/12/2011 revealed the resident up in a wheelchair at the nurses' station socializing with other residents. Resident #1 had long sleeves and arm protectors in place as well as leg protectors. Review of the Care Plan revealed a problem area of fall with approaches including ""... 2 person transfer."" Review of the CNA Care Plan revealed ""... Transfer: Extensive x 2."" Review of the Nurses' Notes for 3/8/2011 at 12 AM stated, ""Bruise noted to R (right) and L (left) lower legs... Denies pain or discomfort. Dr. notified."" Further review revealed the bruises remained to the bilateral lower legs through April 9, 2011. Treatment continued to the resident's legs during that time. Review of the physician's orders [REDACTED]."" A telephone order was written on 3/16/2011 to ""apply Polymen non adhesive to bruises to bilateral legs (lower) wrap with kling until bruises healed."" Review of the Incident Report dated 3/7/2011 and confirmed by the Director of Nurses documented bruising to legs. Under the ""describe what happened"" area only an asterisk was present. The DON stated the asterisk meant there was documentation however she was unable to obtain that documentation because the incident report was closed out and she did not have access. Under comments the CNA was counseled because resident was a 2 person transfer. Review of the 24 Hour Report dated 3/16/2011 revealed the incident occurred on 3/7/2011. The description of events stated, ""On 3/16/2011 the resident's family reported that the resident sustained [REDACTED]."" Review of the 5 Day Report dated 3/23/2011 revealed corrective actions put in place were ""inservice all current staff on abuse and neglect. Coordinate an inservice for all caregivers with therapy on transfers."" The Summary was ""We feel that (Resident #1's) bruises were caused by a CNA not following the CNA Care Plan for (Resident #1) and performed a transfer by herself."" During an interview on 4/12/2011, CNA #1 stated that she was working on 3/7/2011 and was assigned to Resident #1. She stated that she transferred Resident #1 by herself. However, she stated on 3/7/2011 she asked for help from CNA #5 (Review of the time care for CNA #5 showed she was not working 3/7/2011). CNA #1 stated that on 3/18/2011 the Administrator informed her that she was ""let go"" because she transferred Resident #1 by herself. During an interview the Physical Therapy Director stated that all residents were evaluated annually and as needed for appropriate transfers. She stated that Restorative Aides, CNAs and Nurses all report to therapy regarding each resident's transfer capabilities. She also stated that therapy makes the recommendations as to what type of transfer and the degree of assistance required. She further stated that she expected all therapy recommendations to be followed at all times. During an interview on 4/12/2011, the Administrator and DON stated the injury occurred on 3/7/2011. Both stated they were aware of the injury and were aware that the injury was the result of CNA #1 improperly transferring Resident #1. The Administrator confirmed that the incident was not reported or investigated until 3/16/2011 when the family member stated that the injury was caused by abuse. The Administrator further stated that he did not think the fact that CNA #1 transferred the resident improperly and that the transfer caused injury to Resident #1 was neglect. During an interview on 4/12/2011 at 5 PM, Resident #1's responsible party (RP) stated that the CNAs were rough with Resident #1. She also stated that on 3/7/2011 she reported the bruising to Resident #1's legs to the nurse. The RP stated that she was aware that CNA #1 transferred Resident #1 by herself. She then stated that the Administrator was aware of the incident on 3/8/2011. The RP stated that the Administrator informed her that he would investigate and suspend CNA #1. The RP stated that CNA #1 continued to care for Resident #1 after the Administrator assured her that he was investigating the incident. On 3/16/2011, the RP stated that Resident #1's legs looked bad and that she met with the Administrator immediately. She stated that the Administrator looked at the resident's legs and re-opened the investigation, terminated the CNA and reported the CNA to the registry. Review of the facility's Abuse Policy and Procedure revealed the following: ""Neglect: the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness."" ""Protection: Patients will be protected from harm during an investigation. Partners suspected of taking actions that would cause potential harm to a patient or other partners will be immediately placed on administrative leave pending the result of investigation."" ""Reporting: All allegations of possible abuse, neglect or misappropriation of patient property will be immediately assessed to determine the appropriate direction of the investigation. External reporting to the stated survey and certification agency and all other stated required agencies will follow Federal, individual State laws and licensing regulations."" ""Investigation: The investigation is conducted immediately under the following conditions: i. when it is identified that an alleged incident may have occurred, ii. as soon as any partner has knowledge and reports an alleged event.""",2014-08-01
9998,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-02-09,282,D,0,1,OETN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to implement the plan of care for 3 of 15 sampled residents. Resident #1 did not have 4 inch floor mats and padded furniture, Resident #5 did not have the bed alarm attached, and Resident #7 did not have padded furniture per the care plans. The findings included: The facility originally admitted Resident #1 on 5/11/06 with [DIAGNOSES REDACTED]. Review of the medical record on 2/08/11 revealed a current physician's orders [REDACTED]. Pad Locker..."" Review of the medical record revealed Resident #1 sustained a fall from a Broda chair on 12/05/10 while ""trying to get to his locker"". He also sustained a fall from the bed onto the bedside mat on 12/25/10 resulting in a skin tear to the right lower arm, and sustained a fall from the bed onto the bedside mat on 1/22/11. Further review of the medical record revealed the current care plan with latest review date of 2/08/11 identified risk for ""further falls R/T (related to) impaired mobility with balance problem. Hx (history) of falls."" Interventions documented on the care plan included ""4 (inch) matts bilaterally on floor at bedside...Furniture padded for safety."" Observation of Resident #1's room on 2/08/11 at approximately 3:00 PM revealed standard floor mats beside the resident's bed. The mats appeared to be approximately 1 to 1 1/2 inches thick. Further observation revealed the edges of the closet/locker on the left side of the room had padding on the edges; however, the edges of the closet/locker on the right side of the room were not padded. There was no other furniture or structure near the resident's bed. Observation of the room again on 2/09/11 at approximately 2:00 PM revealed the mats were folded and placed on their sides near the walls. Resident #1 was not in the bed at the time of either observation. On 2/09/11 at approximately 4:00 PM, Licensed Practical Nurse (LPN) #2 was asked to observe the mats and closets/lockers in Resident #1's room. The surveyor informed LPN #2 that Resident #1 had a physician's orders [REDACTED]. LPN #3 confirmed that the floor mats were not 4 inches thick and the edges of the closet/locker on the right side of the room were not padded per the orders and care plan. On 2/09/11 at approximately 4:30 PM, the Director of Nursing (DON) confirmed these findings. The facility admitted Resident #7 on 06/02/08 with [DIAGNOSES REDACTED]. Record review on 2/8/11 at 4:55 PM revealed the Resident's Care Plans for 3/11/2010 through 06/09/2010 and 01/20/2010 through 04/20/2011 noted under ""Problems"", ""High risk for falls and related injuries related to history of falls with injury. Also at increased risk for falls related to [DIAGNOSES REDACTED]. The ""Goal"" for both care plans stated ""Resident will be free from serious fall related injuries; fxs (fractures)or injury requiring suture(s)."" Approach #4 on each care plan stated, ""Padded edge of bedside locker and night stand."" On 2/09/11 at 10:00 AM and 3:10 PM observations were made of the resident's room and there was no padding on the edge of the nightstand or the locker. On 02/09/10 at 3:10 PM Licensed Practical Nurse #1 was interviewed about the lack of padding on the resident's locker and nightstand. She revealed the resident had been moved from the room across the hall on August 06, 2010 and at that time the padding was not put in place in the new room. The facility admitted Resident #5 on 02-27-07 with [DIAGNOSES REDACTED]. Record review on 02-08-11 at 3:15 PM of the Cumulative physician's orders [REDACTED]. Further record review on 02-08-11 at approximately 3:30 PM of the Activities of Daily Living (ADL) Flow sheet revealed the following: ""October 2010 ADL Flow sheet AM (morning): Alarms: N/A (No Alarms) for dates 10-01-10 to 10-29-10, 10-31-10. Date of 10-30-10: Blank. October 2010 ADL Flow sheet PM (evening) and Night: Alarms: N/A for dates 10-01-10 to 10-31-10. November 2010 ADL Flow sheet AM: Alarms: N/A for dates 11-01-10 to 11-11-10, 11-13-10 to 11-25-10. Dates of 11-12-10, 11-26-10 to 11-30-10: Blank. November 2010 ADL Flow sheet PM: Alarms: N/A for dates 11-01-10 to 11-30-10. November 2010 ADL Flow sheet Night: Alarms: Date of 11-30-10: Blank. January 2011 ADL Flow sheet AM: Alarms: Date of 01-05-11: Blank. January 2011 ADL Flow sheet PM: Alarms: Dates of 01-07-11, 01-12-11 to 01-13-11, 01-18-11, 01-24-11, 01-27-11: Blank. January 2011 ADL Flow sheet Night: Alarms: N/A for dates 01-05-11 to 01-11-11, 01-13-11 to 01-31-11. Date of 01-12-11: Blank. February 2011 ADL Flow sheet AM: Alarms: Dates of 02-01-11 to 02-09-11: Blank. February 2011 ADL Flow sheet PM: Alarms: N/A for dates 02-01-11, 02-03-11, 02-06-11 to 02-07-11"". Additional record review on 02-08-11 at approximately 4:55 PM of Resident #5's Care Plan dated 08-12-10 and Resident Care Plan Review dated 01-20-11 to 04-20-11 relating to Problem #7: ""At risk for falls relating to (r/t) his cognitive deficits, lack of safety awareness and decreased ambulation abilities"" stated, ""Approach/Frequency: #10. Bed Alarm when in bed"". During interview on 02-08-11 at 5:10 PM with Registered Nurse (RN) #1, she, after chart review, verified the physician's orders [REDACTED]. After RN #1 checked Resident #5's bed, she verified a Bed Alarm was not present. During interview on 02-09-11 at 12:00 PM with the Minimum Data Set (MDS) Coordinator, she, after chart review, confirmed Resident #5's Resident Care Plan with start date of 08-12-10 had been reviewed on 10/28/10 and 1/20/11 and the need for the bed alarm had been continued to 04-20-11. The Nursing Guide to Care also documented the resident required ""Special Equipment: Bed Alarm"".",2014-08-01
9999,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-02-09,157,D,0,1,OETN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interview, the facility failed to notify the responsible party of a change in condition for 1 of 18 sampled residents.(Resident #3) The facility failed to notify the responsible party of the resident's urinary tract infection and subsequent treatment on two occasions. The findings included: The facility admitted Resident #3 on 4/9/08 with [DIAGNOSES REDACTED]. Record review on 2/8/11 revealed physician orders [REDACTED]. Further record review of the nurse's notes and social services' notes revealed no documented evidence that the responsible party had been notified of the resident's urinary tract infections and treatments. During an interview on 2/9/11 at 6:00 PM, RN(Registered Nurse)#2 confirmed that the responsible party was not notified on either occasion of the resident's change in condition and treatment.",2014-08-01
10000,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-02-09,280,D,0,1,OETN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interview, the facility failed to update care plan interventions for 2 of 15 sampled residents. (Residents #8 & #12) Care plans were not revised for Resident #8 for a change in Tube Feeding flow rate and bolus feedings and Resident #12 for current diet and [MEDICAL TREATMENT] days. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review on 2/8/11 revealed a physician's orders [REDACTED]. Further review of the resident's care plan revealed the additional bolus feeds twice a day had not been added and that care plan #1 had not been updated to reflect the resident receiving [MEDICATION NAME] 1.5 @ 75 cc/hour. The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Record review on 2/9/11 revealed a physician's orders [REDACTED]. and days of [MEDICAL TREATMENT] had not been updated to reflect the resident's current status. During an interview on 2/9/11 at 6:00 PM, RN #2 confirmed that the care plans for Resident #8 and Resident #12 had not been updated to reflect their current status.",2014-08-01
10001,C M TUCKER NURSING CARE CENTER / STONE & FEWELL,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-02-09,441,D,0,1,OETN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On one day of the survey, based on observation, record review, interview, and review of facility policies titled ""Catheter Care (Foley)"" and ""Handwashing"", the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 of 3 residents observed for catheter care. After completion of Resident #6's Foley Catheter care, a facility staff member failed to wash her hands after she removed her gloves. In addition, the staff member donned clean gloves, bagged the trash, stored supplies in the supply cart, and then disposed of the trash without washing of her hands afterwards. The findings included: The facility admitted Resident #6 on 10-04-07 with [DIAGNOSES REDACTED]. On 02-08-11 at 11:00 AM, Certified Nursing Assistant (CNA) #1 entered Resident #6's room to perform Foley Catheter care. After CNA #1 completed the Foley Catheter care, she removed her gloves, donned clean gloves without washing her hands, and replaced Resident #6's brief. CNA #1 then removed her gloves, touched her glasses, donned clean gloves again without washing her hands. She was observed to then gather the catheter supplies, bag the trash, and to leave Resident #6's room. CNA #1 removed her gloves and without washing her hands, stored the catheter supplies in a supply cart outside Resident #6's room door and disposed of the trash in the trash container outside the resident's room. CNA #1 proceeded to obtain a lift to assist Resident #6 out of bed without washing her hands. Review of facility provided policy titled ""Catheter Care (Foley)"" on 02-09-11 at approximately 12:30 PM revealed ""Procedure: #9. Remove gloves and discard into plastic bag. Procedure #10. Wash and dry your hands thoroughly. Procedure #11. Arrange covers and leave resident in a comfortable position. Procedure #12. Discard disposables into hall trash container and washcloth in soiled linen container. Procedure #13. Perform hand hygiene"". Review of the facility policy titled ""Handwashing"" on 02-09-11 at approximately 12:30 PM revealed, ""Purpose: To help prevent cross-contamination and control infection by washing hands"". During an interview on 02-09-11 at 1:00 PM with CNA #1, she verified she had failed to wash her hands after she removed her gloves and further failed to wash her hands after the supplies had been stored and the disposal of the trash. She stated, ""Oh, I sure didn't. Yes, you're right. I forgot all about it"".",2014-08-01
10002,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2014-04-09,490,J,0,1,KSUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review, interview, review of facility policies that were not fully implemented, the facility failed to use its resources effectively and efficiently to maintain the highest practicable mental and psychosocial well-being for Resident # 164. The resident was able to attempt the ingestion of potentially hazardous products on four occasions. Lack of sufficient documentation and or communication resulted in Administration denying being informed. The systemic failure placed all cognitively impaired, mobile residents at risk for harm. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervision to prevent potentially serious harm and or injury. The findings included: Record review on 4/7, 4/8 and 4/9/14 revealed Resident # 164 had successfully attempted ingestion of potentially harmful substances starting on 12/26/13 and most recently documented on 4/6/14. During the investigation of the incidents, it was revealed the resident;s careplan had not been updated to include any of the incidents; a careplan that was in place related to generalized safety measures was not followed; a plan to prevent reoccurrence(s) had not been developed; facility policies and procedures had not been followed related to documentation and reporting; and Administration denied being fully aware of 3 of 4 incidents. As a result of the systemic Administrative failure to be informed, investigate and address the concerns placed not only Resident # 164 at risk for further injury and or harm but also placed all cognitively impaired, behavioral, mobile residents at risk. It was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of ""J"". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-490 was removed and the citation lowered in scope and severity to a ""D"".",2014-08-01
10003,LILA DOYLE AT OCONEE MEDICAL CENTER,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2014-04-09,520,J,0,1,KSUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to identify and develop a plan of action to correct deficient practices. The facility failed to identify the failure of staff to report and follow facility policy related to repeated events that had the potential to affect the safety of Resident # 164. The systemic failure of the facility to have a system in place to identify potentially serious behaviors placed all cognitively impaired, mobile resident at risk for harm or injury. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervison to prevent potentially serious harm and or injury. The findings included: Based on record review and interview, it was determined that Resident # 164 had on four occasions attempted to ingest potentially harmful items. There was no evidence that the facility had identified the documented concern, nor developed a plan of action to assure the safety of the resident, until it was brought to their attention during the survey process. This was verified during a meeting on 4/8/14 at approximately 4 PM with multiple members of the Interdisciplinary Team, including but not limited to members of Administration. During the meeting, it was confirmed the team was not aware of the repeated occurrences and therefore had not developed an action plan. On the days of the Recertification and Extended Survey, based on observations,full and/or limited record reviews, interviews,and review of the facility policies, it was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of ""J"". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. In addition, CFR 483.75 F-520 cited at a ""J"" related to the failure of staff to report and follow facility policy related to repeated events that had the potential to affect the safety of Resident # 164. The systemic failure of the facility to have a system in place to identify potentially serious behaviors placed all cognitively impaired, mobile resident at risk for harm or injury. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-520 was removed and the citation lowered in scope and severity to a ""D"".",2014-08-01
10004,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2010-08-04,441,E,0,1,3N7711,"On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Observations of processing resident's personal laundry and interview with staff of the Laundry Department revealed failure to ensure personal laundry was sanitized appropriately per infection control guidelines. The findings included: On 8/4/10 at 10AM, an observation of the facility laundry department was conducted. Upon entering, observations revealed 2 of the 3 washing machines in the process of washing clothes. The washing machines had a display that identified various functions while running. One of the functions allowed display of the current water temperature. Observations of the temperature of the washing machine used for colored clothes displayed a temperature of the water at 53 degrees Farenheit . The temperature continued to read 53 degrees Farenheit on two additional reviews of the washing machine's water. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. On 8/4/10 at 10 :03 AM, an interview was conducted with the Housekeeping Supervisor, identified as in charge of the laundry. He/She confirmed the water temperature and stated no other disinfecting chemicals were used for resident's laundry.",2014-08-01
10005,UNIHEALTH POST ACUTE CARE - BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2011-06-08,463,E,0,1,21LW11,"On the days of the survey, based on observation and interviews, the facility failed to provide a functioning call system in the hydrotherapy room. The findings included: During the Initial Tour of the facility on 6-7-11 beginning at approximately 9:10 AM, it was noted that the whirlpool bath and toilet area (""hydrotherapy room"") had no functioning call system. There was a covered electrical box near the toilet where a call light would have been installed. A hand-operated manual bell was noted on top of a tall metal cabinet in the corner of the room. Bathing articles were near the tub. During an interview on 6-7-11 at 11:10 AM, Certified Nursing Assistant #1 verified that the only way to call for assistance was by use of the manual bell. She stated that the room was used at least two to three times per week, but that residents were not toileted/bathed in the room without an attendant present. During an interview on 6-8-11 at 9:05 AM, the Senior Nurse Consultant observed the bathing room and verified that there was no call system in place. She did see the hand bell on top of the cabinet in the corner of the room. She stated that renovations had been scheduled to include installation of a call system, but this had not been done.",2014-08-01
10006,UNIHEALTH POST ACUTE CARE - BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2011-06-08,371,E,0,1,21LW11,"On the days of the survey, based on observation and interview, the facility failed to remove from inventory skim milk that had passed its expiration date. The findings included: Observation on 6/7/11 at approximately 9:10am revealed 2 half pint cartons of skim milk with an expiration date of 6/4/11 and 2 crates (50 half pint cartons each) of skim milk with an expiration date of 6/6/11 in the milk cooler. Observation at 11:20am revealed the above situation was ongoing. Interview with the Certified Dietary Manager (CDM) at the time of the second observation indicated that milk had been delivered the day before and that the driver was suppose to check the expiration dates at the time of delivery. The CDM further indicated that she usually checked the milk for expiration dates but was not working the day the milk was delivered. There was no one else assigned to check expiration dates. Review of the dietary policies and procedures on 6/8/11 with the CDM revealed no policy/procedure for checking the expiration date of food items.",2014-08-01
10007,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,156,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of Medicare Denial Letters, Liability Notices, Advanced Directives, and interviews, the facility failed to provide the required Liability Notice ( Form or one of five other approved forms) to Resident A upon completion of therapy, but having Medicare days left and remaining in the facility. There was no evidence that Advanced Directives had been discussed with Resident #8 at time of admission. ( 1 of 3 residents reviewed for issuance of the correct liability notice and 1 of 13 residents reviewed for advanced directives.) The findings included: Review of Medicare Denial letters with the Business Office Manager on 1/25 and 1/26/11, revealed that Resident A had not been issued a Liability Notice (Form or one of the five other approved forms) upon completion of her therapy. The resident had Medicare days remaining and continued to reside in the facility. The Business Office Manager had issued Form but stated she was not aware that she also needed to issue the other form. The facility initially admitted Resident #8 on 12-29-09 and readmitted him on 7-5-10 and 12-9-10. Record review on 1-24-10 at 3 PM revealed no documentation under the ""Advance Directives"" tab in the medical record. There was no evidence found in the medical record that the resident had been afforded the right to formulate his own advance directive. The current physician's orders [REDACTED]. Review of the 7-5-10, 9-29-10, and 12-9-10 Admission Nursing Assessments revealed that the resident was alert and oriented to person, place, and time, and had no memory problems. The 7-16-10 Admission Minimum Data Set (MDS) Assessment noted no short- or long-term memory deficits. The resident was noted as independent with cognitive skills for daily decision-making. In the most recent Quarterly MDS (Assessment Reference Date of 11-28-10), the resident scored ""15"" on the Brief Interview for Mental Status (BIMS), indicating that he was ""cognitively intact"". During an interview on 1-25-11 at 3:05 PM, the MDS Coordinator reviewed the medical record and verified the coding of the MDS Assessments as noted. When she was unable to locate advance directives forms in the record, she stated she was aware that the resident had been a ""DNR (Do Not Resuscitate)"" during a previous admission. The MDS Coordinator noted that Social Services was responsible for completing the advance directive documentation and placing them on the chart. During an interview on 1-26-11 at 10 AM, Social Services stated that she had made no attempt to speak with the resident on admission related to his preferences/advance directives. She stated one physician had signed a form indicating that the resident was unable to make health care decisions. However, she sometimes had to wait months to obtain a concurring physician's signature. Social Services further stated that this was the reason the resident remained a ""full code"". Review of the physician certification of inability to consent noted the resident had Dementia. Further review of the medical record revealed the cumulative [DIAGNOSES REDACTED].",2014-08-01
10008,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,164,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, review of ""Assisting in Long Term Care"", Second Edition, Section 5, page 295, Procedure 21 Giving Female Perineal Care and review of the facility policies entitled ""Peri Care"" (undated) and ""Catheter Care"" (undated), the facility failed to provide care in a way so as to maintain privacy of body for one of five residents observed for treatments. Staff failed to sufficiently drape/cover Resident #7 during treatments so as to ensure privacy/dignity. The findings included: The facility admitted Resident #7 on 10-19-06 and readmitted her on 6-10-10 with [DIAGNOSES REDACTED]. Prior to observation of treatments on 1-25-11 at 3:10 PM, Certified Nursing Assistant (CNA) #3, assisted by CNA #1, uncovered the resident from the epigastric area to the ankles. CNA #3 provided [MEDICAL CONDITION] care, Foley catheter care, and suprapubic catheter care, leaving the bedside multiple times to cleanse her hands in the resident's bathroom. The CNA also left the room to summon the nurse to check an area of compromised skin integrity in the resident's perianal area. Neither CNA made any attempt to cover or drape the resident at any time. The resident remained exposed as noted above throughout the three treatments. At 4 PM on 1-25-11, CNA #3 confirmed that the resident had been left exposed throughout the time it took to complete the three treatments. She stated, ""When you're working with one part, you should leave the other part covered."" Review of the facility policy entitled ""Peri Care"" (undated), provided by the facility on 1-25-11 at 4:30 PM, revealed the following: ""...6....Note: If you must leave the area for any reason before the care is complete drape the resident..."" Review of the facility policy entitled ""Catheter Care"" (undated) on 1-25-11 revealed: ""...4. d. Drape resident."" Review of ""Assisting in Long Term Care"", Second Edition, Section 5, page 295, Procedure 21 Giving Female Perineal Care, revealed instructions to: ""5. Cover resident...9. Position bath blanket (drape) so only the area between the legs is exposed.""",2014-08-01
10009,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,225,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of allegations of abuse/neglect (""[MEDICATION NAME]""), the facility failed to provide evidence of a thorough investigation for one of three allegations reviewed. (Resident D) The findings included: As part of the Entrance Conference Checklist, the facility provided the files of reportable allegations of abuse/neglect that had occurred since the previous survey. Review of Resident D's file on 1-26-11 at 12:30 PM revealed that the resident reported physical (rough handling) and possibly verbal abuse by two Certified Nursing Assistants to a staff member on 1-10-11. Written statements were obtained by the alleged perpetrators and six residents were questioned regarding the care they had received the day of the incident. However, there were no staff interviews or statements to determine if anyone had witnessed the reported behavior. During an interview on 1-26-11 at 1 PM, the Director of Nurses reviewed the file and verified that no staff interviews had been obtained as the resident was alert and oriented.",2014-08-01
10010,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,278,E,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, Minimum Data Set (MDS) reviews, and interviews, the required resident interview related to pain in Section J of the MDS had not been attempted for Resident's #1, #3, #4, # 6, # 8, # 9, #10, and #13. Limitations of Range of Motion had not been coded for Resident # 1. ( 8 of 11 sampled residents reviewed for MDS accuracy.) The findings included: The facility admitted Resident #3 on 7/27/09 with [DIAGNOSES REDACTED]. Medical record review and MDS review on 1/24/11 revealed that Section J, related to pain and a required resident interview section, had not been completed for this resident. The resident was able to voice his needs and could ask for pain medication as documented in Section B0600, B0700, and J0800 of the MDS. The facility admitted Resident #4 on 9/28/10 with [DIAGNOSES REDACTED]. Medical record review and MDS review on 1/24/11 revealed that Section J, related to pain and a required resident interview section, had not been completed for this resident. The resident was able to voice his needs and could ask for pain medication as documented in Section B0600, B0700, and J0800 of the MDS. The facility admitted Resident #6 on 3/21/01 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review and MDS review on 1/24/11 revealed that Section J, related to pain and a required resident interview section, had not been completed for this resident. The resident was able to voice his needs and could ask for pain medication as documented in Section B0600, B0700, and J0800 of the MDS. Section C related to Cognitive Patterns and Section D related to Mood also had not been completed for this resident. The resident was able to speak and make her wishes known. The facility admitted Resident #10 on 11/10/04 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review and MDS review on 1/24/11 revealed that Section J, related to pain and a required resident interview section, had not been completed for this resident. The resident was able to voice his needs and could ask for pain medication as documented in Section B0600, B0700, and J0800 of the MDS. The Coordinator stated she did not understand or realize that the residents had to be interviewed or at least attempted to interview for the Section J on pain. The facility initially admitted Resident #8 on 12-29-09 and readmitted him on 7-5-10 and 12-9-10. Review of the Quarterly MDS Minimum Data Set with an assessment reference date of 11-28-10 on 1-24-11 at 3 PM revealed that Section J- Health Conditions was not completed. The Pain Assessment interview had not been conducted and the Staff Assessment for Pain was incomplete. J0200 was coded as ""0"" indicating that the pain interview should not be conducted because the resident was ""rarely/never understood"". In fact, this resident was coded under B0700 as ""0"" (understood) and scored ""15"" on the Brief Interview for Mental Status (BIMS) on the same assessment, indicating that he was ""cognitively intact"". After reviewing the assessment with the surveyor on 1-26-11 at 9:15 AM, the MDS Coordinator confirmed the above information and stated that she did not have a good understanding of how the form needed to be completed. The facility admitted Resident #13 on 11-27-09. Review of the Quarterly Minimum Data Set with an assessment reference date of 12-12-10 on 1-26-11 at 8:30 AM revealed that resident interviews in Section C - Cognitive Patterns, Section D - Mood, and Section J- Health Conditions were not completed. C0100, D0100, and J0100 were all coded as ""0"", indicating that the resident interviews should not be conducted because the resident was ""rarely/never understood"". However, B0700 was coded to indicate that the resident was ""sometimes understood"" and all interviews should have been attempted. During an interview on 1-26-11 at 9:15 AM, the MDS Coordinator reviewed the interview coding and stated that she did not realize she had to attempt the interviews as the resident was confused. She further stated that she did not have a good understanding of how the form needed to be completed and would review the RAI Manual. The facility admitted Resident #1 on 7/12/10 with [DIAGNOSES REDACTED]. Observations on 1/24/11 and 1/25/11 revealed Resident #1 answering questions and speaking clearly. Review of the Quarterly MDS assessment dated [DATE] on 1/26/11 revealed in section B0700 that Resident #1 had been coded as being ""Usually understood"" and that she ""Usually understands"". Section B0600 had documented her speech as being clear. Review of section J0200 (Should Pain Assessment Interview be Conducted?) had been marked ""No (Resident is rarely/never understood)"". Section J0300, the Pain Assessment Interview, had been skipped; and Section J0800, (Staff assessment for Pain) had been marked that none of the indicators of pain or possible pain had been observed or documented in the last 5 days. During an interview on 1/26/11 at approximately 12:00 Noon, the MDS Coordinator verified the resident was able to carry on a conversation and stated she had not realized the pain interview should have been conducted for this resident. She stated she would now attempt pain interviews on all residents unless comatose. Observations on 1/25/11 revealed Resident #1 wearing bilateral AFO's on her feet and elbow splints. Review of section G0400 of the Quarterly MDS assessment dated [DATE] revealed Resident #1 had been coded as having ""No impairment"" in functional limitations in range of motion that interfered with daily functions or placed resident at risk of injury. Review of the Plan of Care dated 1/7/11 revealed an entry for ""Self Care Deficit in ADL's (Activities of Daily Living) related to needs total care for ADLS secondary to HX (History)[MEDICAL CONDITION], Dementia, [MEDICAL CONDITION]. (With) Contractures-potential for further"". Under Approaches/Interventions was listed ""ROM (Range of Motion) with ADL Care Daily... Therapy as ordered for contracture management (and) prevention..."". There was also an entry dated 1/4/11 that stated ""elbow splint alt(ernate) (right) and (left) (with) turning..."". Another approach dated 11/8/10 under ""Skin"" listed ""(Bilateral) AFO's (While in Bed) or geri-chair day and night. Review of PT (Physical Therapy) Daily/Weekly Progress Reports revealed a noted dated 11/18/10 that stated ""Staff trng (training) done. Staff to don AFO. Pt. (Patient to wear day and night to prevent contractures and decrease heel pressure while in bed"". During an interview on 1/26/11 at approximately 12:00 Noon, the MDS Coordinator verified the MDS entry indicated there were no functional deficits in ROM while the Care Plan indicated the resident had contractures and used elbow splints and bilateral AFO's. She stated since the resident was total care and wasn't going to walk, she did not think there were any functional limitation in the resident's ROM. The facility admitted Resident #9 on 6/11/10 with [DIAGNOSES REDACTED]. Observations on 1/24/11 through 1/26/11 revealed Resident #9 answering questions appropriately and speaking clearly. Review of the Annual MDS assessment dated [DATE] on 1/26/11 revealed in section B0700 that Resident #9 had been coded as being ""Understood"" and that she ""Understands"". Section B0600 had documented her speech as being clear. Review of section J0200 (Should Pain Assessment Interview be Conducted?) had been marked ""No (Resident is rarely/never understood)"". Section J0300, the Pain Assessment Interview, had been skipped and Section J0800, (Staff assessment for Pain) had been marked that none of the indicators of pain or possible pain had been observed or documented in the last 5 days. During an interview on 1/26/11 at approximately 12:00 Noon, the MDS Coordinator stated she had not realized the pain interview should have been conducted for this resident but she would now attempt pain interviews on all residents unless comatose.",2014-08-01
10011,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,314,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, interviews, and review of the policy provided by the facility entitled ""Dressing Change"" (Revised 9/13/07)"", the facility failed to ensure that 2 of 3 residents observed for wound care, Resident #1 and #2, received the necessary treatment and services to promote healing. The findings included: The facility admitted Resident #1 on 7/12/10 with [DIAGNOSES REDACTED]. Observation on 1/25/11 at 10:18 AM of wound care for a Stage IV Sacral Pressure Ulcer revealed Licensed Practical Nurse (LPN) #2 removing the old dressing, washing her hands, re-gloving, and cleaning the wound. At that time the resident complained of pain and the nurse stopped the treatment. Before going to call the Physician for something for pain for the resident, she re-fastened the same disposable brief the resident had on at the beginning of the treatment without covering the wound first. After calling and leaving a message for the Physician, the nurse returned to the room, washed her hands, gloved, unfastened the diaper and applied 4x4's to the wound with tape. The sacral wound treatment resumed on 1/25/11 at 12:10 PM. Certified Nursing Assistant #4 held the resident on her left side and held the sacral wound area open while LPN #2 cleaned the wound, removed her gloves, and went to wash her hands. CNA #4 then draped a sheet over the resident's lower extremities and over part of her lower buttocks. While the nurse washed her hands, CNA #4 no longer held the buttocks apart allowing the skin of the buttocks to fold over into the wound contaminating it, with the wound no longer visible. LPN #2 returned, wiped the buttocks area (around the non-visible wound) with skin prep, and again went to wash her hands. The CNA draped the sheet over the resident again, and, when the nurse returned, the CNA parted the buttocks allowing the wound to become visible. The nurse then packed the wound and applied the top dressing without cleaning the wound after it had been contaminated. During an interview on 1/26/11 at 9:35 AM, LPN #2 was told that she had been observed during the first attempt at wound care re-fastening the same disposable brief over the wound without covering the wound first. She thanked the surveyor for the information. She verified that the skin of the buttocks had closed over onto the sacral wound and had not been cleansed again before packing the wound and applying the top dressing. The facility initially admitted Resident #2 on 3-24-10 and readmitted him on 10-15-10. During observation of incontinent care on 1-24-11 at 2:25 PM, as Certified Nursing Assistants (CNAs) #1 and #2 repositioned the resident, a dressing dated 1-24-11 was noted on the right hip and an undated island dressing (approximately 2.5 X 2.5 inches) was noted on the left outer foot. The foot dressing had a circular area of yellowish drainage approximately 1/2 inch in diameter. When questioned, CNA #1 stated that she had been bathing the resident the previous Thursday (1-20-11) and that she had removed a sock that was ""stuck"" to this open area. The CNA stated that she reported the skin breakdown to two nurses and that one had placed the dressing on it. She thought it was the same dressing. During an interview on 1-24-11 at 3:05 PM, when asked if she could explain how she knew what treatments were to be performed for Resident #2, Licensed Practical Nurse (LPN) #1 reviewed the Treatment Book with the surveyor. The only scheduled wound care was for the right hip. There was no evidence to indicate that there had been a treatment ordered for the left foot. Review of the resident's medical record on 1-24-11 at 3 PM revealed no Physician's Order for a treatment to the left foot. Review of Nurse's Notes revealed no entry from 1-20-11 through the date of the survey to indicate that the physician or family had been notified of the skin breakdown. During an interview on 1-24-11 at 3:30 PM, LPN #2 stated that she had applied the dry dressing to the resident's left foot when the CNA informed her about the skin breakdown. The LPN stated she 'was going to wait until Monday (1-24-11) to recheck the area and get an order'. At 3:45 PM, LPN #2 came to get the surveyor to observe the area. The nurse entered the resident's room, donned gloves without first washing her hands and removed the soiled dressing. She noted that the open area was 1 X 1 cm (centimeter) Stage II with serous drainage. Following physician notification, LPN #2 initiated the new treatment. She placed treatment supplies on the roommate's overbed table that had been used for the noon meal without cleansing the table or using any type of barrier. Following application of the prescribed treatment, LPN #2 left the room without washing her hands, opened the biohazard room with a key, deposited the trash in the container, and left the room without washing or sanitizing her hands. LPN #2 stated she was going to the nursing station to wash her hands. When asked, she verified that a hand sanitizer was available on the wall in the biohazard room and that she should have used it. During an interview on 1-26-11 at 10:45 AM, LPN #2 verified the observations as above noted. Review of the facility policy entitled ""Hand Hygiene"" provided by the facility on 1-25-11 at 4:30 PM revealed that hand hygiene should be performed ""Before having direct contact with a resident"" and ""After contact with...wound dressings"". Review of the facility policy entitled ""Dressing Change"" (Revised 9/13/07) provided by the facility on 1-25-11 at 4:30 PM revealed the following: ""2. Set up materials on over bed table. a. Clean table then place clean towel on table-set up supplies...6. B. Wash hands and put on clean gloves. C. Remove old dressing..."" After application of the treatment: ""I. Wash Hands. J. Gather trash bag tie bag. K. Remove towel from table. L. Take and dispose of in proper containers in soiled utility rooms. M. Wash hands again.""",2014-08-01
10012,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,315,E,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the policies provided by the facility entitled ""Peri Care"" and ""Catheter Care"", the facility failed to provide appropriate Incontinent/Catheter Care for Resident #1, 2, and 7. ( 3 of 3 sampled residents reviewed for Incontinent/Catheter Care.) The findings included: The facility admitted Resident #1 on 7/12/10 with [DIAGNOSES REDACTED]. Observation of Catheter/Perineal Care on 1/24/11 at 3:15 PM revealed Certified Nursing Assistant (CNA) #5 performing Catheter/Perineal Care while CNA #6 assisted. CNA #5 opened the resident's legs, spread the labia with her gloved hand, and wiped down one side of the labia disposing of the wipe. She then wiped down the other side of the labia with a second wipe and disposed of the wipe. She then told the resident she would ""open you up again"" and spread the labia again, wiping down the middle. She did not clean the catheter tubing. CNA #5 then turned the resident to her left side assisted by CNA #6. CNA #5 then wiped the resident's anal area with a wipe and discarded it. She then wiped the anal area with a 2nd wipe and discarded the wipe. CNA #5 then assisted the resident to turn onto her back touching the resident's leg with the same soiled gloved hands she had used to provide the perineal care. She assisted CNA #6 in putting on a clean disposable brief and pulling the resident up in bed before removing her soiled gloves. Review of the policy entitled ""Peri Care"" on 1/26/11 revealed that once the perineal care was done and the soiled brief removed, the CNA was to ""Remove soiled gloves- put in trash bag..., Secure clean brief, Replace linen, ..."". During an interview on 1/26/11, CNA #5 verified she had not cleaned the catheter tubing. She stated she should have continued wiping the catheter when she cleaned down the middle. When the Surveyors obsesrvations were shared with the CNA, she stated that she needed to ""do that again"". The facility initially admitted Resident #2 on 3-24-10 and readmitted him on 10-15-10. During observation of incontinent care on 1-24-11 at 2:25 PM, while the resident was positioned on his left side, Certified Nursing Assistants (CNAs) #1 and #2 opened the resident's urine-soaked brief and CNA #1 proceeded to cleanse the anal area. She stated, ""He's a heavy wetter."" The CNAs then repositioned the resident, removed the soiled disposable brief, and placed a clean incontinent brief on the resident without cleansing the genital area. Review of the policy entitled ""Peri Care"" supplied by the facility on 1-25-11 at 4:30 PM revealed that it failed to address care of the male patient. Other policies related to incontinent care were requested from the Director of Nurses on 1-25-11 and 1-26-11 but were not provided. Review of ""Assisting in Long Term Care"", Second Edition, Section 5, page 296, Procedure 22 Giving Male Perineal Care revealed instructions to: ""13...be sure entire penis is washed. 14. Wash scrotum..."" The facility admitted Resident #7 on 10-19-06 and readmitted her on 6-10-10 with [DIAGNOSES REDACTED]. During observation of Foley and suprapubic catheter care on 1-25-11 at approximately 3:20 PM, Certified Nursing Assistant (CNA) #1 noted that the incontinent pad was saturated with urine. She stated that the pad had been saturated that morning as well when she had assisted the resident with her bath. The resident stated, ""It must be time to change them (catheters). They're changed once a month."" CNA #3 proceeded to cleanse the inner labia and Foley catheter tubing. The CNAs then positioned the resident onto her right side. CNA #3 cleansed from posterior mid-thigh, between the legs, upward toward the urinary meatus and across the perineum and anal area four times, using four separate disposable wipes. A bleeding split in the skin was noted in the perineal area that was immediately reported to the nurse. The CNAs turned Resident #7 to her left side, removed the soiled underpad, and replaced it with a clean incontinent pad. CNA #1 held up the resident's abdominal folds while CNA #3 cleansed the suprapubic stoma site. The inner thigh areas, outer labia, abdominal folds, and buttocks were never cleansed to remove the residual urinary leakage. During observation of wound care on 1-25-11 at 10:50 AM, the resident was noted to have five small (~ .5 centimeters in diameter each) breaches in skin integrity in a contiguous scarred area to the left of the sacrum. During an interview on 1-25-11 at 3:45 PM, immediately following the treatment, CNA #3 verified the observations as above noted. At 4 PM, CNA #1 also verified these observations. Review of the South Carolina Nurse Aide Candidate Handbook (January 2010) page 39 regarding provision of perineal care revealed: ""8. Washes genital area, moving front to back...11...washes and rinses rectal area moving front to back..."" Review of ""Assisting in Long Term Care"", Second Edition, Section 5, page 295, Procedure 21 Giving Female Perineal Care, revealed instructions to: ""12...separate the vulva...one downward stroke along the...outer labia to perineum...15. Expose anal area. Wash area, stroking from perineum to coccyx.""",2014-08-01
10013,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,160,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds and interview, the facility failed to convey funds to the individual or probate jurisdiction administering the resident estate. The facility conveyed the funds to funeral homes for 2 of 5 resident records reviewed for conveyance of funds. (Resident B and C) The findings included: On [DATE], review of funds conveyed upon death for Resident B and C revealed that the balance of resident trust accounts for these two residents had been sent to funeral homes. Resident B expired on [DATE] and a check dated [DATE] had been issued to a Funeral Home. Resident C expired on [DATE] and a check dated [DATE] had been issued to a Funeral Home. The Business Office Manager had no documentation to show that the persons acting as the Power of Attorney or Responsible Party prior to death had been appointed executor of these estates which would have enabled them to direct the facility to issue the remaining balance to the funeral homes.",2014-08-01
10014,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,322,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policy entitled ""Tube Feeding Flush"", 1 of 3 residents observed receiving a Gastrostomy-Tube ([DEVICE]) flush, Resident #1 did not receive the appropriate treatment and services per facility policy when a water flush was performed and the water was pushed into the tubing and not allowed to flow by gravity. The findings included: The facility admitted Resident #1 on 7/12/10 with [DIAGNOSES REDACTED]. Observation of medication administration with a [DEVICE] Flush on 1/25/11 at 10:40 AM revealed Licensed Practical Nurse (LPN) # 1 pulling up 30 milliliters (ml) of water into a syringe. She then squirted the water into the [DEVICE]. She then pulled up 2 ml of [MEDICATION NAME] (10 milligrams) and squirted the [MEDICATION NAME] into the [DEVICE]. After that she pulled up another 30 ml of water into the syringe and squirted the water into the [DEVICE]. She did not allow the medication or the water flushes to go in by gravity. Review of the policy provided by the facility on 1/26/11 revealed that the flush was to done by pouring the water into the syringe to allow it to flow by gravity. During an interview on 1/26/11, the Director of Nursing (DON) stated that the nurse should have tried give the medication and water flush by gravity first. The nurse was not available for interview at the time.",2014-08-01
10015,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,367,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, and interview, Resident #6, on a pureed diet, was given a Fig Newton cake during an activity. ( 1 of 7 residents reviewed for therapeutic diets.) The findings included: The facility admitted Resident #6 on 3/21/01 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 1/24/11 revealed the resident to be ordered a pureed, NAS (No Added Salt), NCS (No Concentrated Sweet), Diet. On 1/25/11 at 12:05 PM, an observation was made of Resident #6 sitting at a table in the Dinning Room immediately following an Activity. A can of Coke and an empty package of chocolate chip cookies was on the table in front of the resident. The Activity Assistant was questioned about the refreshments. She stated there had been three other residents sitting at that table, and one of them must have let the empty can and package. She verbalized she was aware that Resident #6 was on a pureed diet and no sugar. She stated, "" I gave the resident Fig Newtons and a half glass of juice."" When questioned ""How do you know what foods to give the residents?"" She stated, ""I've worked a long time and know most of the residents. I know the Director had a list of all the residents with special diets."" When asked to see the list, the assistant could not locate it in the office. An interview with the CDM (Certified Dietary Manager) and Trainee on 1/27/11 at 10:15 AM, they confirmed that the Fig Newtons should not have been given on a pureed diet. They also confirmed the Activity Assistant had not yet received any training on foods to be used for each special diet.",2014-08-01
10016,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2011-01-26,272,D,0,1,1KZV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews, and review of the facility provided policy and procedure for restraint use, the facility failed to ensure that 2 of 4 residents reviewed for physical restraints had assessments related to the use of physical restraints. Resident #5, with an order for [REDACTED].#4, did not have an assessment related to the possible restriction of freedom as a result of having a full side rail and the bed placed against the wall. The findings included: The facility initially admitted Resident #5 on 1/8/08 and readmitted the resident on 5/28/10 with [DIAGNOSES REDACTED]. Observations on 1/24/11 at 2:18 PM and 1/25/11 at 8:35 AM revealed Resident #5 lying in bed. During the observations, one side of the bed was against the wall and no side rails were observed in use. Review of the cumulative physician's orders [REDACTED]. Review of the December 2010 and January 2011 Treatment Records revealed nursing staff had initialed that the side rail had been used for safety. During an interview on 1/26/11 at approximately 12:10 PM, the MDS (Minimum Data Set) Coordinator stated that the resident should have had a side rail assessment on re-admission in October 2010 and then again in December 2010 when the quarterly MDS Assessment was completed. The last documented informed consent for safety devices was reviewed and updated on 5/27/10. She was unable to locate any side rail assessments for Resident #5. The facility admitted Resident #4 on 9/28/10 with [DIAGNOSES REDACTED]. Record review on 1/24/11 revealed a physician's orders [REDACTED]. There was also a order for bed alarm while in bed for history of falls. Observations made on initial tour 1/24/10 at 10:45 AM, and again at 1:00 PM, revealed the residents's bed to be pushed against the wall. On 1/25/11 at 12:30pm, the resident was observed in bed with the right full length side rail up. The left side of the bed was against the wall. Further review revealed a Side Rail Assessment last updated on 10/5/10 which documented ""side rails are not appropriate at this time."" The assessment had not been updated to reflect when or why the side rail had been placed. The Care Plan had been updated to reflect that side rail x 1 had been placed on the bed 10/18/10 after the resident had a fall. During an interview with the MDS (Minimum Data Set) Coordinator on 1/26/11 at 10 AM, she stated she would not update the assessment until the resident came up for the next regularly required MDS assessment. She also stated that the facility had never considered having one side of the the bed against the wall as having the potential to be a restraint for the residents. The facility provided policy and procedure for restraint/enabler use (undated) which defined the use of a restraint as ""any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily and which restricts freedom of movement or normal access to one's body."" The policy stated that every resident who is in need of a restraint, enabler or positioning device will be assessed, using the restraint assessment form. The documentation will indicate how the device is to be used, either as a physical restraint, positioning device or enabler. ...Ongoing monitoring should be done to determine if continued restraint use is appropriate or if a resident is a candidate for restraint reduction or elimination. ...It is the policy.... ""to assess ongoing all residents who have restraints to determine the continued need for the restraint to determine if there are less restrictive measures that can be used.""",2014-08-01
10017,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,323,G,1,0,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to ensure that 1 of 13 residents reviewed for falls received adequate supervision and assistive devices to prevent accidents. Resident # 5 was left unattended and unrestrained in the day room, after repeated incidents of attempting to ambulate the previous 2 days. The resident fell and sustained a fractured hip. Also the following concerns; after an X-ray on 3-28-11 determined that Resident # 5 had a left hip fracture, Resident # 5 was observed sitting in a wheel chair, not in a Geri-chair with a lap tray as per the physician's orders [REDACTED].# 5 was left in the day area with the brakes on the wheel chair unlocked. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. On 2-3-11 Resident # 5 was sent to the hospital for a Right Hip Fracture, which was sustained in the facility. She returned to the facility on [DATE]. She was again at the hospital from 2-28-11 till 3-2-11. Nurse's Notes dated 3-26-11 at 12:45 PM indicated the following: ""Resident up in w/c (wheel chair) c (with) w/c alarm in place.....Resident observed attempting to stand several times so far this shift."" On 3-27-11 at 5:00 PM the following Nurse's Note was recorded: ""Resident attempting x (times) 4 to ambulate independently. Alarm in place.... Order for soft belt x 24 hours and resident to be eval(uated) on 3-28-11 due to unsteady gait. Soft belt applied for safety, will be released Q (every) 2 hours for 15 min(utes)."" Review of the physician's orders [REDACTED]."" During an interview with the Certified Nursing Assistant (CNA) # 2, on 4-25-11 at 4:55pm, she stated that on 3-28-11 she was assigned to Resident # 5. She further stated that during report that day, she had been instructed by the Unit Manager not to place any restraints on Resident # 5 because the 24 hour order for the soft belt restraint was over. After completing morning care, CNA #2 put Resident # 5 in a wheel chair, placed her into the day room, and left her there unattended, while going back to the change the linen in Resident # 5's room. On 3/28/11, Resident # 5 while left unattended, fell which resulted in a fracture to the left hip. During an interview with the Unit Manager, Registered Nurse (RN) # 1, on 4-25-11 at approximately 4:20 PM, RN #1 verified that she met with the Certified Nursing Assistants (CNA's) on 3-28-11 and informed them that the 24 hour period was over for the soft belt restraint for Resident # 5. She informed them that Physical Therapy would have to evaluate Resident # 5 and make recommendations before another restraint could be placed on the resident. She further stated that she was in the morning meeting and had not been able to talk to Physical Therapy when she was notified that Resident # 5 had fallen. She went to assess the resident and the resident did not show any signs of pain or discomfort. During an interview with Licensed Practical Nurse (LPN) # 2 on 4-25-11 at approximately 4:10 PM, LPN #2 stated that she was the medication nurse on 3-28-11, and at approximately 10:45 AM, she was working at her medication cart which was parked near the day room on the 100 Unit. LPN # 2 further stated that she saw Resident # 5 stand, she yelled out and before she could get into the day room, Resident # 5 had fallen. She stated she did not hear a chair alarm sound. After an assessment of the resident was made, she continued to sit with Resident # 5 and assisted her with lunch. LPN #2 further stated that she gave Resident # 5 two Aleve for pain at 12:25 PM, even though she did not complain of pain. Review of the medical record revealed that on 3-28-11, the resident was sent to the ER (emergency room ) for an X-Ray related to the fall, which revealed a Left Hip Fracture. The X-Ray report from the Hospital dated 3-28-11at 14:07 (2:07 PM) stated: "" Concerning the left hip, there appears to be a nondisplaced somewhat subtle subcapital fracture with minimal impaction. This was discussed with Dr. _____ ( Resident # 5's primary physician, who was also the Medical Director of the facility.)"" Further review of the hospital records revealed Resident # 5 was not admitted to the hospital for surgery until 3-29-11 at 14:49 (2:49 PM). Surgery notes from the hospital revealed the following statement: ""We hoped we could fix the fractured femoral neck with percutaneous pins, but (illegible) it became obvious there was a completely displaced femoral neck fracture and only hemiarthroplasty would suffice."" On 4-25-11, review of the physician's orders [REDACTED]. "" Review of the Care Plan with run date of 4-19-11 listed problem # 12 as: ""Resident requires geri-chair w/lap tray while oob (out of bed). Approaches listed were 1. Geri-chair w/lap tray while oob.. 2. Release every 2 hours for 10 minutes. Provide exercise: PROM (Passive Range of Motion). 3. Monitor resident's response to device."" There were no Approach Start Dates listed. On 4-25-11 after the survey team entered the building an updated care plan was placed on the chart. On 4/25/11, observation of Resident # 5's room at 2:15 PM revealed a lap tray in the room. Resident # 5 was observed to be in the day room, sitting in a wheelchair ( not in a geri-chair) at that time. On 4-26-11 at approximately 8:55 AM, the Resident was observed to be sitting in the day area with other residents. The brakes on her wheel chair were not in a locked position. This was confirmed with RN # who stated she was unaware who had moved Resident # 5 into the day area after breakfast. None of unit 100 staff stated that they had moved the Resident. RN #1 then stated that a new order had been written on 4-25-11 for Resident # 5 to be up in a wheel chair with a pommel cushion and a lap buddy to prevent falls.",2014-08-01
10018,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,281,G,1,0,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the professional resource of Perry-Potter Clinical Nursing Skills & Techniques 7th Edition, the facility failed to maintain professional standards related to medication administration for one of ten sampled residents reviewed for professional standards. The facility nursing staff repeatedly documented that [MEDICATION NAME] (a [MEDICAL CONDITION] medication) was administered as ordered to Resident # 5. However, the medication was not available for administration. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. Review of the medical record revealed labs drawn for [MEDICAL CONDITION]-Stimulating Hormone (TSH) done in 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of ""Repeat (lab) 1-9-11 and 100 mcg every day."" The Medication Administration Records (MAR), documented that [MEDICATION NAME] was administered for 69 doses from February to April 2011. During an interview with the Pharmacy Consultant on 4-27-11 at approximately 10:00 AM, she stated that the pharmacy last supplied this medication on 1-27-11 and had sent only 30 pills to the facility at that time which would have depleted the medication on 2-15-11. On 4-27-11 at approximately 10:05 AM, Licensed Practical Nurse # 1 confirmed that there was no [MEDICATION NAME] 100 mcg in either of the medication carts on Hall 100. On 4-27-11 at approximately 11:00 AM, during an interview with the DON, she stated she did not know of any source of medication except through the pharmacy and did not know why the medication was documented as administered when the medication was not available. Perry-Potter Clinical Nursing Skills & Techniques 7th Edition, page 515- 518 states: ""Standards are those actions that ensure safe nursing practice. To ensure safe medication, nurses follow the nursing standard called the six rights of medication administration every time they administer medications. The process includes assuring the right medication, the right dose, the right patient, the right route, the right time and the right documentation....When preparing medications, compare the label of the medication to the MAR indicated [REDACTED].",2014-08-01
10019,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2011-04-04,225,D,1,0,WBVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interviews and review of the facility's policy on abuse/neglect, the facility failed to ensure 1 of 1 allegations of abuse were reported to the appropriate state agencies. The findings included: The facility admitted Resident #1 on 2/4/2011 with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the Grievance Log revealed an entry for Resident #1 dated 2/7/2011. The resident reported a staff member pushing her and telling her to stay in bed. The action taken by the facility was to interview the nurse who stated she did not push the resident but did remind her not to get out of bed ""but not in an aggressive manner."" The resident was interviewed (she was interviewable) and stated that she was very upset that night and thinks she might have been dreaming. The interviews were discussed with the daughter. The resolution of the Grievance was ""not resolved"" and the ""daughter states she is unhappy with her mother's care."" Review of the reportable incidents revealed no report related to Resident #1 was made to the State Agency. During an interview on 4/4/2011, the Director of Nurses (DON) confirmed that the incident was not reported to Certification. She stated that she knew that the incident should have been reported and the results of the full investigation submitted within 5 Days. The DON stated that she did investigate the incident but did not report. Review of the facility's policy on Abuse/Neglect revealed the following: the facility will ""report any and all suspected incidences of abuse/neglect and/or misappropriation of resident property within 24 hours of the incident to the required State Agency.""",2014-08-01
10020,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-04-26,280,H,1,0,032B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure 4 of 11 resident's care plans were reviewed and revised with adequate interventions to prevent falls/injuries from occurring. Residents #1, #2, #3, and #5's care plans were not updated with adequate interventions to prevent falls. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, ""...Mental Status: Oriented x2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation..."" Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) scored him as 8. Review of the Nurse's Notes on 4/26/2011 revealed Resident #1 fell 21 times between 11/15/2010 and 4/26/2011; eight of these falls resulted in skin tears and/or a laceration, one of the eight falls resulted in a laceration that required sutures. The notes showed that Resident #1's had difficulty at times standing to sitting down without dropping down that seemed to cause him to fall. ""Resident is encouraged to call for assistance but is unable."" Review of the Care Plan dated 11/30/2010 and revised 3/1/2011 revealed a problem area identified for ""risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance."" Added to the problem area was ""risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker."" Approaches included: ""Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device."" On 12/10 the care plan was updated with an approach to ""observe resident at all times, remind resident not to throw clothes on floor."" Chair alarm was added without a date and then crossed off due to ""resident refused."" In February 2011, the care plan was updated to include ""OT in to work with resident.... Assist resident to and from meals."" In March 2011, the care plan was updated to include ""encourage use of wheelchair when ambulating (son to bring in)."" Further review of the care plan revealed no evidence that the care plan was updated and individualized for Resident #1 assessed as have difficulty with recall and decision-making. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) scored her as 4. Review of the Nurse's Notes revealed Resident #2 had 16 falls that resulted in 6 injuries (skin tears/lacerations and bruises) between 1/9/2011 and 4/25/2011. Review of the Care Plan dated 1/7/2011 and reviewed on 2/8/2011, 2/16/2011 and 3/3/2011 revealed a problem area identified related to ""Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications."" The approaches included: ""encourage use of assistance device, PT/OT evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. An update on 1/7/2011 included ""bed/chair alarm at all times"" and ""observe resident frequently related to attempts to ambulate without assist."" On 3/8/2011 the care plan was updated to include ""Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised."" Eight falls occurred prior to the seatbelt being added to Resident #2's wheelchair. After the seatbelt was added the resident fell out of her wheelchair 3 times and was found twice on the floor in the bathroom. No additional interventions were added related to these falls. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Review of the Nurse's Notes between 11/20/2010 and 4/22/2011 revealed Resident #3 fell 26 times. On 12/13/2010 he complained of pain in the right wrist, an x-ray revealed a fracture; on 3/14/2011 and 4/19/2011 he sustained lacerations due to falls. Review of the Care Plan revealed a problem area related to ""risk for further falls/injury."" The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. ""Continues to roll self out of bed without injury. Resident aware of rolling from bed. Bed pad alarms tried prior to readmit, resident destroys alarms."" On 12/1/2010, the care plan was updated with ""will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include ""encourage resident to remain in common areas when out of bed."" On 12/5//2010, the care plan was updated to include the same approach of ""encourage resident to remain in common areas when out of bed."" On 12/10/2010, the care plan was updated to include ""observe resident frequently when in room or out of room."" On 12/14/2010, the care plan was reviewed and included the following: ""Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms."" The care plan was last reviewed 12/14/2010, the resident fell or was found on the floor 15 times between 12/14/2010 and 4/22/2011; no additional interventions were put in place after 12/14/2010. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Review of the Nurses Notes between 10/9/2010 and 4/5/2011 revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. Review of the Care Plan revealed a problem area identified related to ""Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to ""continue with current problem."" The care plan was reviewed again on 3/2/2011. Approaches included: ""walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance."" On 10/11/2010, Resident #5's care plan was updated to include the following approach: ""Remind resident not to stand without assist. Keep resident in common area when out of bed."" Review of the care plan revealed no intervention related to the concern that Resident #5 fell on [DATE] and 1/27/2011 from the wheelchair while bending over. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. Cross Refers to F-323 as it relates to the facility's failure to implement new and appropriate interventions for each resident to prevent falls/injuries.",2014-08-01
10021,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2011-04-26,323,H,1,0,032B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices for 4 of 11 residents reviewed for falls. Residents #1, #2, #3 and #5 had multiple falls and injuries without adequate interventions put in place to prevent further injury. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, ""...Mental Status: Oriented x 2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation..."" Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) score was 8. Observation of Resident #1 on 4/26/2011 at 7:20 AM, revealed the resident sitting on the side of the bed attempting to dress. Resident #1 had no alarms in place, no fall mats were seen and no wheelchair observed. A recliner with a manual footrest was observed. No lift chair was observed. Resident #1 also did not have a wheelchair. Observation of Resident #1's bathroom revealed bright red blood on the floor between the vanity and the toilet. The outside of the toilet bowl was smeared with bright red blood. The surveyor obtained staff assistance. Resident #1 stated that he fell this morning in the bathroom. The fall was reported to the CNA (certified nursing assistant) present in the room. Review of the Cumulative physician's orders [REDACTED]."" Further review of the Cumulative Orders revealed the Chair Alarm was originally ordered on [DATE] and the Lift Chair was originally ordered on [DATE]. Review of the ""Fall Risk Assessment"" revealed only one entry dated 11/15/2011 that scored Resident #1 as a ""6"" indicating he was not at ""High Risk"" for falls. Review of the Nurse's Notes revealed the following entries: On 11/15/2010 at 12:30 PM, Resident #1 was found on the floor; a foam mattress was placed by the bed. On 11/16/2010 at 9:30 PM, Resident #1 fell and sustained a skin tear to the left forearm. It was noted that he was hanging clothes and slipped on a foam mattress. The foam mattress was removed. On 11/21/2010 at 9:30 AM, Resident #1 fell in the bathroom and sustained a laceration to the arm. On 11/23/2010 at 5:00 AM, Resident #1 fell on the floor in the room and sustained a rub burn to his/her knee. (A chair alarm was ordered per the telephone orders). On 12/8/2010 at 4:30 PM, Resident #1 fell in the bathroom and sustained a skin tear. On 12/10/2010 at 6:00 PM, Resident #1 fell in the bathroom and sustained a laceration to his head requiring sutures. (An order was written to send to the ER (emergency room ) status [REDACTED]. On 1/7/2011 at 9:30 AM, Resident #1 fell in the room no injuries were noted. On 1/9/2011 at 2:00 PM, Resident #1 fell in his room while trying to go to the bathroom. At 6:30 PM, Resident #1 fell again next to his recliner. (An order was written on 1/17/2011 for a ""Lift Chair."") On 1/21/2011 at 6 PM, Resident #1 fell in his room and was found ""scooting towards bathroom."" On 2/11/2011 at 6 PM, Resident #1 fell in the bathroom. On 2/16/2011 at 9:45 PM, Resident #1 fell in the bathroom and hit his back on the shower bench. On 2/23/2011 at 4:20 PM, Resident #1 fell in the hallway no injuries were noted. On 3/3/2011 at 2:00 PM, revealed the following entry: ""On February 16, 2011, this committee met to discuss new interventions that would decrease or prevent risk of falls. At this time the team implemented having a staff person assist resident to and from meals/walking. Resident's impulse control is effected due to [DIAGNOSES REDACTED]. Resident has difficulty at times standing from sitting down without dropping down. This is what seems to have the resident fall. Resident continues to walk with walker but does need some reminders. Resident is encouraged to call for assistance but is unable. The resident had been offered a chair alarm x 2 but declined. In 12/2010 a seat belt was offered and both resident and family declined. The resident is taken/asked every 1-2 hours for toileting needs but resident is continent and does not have a toileting pattern. Resident is also independent and becomes agitated at times when you offer assistance with bowel and bladder needs. Discussed the usage of a merry walker and at this time therapy could not see how this would work. Decided as a team to have resident use wheelchair for ambulation. Resident's family and resident are aware that resident is a fall risk any time he is up ambulatory and agreed that we should encourage the use of wheelchair. Family to bring wheelchair in from home. Care Plan revised."" On 3/5/2011 at 12:15 PM, Resident #1 fell in the bathroom sustaining an abrasion to his right temple. On 3/10/2011, Resident #1 fell in his room. On 3/16/2011 at 5:15 PM, Resident #1 was found on the floor of his room with scalp laceration. The resident was sent to the emergency room for evaluation. On 4/1/2011 at 4:00 PM, Resident #1 fell in the bathroom. On 4/9/2011 at 12:30 PM, Resident #1 fell in the dining room. On 4/16/2011 at 9:30 PM, Resident #1 fell attempting to go the bathroom and sustained an abrasion to the right side of the face. On 4/24/2011 at 7:00 AM, Resident #1 was found on the floor in his room and had ""hit his head."" Review of the Incident Reports provided by the facility revealed the following: On 11/15/2011, the corrective actions taken to prevent further falls were ""Resident unaware of safety measures due to disease process. Can ambulate safely once up from sitting position. At times resident may fall backwards. Resident refuses tab alarm due to the same agitation. Talked with family about helmet-family refuses. Family wants resident to remain independent with walking and states they are aware of the consequences."" The incident report dated 11/23/2011 revealed the corrective action taken related was ""encourage resident to take his time while attempting to get up out of chair."" On 1/7/2011 the corrective actions taken were to ""encourage resident to go slow when ambulating in room and to use walker at all times."" On 1/9/2011 the actions taken to prevent further falls was to ""attempt to check in more frequently. Hopefully he will allow is to keep his door open"". The corrective actions taken for the second fall on 1/09/2011 were ""reminded resident to call for assist, notified door would be left ajar while in room."" On 1/21/2011, the corrective actions taken were to ""remind resident to call for help-re-attach chair alarm."" On 1/25/2011, the actions taken were to ""monitor patient closely."" On 2/12/2011, the corrective actions taken were ""assisted resident in getting dressed and cleaning up his bathroom."" On 2/16/2011, the corrective actions taken to prevent falls were ""reminded to call for assist."" On 3/5/2011, the actions taken were ""will continue fall precautions."" On 3/10/2011, the corrective actions taken were ""patient is checked at least every 1-2 hours but due to dementia never asks for help rings call bell."" On 3/16/2011, the summary of actions taken to prevent further falls was ""pressure applied- call to doctor and family."" On 4/1/2011, the actions taken were to ""continue to check on patient every 1-2 hours for toileting."" On 4/9/2011, the corrective actions taken were ""instruct patient to call for assistance."" On 4/16/2011, the corrective actions taken were to ""monitor closely."" No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area identified for ""risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance."" Added to the problem area was ""risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker."" The original date of the care plan was 11/30/2010 and reviewed 3/1/2011. Approaches included: ""Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device."" On 12/10 the care plan was updated with an approach to ""observe resident at all times, remind resident not to throw clothes on floor."" Chair alarm was added without a date and then crossed off due to ""resident refused."" In February 2011, the care plan was updated to include ""OT (occupational therapy) in to work with resident and colostomy. Assist resident to and from meals."" In March 2011, the care plan was updated to include ""encourage use of wheelchair when ambulating (son to bring in)."" Further review of the care plan revealed no evidence that the care plan was updated with the resident's numerous falls or that individualized interventions put in place to prevent further falls from occurring. During an interview with the surveyor on 4/26/2011 at 2:30 PM, Resident #1's son stated that he was aware of his father's multiple falls. He further stated that his father would not call for assistance. Resident #1's son stated that his father needed assistance with his colostomy and had requested the colostomy care be scheduled to reduce the risk of falls in the bathroom. He stated that his request was not followed and that the colostomy care was not scheduled. He further stated that he did attend a meeting regarding his father's falls and he stated that at no point during the meeting was a merry walker, seat belt or other type of device discussed. He stated that his father would routinely disconnect the alarms that were applied at one point. He also stated that he brought in his father's wheelchair from home, however, his father did not use it and he stated that no one in the facility encouraged its use. He also stated that he was never requested to take the wheelchair home and did not know where it was located. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) score was 4. Observation of Resident #2 on 4/26/2011 at 8 AM revealed the resident in the living room seated in a high backed wheelchair. A chair alarm was observed in place. The resident was noted to be unable to propel herself in the wheelchair. No seat belt was observed. A bed alarm was observed in the resident's room. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed the Safety Devices ordered were ""seat belt and bed and chair alarms."" Further review of the telephone orders revealed the original order for the bed and chair alarms was 1/11/2011. The original order for the seat belt was 3/3 for a trial of the seat belt then 3/8/2011 the seat belt was ordered. On 4/25/2011 a telephone order was written to ""d/c (discontinue) the seatbelt - ineffective broken x 2."" Resident #2 was noted to receive Hospice Care due to a rapid decline in April 2011. The primary [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 11/29/2010 (a previous admission) that scored the resident as a ""5"" indicated she was not at high risk for falls. Review of the Nurse's Notes revealed the following entries: On 1/9/2011 at 5:20 PM, Resident #2 fell in hallway and sustained a laceration to her head and bruising. On 1/16/2011 at 10:30 AM, Resident #2 fell in room while attempting to toilet self. On 1/20/2011 at 3 PM, Resident #2 fell to her knee, no injuries. On 1/24/2011 at 12:30 AM, the resident fell out of bed and abraded her/his back. On 1/26/2011 at 2:50 AM, Resident #2's bed alarm sounded and the resident was found on the floor. On 2/8/2011 at 8 PM, Resident #2 was found on floor by bathroom, she sustained a skin tear and a hematoma to the left hip. On 2/26/2011, Resident #2 fell and was found unresponsive with pupils fixed. On 3/2/2011 at 1 PM, Resident #2 was found of floor beside bed. On 3/3/3011, ""meeting held with MDS coordinator, DON, Activities, and Physical Therapist to discuss resident's falls. Care Plan for falls reviewed at this time to discuss interventions."" On 3/8/2011 at 2:15 PM, the resident fell in the living room and sustained a bump on the head. On 3/21/2011 at an unknown time, the resident was found on the floor with the chair alarm sounding. On 3/27/2011, the resident was found on the bathroom floor. On 4/15/2011 at 9:30 AM, the resident was found on the floor of the bathroom with the chair alarm sounding. On 4/18/2011 at 8 PM, Resident #2 fell out of the wheelchair and sustained an abrasion to her back. On 4/25/2011 at 9:40 PM, Resident #2 fell out of bed and sustained an abrasion to her nose. Review of the Incident Reports provided by the facility revealed the following: On 1/9/2011 the corrective action taken to prevent further falls was ""close monitoring."" On 1/16/2011 the corrective action taken was to ""encourage resident not to get out of wheelchair without assistance, resident has fallen previously and has had a cognitive decline."" On 1/20/2011, the alarm appropriately sounded and the corrective action taken was to ""remind resident to ask for assist with transfers and to keep patient close to nursing station."" On 1/24/2011, the bed alarm sounded appropriately and no corrective action was documented. On 1/26/2011 the bed alarm sounded appropriately and the corrective action taken was ""encouraged resident to utilize call light when toileting is needed. Call light in reach and resident oriented to proper use."" On 2/8/2011 there was no indication of any alarm. The corrective action taken was for the resident to ""call for help and using the call bell."" On 3/2/2011 there was no indication that the alarm sounded. The corrective action taken was ""transferred to common area and needs more frequent monitoring."" On 3/8/2011, there was no indication that the resident had a seatbelt in place and the corrective action taken was ""will try to monitor further and more often"" and ""patient is scheduled to receive a belt for wheelchair."" On 3/21/2011, there was no indication that a seatbelt was in place or that the alarms sounded. The corrective action taken was for the resident to ""comply with instructions to call for help. Have staff check every 1-2 hours."" On 3/27/2011, there was no indication that the resident's alarms sounded or that the seat belt was in place. The corrective actions taken were to ""continue bed alarm, chair alarm, low bed, seatbelt."" On 3/30/3011, the resident's alarm appropriately sounded and the resident had unfastened the seatbelt. The corrective action taken was ""resident will not comply to instructions related to safety seat belt. Will continue to monitor, will continue to assess resident for pain, will continue to apply alarms, will continue to encourage resident not attempt to get up out of wheelchair."" On 4/9/2011 the bed alarm sounded appropriately. The corrective actions taken were ""continue bed alarm and low bed."" On 4/15/2011, the corrective actions taken were ""will check patient even more frequently than usual due to Urinary Tract Infection."" On 4/18/2011, the corrective actions taken were ""assessment done, v/s (vital signs) taken, continue chair and bed alarm and low bed."" On 4/25/2011, the corrective actions taken were to ""continue low bed with bed alarm."" Review of the Care Plan revealed a problem area identified related to ""Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications. The care plan was dated 1/7/2011 and was reviewed on 2/8/2011, 2/16/2011 and 3/3/2011. The approaches included: ""encourage use of assistance device, PT/OT (physical therapy/occupational therapy) evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. The care plan was updated on 1/7/2011 to include ""bed/chair alarm at all times"" and ""observe resident frequently related to attempts to ambulate without assist."" On 3/8/2011 the care plan was updated to include ""Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised."" There was no indication the care plan was updated with appropriate interventions to prevent further fall. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Observation of Resident #3 on 4/26/2011 at 8:40 AM, revealed the resident was in the dining room seated in a wheelchair. A chair alarm was observed in place. The resident was noted to self propel himself. Observation of the resident's room revealed Resident #3 had a bed alarm in place. The bed was note against a wall. One fall mat was observed folded in half and stored against the wall. A lift recliner was observed. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed no orders for any type of alarm, fall mat, recliner etc. Review of the Falls Risk Assessment revealed one entry dated 7/19/2010 that scored Resident #3 as a ""16"" indicating he was at ""high risk"" for falls. Review of the Nurse's Notes revealed the following entries: On 11/20/2010 at 10 PM, the resident was found on the floor beside wheelchair. On 11/22/2010 at 11:50 AM, the resident was found on the floor at the end of the bed scooting towards the door. 11/23/2010 at 3:20 AM, the resident was found on the floor attempting to urinate. On 11/24/2010 at 2 AM, the resident was found on the floor and stated that he was taking a walk and fell . On 11/25/2010 at 10:15 AM, the resident was found on the floor. On 11/29/2010 at 9 PM, the resident was found sitting on the floor. On 12/3/2010 at 2:55 AM, the resident was found sitting in the floor. At 8:45 AM, the resident was found sitting ""Indian style on bathroom floor."" At 2:30 PM, the resident was found sitting on the floor in front of recliner. On 12/10/2010 at 4:30 AM, the resident was found sitting in his room beside the bed. At 10:35 PM, the resident was found on the floor by his dresser. On 12/13/2010 the resident reported pain in the right wrist. X-rays were obtained and were positive for a wrist fracture. On 12/15/2011 at 8:15 PM, the resident was found on the floor. At 9:20 PM, the resident was found on the floor at the head of the bed. On 12/20/2010 at 7:45 PM, the resident was found on the floor by the dresser. On 1/10/2011 at 4:30 AM, the resident was found on the floor by the bed. On 1/11/2011 at 7:25 PM, the resident fell out of the wheelchair attempting to adjust his socks. On 1/21/2011 at 11:30 AM, the resident was noted to be lying on the floor in his room. On 1/26/2011 at 7:30 PM, the resident was noted on the floor. On 2/23/2011 at 1:40 PM, the resident ""repeatedly rolled forward out of wheelchair sounding the chair alarm."" On 3/5/2011, 9:10 PM, the resident was found sitting on floor with legs folded, sitting on feet. At 9:20 PM, the resident was found again on the floor with legs crossed. On 3/6/2011 at 9 PM, the resident was found sitting on the floor with legs crossed. On 3/14/2011 at 12:50 AM, the resident's bed alarm was sounding; the resident was found on the floor with his head on the ground. Abrasion to right forehead noted. On 3/25/2011 at 11:20 AM, the resident's chair alarm was sounding and the resident was found on the floor in front of the wheelchair. On 4/6/2011 at 11:50 AM, the resident was found on the floor in front of the wheelchair, buttocks and coccyx reddened. On 4/19/2011 at 6:45 PM, the resident was found on the floor in the hallway in front of the wheelchair. An abrasion was noted to his forehead. 4/21/2011 at 6:40 AM, the resident was lowered to the floor by a CNA after a transfer to the wheelchair. On 4/22/2011 at 2:30 PM, the resident rolled off low bed and onto low mat, the resident was noted crawling around room. At 9:50 PM, the resident was on left side of mat on left elbow. Review of the Incident Reports provided by the facility revealed the following: On 11/20/2010, there was no documentation of alarms and no documentation of corrective action taken to prevent further falls. On 11/20/2010, there was no documentation of alarms or no documentation of corrective action taken. On 11/22/2010 there was no documentation that the alarms were sounding and the corrective action was ""reminded to call for assist."" On 11/14/2010 there was no documentation that the alarms sounded and the corrective action was ""resident is on low bed with mats, in the past he has admitted to deliberately putting himself on the floor from the bed. This is a recurring behavior and it is unsure if this is a true fall. Intervention low bed and mat continues. Have tried tab alarms x 2 in the past but resident has destroyed them beyond repair."" On 11/29/2010 there was no documentation that the alarms sounded and the corrective action taken was ""is on low bed with mats, refuses tab alarm."" Another corrective action was ""may need to move room to closer to nurses desk, questionable 1:1 care, continue to encourage to ask for help with assist."" (The resident's room did not change nor was he ever placed on 1:1 care). On 1/10/11 there was no documentation that the alarm sounded, the resident sustained [REDACTED]. There was no corrective action documented. On 1/11/2011, the corrective action taken was ""nursing assessment completed assisted back to chair, monitored. Encourage resident to ask for help when reaching towards shoes, ground etc. Understood by resident."" On 1/21/2011, the corrective action taken was ""chair alarm in place, will follow up with doctor regarding lab results for possible reasons for decreased pulse."" On 1/26/2011 there was no documentation that the alarms sounded, the corrective action taken was ""we'll monitor closely, needs to be more often at common areas for monitoring."" On 2/23/2011, the alarms sounded appropriately, the corrective action taken was ""encouraged to ask staff for assistance"" and ""proper use of chair alarm, resident non compliant."" On 3/5/2011, there was no documentation that the alarms sounded, the corrective action taken was continue low bed, bed alarm."" On 3/5/2011, the bed alarm sounded and the corrective action taken was to ""continue low bed with bed alarm."" On 3/6/2011, the bed alarm sounded and the corrective action taken was ""will keep resident up until Trazadone given."" On 3/14/2011, the bed alarm sounded appropriately, the corrective action taken was ""Neuro checks due to small abrasion on forehead."" On 3/25/2011, the alarm sounded appropriately, the corrective action taken was ""resident unaware of own limitations, refuses to follow instructions to call for help when assistance required. Performed Body Audit, v/s, assessed for pain, notified nurse practitioner. Will continue with chair and bed alarm and will continue to assess for pain. On 4/6/2011, there was no documentation the alarms were sounding, the corrective action taken was ""will keep trying to have patient involved with activities in living room where can be supervised. All safety measures are being used as able."" On 4/6/2011 the corrective action taken was ""all precautions devices in use"" and ""resident needs to call for help."" On 4/19/2011, there was no documentation that the alarms were sounding; the resident sustained [REDACTED]. The corrective actions taken were to ""continue with chair alarm."" On 4/22/2011, there was no documentation that the alarms were sounding, the corrective action taken were ""will continue bed and chair alarm."" No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area related to ""risk for further falls/injury."" The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. ""Continues to roll self out of bed without injury. Resident aware of rolling from bed. A Bed pad alarm tried prior to readmit, resident destroys alarms."" On 12/1/2010, the care plan was updated with ""will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include ""encourage resident to remain in common areas when out of bed."" On 12/5//2010, the care plan was updated to include the same approach of ""encourage resident to remain in common areas when out of bed."" On 12/10/2010, the care plan was updated to include ""observe resident frequently when in room or out of room."" On 12/14/2010, the care plan was reviewed and included the following: ""Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms."" The care plan was not adequately updated with appropriate interventions to prevent further falls/injuries. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Observation of the Resident #5 on 4/26/2011 revealed the resident in the commons area seated in a wheelchair, a chair alarm was present. Observation of the resident's room revealed a bed alarm on the night table. Review of the Cumulative physician's orders [REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 9/13/2010 that documented the resident's score as a ""14"" indicating she was at ""high risk"" for falls. Review of the Nurse's Notes revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. No Incident Reports were provided at the time of the survey for Resident #5. Review of the Care Plan revealed a problem area identified related to ""Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to ""continue with current problem."" The care plan was reviewed again on 3/2/2011. Approaches included: ""walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance."" On 10/11/2010, Resident #5's care plan was updated to include the following approach: ""Remind resident not to stand without assist. Keep resident in common area when out of bed."" There was no evidence that Resident #5 had adequate interventions put in place to prevent further falls/injuries from occurring. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. The DON also confirmed the Falls Risk Assessments were not current and were not accurate for all residents. She stated that there was not a facility policy related to the assessments but stated that she expected the assessments to be completed after each fall. The DON stated that Resident #1 was not alert and oriented and was not able to make his own decisions. The DON also confirmed the actual harm and injuries sustained by Residents #1, #2, #3 and #5 related to falls and they had noticed an increase in the number of falls. The DON stated that a new Medical Director had just started but that no actions had been put in place. During an interview with the surveyor on 4/26/2011, the Medical Director stated that he started on 4/16/2011. He stated that he was not aware of the high number of falls. He stated that he had not yet attended a Quality Assurance Committee.",2014-08-01
9914,AZALEAWOODS REHAB & NURSING CENTER,425014,123 DUPONT DR,AIKEN,SC,29801,2010-07-07,246,D,0,1,56KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to use appropriate methods to accommodate 1 of 1 sampled resident's need for a bed that would be the correct length. The findings included: The facility admitted Resident #2 on 9/21/09 with [DIAGNOSES REDACTED]. During the initial tour on 7/6/10 at approximately 11:30 AM, the resident was observed in bed with his feet extended over the foot of the bed. During all days of the survey, the resident was observed in bed in the same situation , either with a folded towel or pillow under his feet. In an interview with a family member on 7/6/10 at 8:25 PM, he/she stated that when visiting, he/she would try to pull the resident up in order to be more comfortable. In an interview with the Administrator, Director of Nursing and Nursing Consultant on 7/7/10 at 10:35 AM, they stated that the resident would slip down in the bed. A later observation revealed a blue foam wedge between the end of the mattress and the foot of the bed. with the resident's feet on the wedge.",2014-09-01
9915,AZALEAWOODS REHAB & NURSING CENTER,425014,123 DUPONT DR,AIKEN,SC,29801,2010-07-07,281,E,0,1,56KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility nursing staff failed to provide care that met professional standards of practice for one of four sampled resident's reviewed with sliding scale insulin. The nursing staff failed to clarify incomplete sliding scale insulin orders and failed to transcribe the correct sliding scale insulin to the Diabetic Flow Chart for Resident # 9. Furthermore, the nurses failed to identify the discrepancy between the MAR (Medication Administration Record) and the Diabetic Flow Chart for Resident # 9 . In addition, the nursing staff failed to correctly reconcile Physician orders [REDACTED]. The findings included: The facility admitted Resident # 9 on 3/25/09 with [DIAGNOSES REDACTED]. On 7/6/10 review of the resident's clinical record revealed that the resident had returned to the facility on [DATE] with readmission orders [REDACTED]= 2 units, 201-250 = 4 units, 251- 300 = 6 units, 301-350 = 8 units. There were no additional orders for what to administer if the resident's blood sugars were above 350. Review of the June MAR (Medication Administration Record) revealed that the new sliding scale insulin order had been correctly transcribed to the MAR and nine different nurses had initialed that the sliding scale had been administered twice a day. Review of the Diabetic Flow Chart revealed that the nursing staff had failed to update the chart to reflect the new sliding scale parameters and the nurses had administered the insulin following the old parameters. Further review of the chart revealed that there were no additional orders written related to sliding scale insulin. Interview with LPN # 1 on 7/6/10 at approximately 2:45 PM revealed that he/she had written the readmission orders [REDACTED]. When questioned related to the sliding scale parameters stopping at 350, he/she stated that he/she did not clarify the order and that if the blood sugar was above 400, the nurse should call the Physician. When questioned what the nurse should do if the blood sugar was above 350 since there were no guidelines, LPN # 1 stated call the Physician. LPN # 1 confirmed that the facility nurses' had failed to update the Diabetic Flow Chart to reflect the new sliding scale parameters and should have. LPN # 1 confirmed that multiple nurses' had signed the MAR and not identified the discrepancy between the MAR and Diabetic Flow Chart. LPN # 1 was questioned if the facility had any system in place to identify this type of error and responded that a facility nurse checks that the resident is receiving the correct dose of insulin on a weekly basis. Interview with the facility DON (Director of Nurses) on 7/6/10 at 3 PM, revealed that the facility had standing orders for sliding scale insulin however confirmed that not all resident's at the facility received insulin per this scale. The DON stated that the nurse receiving the readmission orders [REDACTED]. The DON confirmed that the facility nurses' had failed to update the Diabetic Flow Chart and failed to identified the discrepancy. The DON confirmed that no additional orders had been received related to the resident receiving insulin per the facility standing sliding scale insulin. On 7/7/10 additional review of the record revealed that the July monthly Physician orders [REDACTED]. Review of the July MAR and Diabetic Flow Chart revealed that the orders were not updated to reflect the change in the sliding scale insulin. The DON confirmed this. LPN # 2 stated that he/she had reconciled the orders on 6/30/10. When questioned if he/she had compared the printed orders and MAR with the chart to confirm that they were correct, he/she stated yes. LPN # 2 confirmed that the July monthly orders and MAR did not reflect the correct updated sliding scale and confirmed that he/she had not identified this during the monthly change over.",2014-09-01
9916,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-05-23,225,D,1,0,PQJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review, interview and review of the facility's policy on Abuse and Neglect, the facility failed to report and thoroughly investigate an allegation of misappropriation of resident funds. Resident #7 reported to the facility that CNA (Certified Nursing Assistant) #1 stole a $50.00 gift card. The facility failed to investigate or report the allegation. The findings included: The facility admitted Resident #7 on 7/9/2010 with [DIAGNOSES REDACTED]. During an interview on 5/23/2011, Resident #7 stated that CNA #1 routinely provided care to her. She stated that one day ""a couple months ago"" CNA #1 was acting strange and came into her room. Resident #7 stated that the CNA was not assigned to her that day. She further stated that the CNA rummaged through her dresser, closet and desk ""looking for a missing pen."" The resident stated that CNA #1 had ""white makeup or something on her face."" Resident #7 then noted that her $50 gift card that she had received as a present from her son was missing. She stated that she put the gift card in a travel bag with clothes on top of it in the back left part of her closet. Resident #7 stated that she reported the incident and the CNA to the Administrator. She stated that the Administrator told her the employee was terminated and that there was nothing they could do about it. Review of the ""Lost or Missing Articles Report"" dated 4/11/2011 revealed Resident #7 lost a $50.00 gift card approximately 4 weeks prior. The report indicated that the gift card ""was in the back of her closet in a small case."" Resident #7 named CNA #1 as the perpetrator. The findings were ""Employee that resident is suspicious of was terminated on 3/17/2011 due to care concerns."" The action taken was ""no action needed at this time; see findings above."" During an interview on 5/23/2011 at 12 PM, the Administrator confirmed Resident #7 had a $50 gift card stolen. The Administrator confirmed that Resident #7 accused CNA #1 of taking the gift card. The Administrator stated that she did not report the allegation or do any further investigation. She stated in ""hindsight"" she ""should have."" Review of the facility's policy on Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents revealed: ""Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent."" Further review of the policy revealed ""Investigation- all reports of resident abuse, neglect shall be promptly and thoroughly investigated by facility management."" ""Upon receipt of an allegation of abuse or neglect, the Administrator or designee will notify the appropriate state agency as soon as practicable, but not to exceed 24 hours... Following the investigation, a five day report will be filed with the appropriate state agency summarizing the investigation, corrective action taken and the outcome of the investigation.""",2014-09-01
9917,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-05-23,226,D,1,0,PQJL11,"On the day of the inspection based on record review, interview, and review of the facility's policy on Abuse and Neglect, the facility failed to report and thoroughly investigate an allegation of misappropriation of resident funds. Resident #7 reported to the facility that CNA (Certified Nursing Assistant) #1 stole a $50.00 gift card. The facility failed to investigate or report the allegation. The findings included: Cross Refers to F225 as it relates to the facility's failure to thoroughly investigate and report an allegation made by Resident #1 that CNA #1 took a $50.00 gift card. In an interview with the surveyor on 5/23/2011 Resident #1 stated that she reported CNA #1 and the missing $50.00 gift card to the Administrator, who told her the CNA had been terminated and there was nothing she could do.",2014-09-01
9918,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2011-05-09,225,E,1,0,16RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on interviews and review of the facility's reportable incidents, the facility failed to report and thoroughly investigate four reportable incidents. Resident #4 sustained a [MEDICAL CONDITION] that was not reported to the State Certification Agency. Resident #5 sustained a coccygeal fracture of unknown origin that was not reported to the State Certification Agency. Resident #6 sustained a laceration to the forehead that was not reported to the State Certification Agency. Resident #7 was found with the call light cord wrapped around her/his neck, the facility failed to investigate the incident thoroughly and failed to report the incident to the State Certification Agency timely. The findings included: The facility admitted Resident #4 on 4/1/2011 with [DIAGNOSES REDACTED]. Review of the Incident Report dated 4/1/2011 at 9:10 PM, revealed Resident #4 ""was found on the floor in the bedroom by family. Resident lying on L (eft) side with blood on floor, face, elbow and hands."" Review of the summary sent to the State Licensing Agency revealed Resident #4 sustained a fracture to his nose. The facility admitted Resident #5 on 4/7/2011 with [DIAGNOSES REDACTED]. Review of the reportable incidents revealed on 4/27/2011, Resident #5 reported low back pain. On 4/28/2011 an X-ray was obtained that indicated an acute distal coccygeal fracture. Review of the summary sent to the State Licensing Agency revealed Resident #5 had a history of [REDACTED]. However, no fall was identified as causing the fracture. The facility admitted Resident #6 on 1/26/2011 with [DIAGNOSES REDACTED]. Review of the Incident Report dated 4/20/2011 at 3:15 PM, revealed Resident #6 was ""found on the floor beside her (his) bed. Laceration to left center of forehead. Skin tear to right index finger. Canary alarm was sounding. Resident's call light was not on."" The incident was not reported to the Stated Certification Agency. The facility admitted Resident #7 on 10/6/2010 with [DIAGNOSES REDACTED]. Review of the Incident Report revealed on 3/ at 4:30 PM, a CNA entered Resident #7's room ""when canary alarm was sounding and call light was on. CNA observed resident to have call light tangled around neck and resident pulling on the cord. Slight red area observed on neck across front. Call light removed and bell placed and bedside. Dr. assessed resident. No new orders."" Review of the Investigation file revealed no staff statements were found and the incident was not reported to the State Certification Agency until 5/4/2011. During an interview on 5/9/2011, the DON confirmed a thorough investigation was not conducted. She also confirmed that no staff statements were obtained. The DON also stated that the incident was reported to the State Certification Agency on 5/4/2011. The DON confirmed that Resident #4's fracture and unwitnessed fall; Resident #5's fracture of unknown origin and Resident #6's laceration to the forehead and unwitnessed fall was not reported to the State Certification Agency. Review of the facility's policy on Abuse and Neglect revealed ""Reporting: All alleged violations concerning abuse, neglect, misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies according to state law including the State Survey and Certification Agency."" Further review revealed ""Investigation: the facility maintains that all allegations of abuse, neglect, misappropriation of property etc are thoroughly investigate and appropriate actions are taken... Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions.""",2014-09-01
9919,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2011-05-09,226,E,1,0,16RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on interviews, review of the facility's reportable incidents and review of the facility's policy on Abuse and Neglect, the facility failed to implement their written policies related to investigation and reporting incidents. The findings included: Resident #4 sustained a [MEDICAL CONDITION] that was not reported to the State Certification Agency. Resident #5 sustained a coccygeal fracture of unknown origin that was not reported to the State Certification Agency. Resident #6 sustained a laceration to the forehead that was not reported to the State Certification Agency. Resident #7 was found with the call light cord wrapped around his neck, the facility failed to investigate the incident thoroughly and failed to report the incident to the State Certification Agency timely. Review of the facility's policy on Abuse and Neglect revealed ""Reporting: All alleged violations concerning abuse, neglect, misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies according to state law including the State Survey and Certification Agency."" Further review revealed ""Investigation: the facility maintains that all allegations of abuse, neglect, misappropriation of property etc are thoroughly investigate and appropriate actions are taken... Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions."" Cross-refers to F 225 as it relates to the facility's failure to implement their written policy regarding investigating and reporting incidents.",2014-09-01
9920,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2011-05-09,281,G,1,0,16RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record reviews and interviews the facility failed to assure nursing staff acted in accordance with professional standards of practice for 2 of 10 sampled residents. Resident #3 failed to have the necessary interventions put in place after his admission, did not have an interim care plan developed to address immediate needs after admission, did not receive the appropriate interventions for respiratory distress and was not sent to the emergency room timely. Resident #4 was not assessed after a fall that resulted in a [MEDICAL CONDITION]. The findings included: The facility admitted Resident #3 on 5/5/2011 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 5/9/2011 at 9:30 AM revealed the First Responders were arriving to the resident's room. The resident was observed on 5 L oxygen via nasal cannula; pale and pursed lip breathing. The resident's oxygen saturation was 71-73 %. The first responders placed a non-rebreather mask at 100 % oxygen. Resident #3's saturation slowly increased to 91-93%. EMS arrived at 9:45 AM and transported the resident to the emergency room . Record review on 5/9/2011 revealed Resident #3 did not have a Discharge Summary, Transfer Summary or History and Physical on record. The Director of Nurses located an envelope that included Transfer Orders and a Hospital Course Summary. Review of the Transfer Summary revealed Resident #3 was to have 5 L High Flow Nasal Cannula Continuously. Review of the Hospital Course Summary revealed Resident #3 had ""Acute on Chronic [MEDICAL CONDITION], status [REDACTED]. Review of the Nurses Notes revealed on 5/8/2011 at 10:35 PM, Resident #3 was ""alert and pale O2 at 5 L, O2 sats 64-84%. Daughter notified and agrees with resident to be sent to emergency room . Nurse Practitioner notified. Resident changed to mask and O2 sat increased to 90 %... At 10:46 PM, ""First responders in to evaluate."" At 11:00 PM, ""EMS in to evaluate, O2 sats 88-90% on 5 L. Resident alert and talkative, decision made per EMS, ER doc, and resident daughter and resident to remain in facility at this time."" At 4:00 AM, O2 sats ""fluctuating 70's and low 80's. NP notified new order received gave [MEDICATION NAME] per order. O2 sat increased to 88%."" 5/9/2011 at 7:00 AM, ""vitals done on resident again O2 sats was (sic) low dtr (daughter) notified and she wanted him sent out to hospital for evaluation and treatment. Oxygen saturations were fluctuating... Ambustar called and awaiting their arrival."" At 0915 AM, Ambustart arrived O2 sats were 62% on high flow O2. I informed Ambustar that I would call EMS. EMS arrived around 9:20-9:25 AM. They put O2 on the resident and sats increased to 93%...he was taken via stretcher to SRMC."" Review of the EMS paperwork dated 5/8/2011 at 10:50 PM, revealed Nursing staff stated that earlier pt (patient) sat had dropped to 60 while they were changing his diaper and sheets... Partner called ER physician and Dr stated that if he was not showing any signs or symptoms then there was nothing he could do for him. After discussing with staff and pt and daughter we all determined that pt would not be transported unless something changed. Pt and staff was advised to call back if something changed."" Review of the Interim Care Plan revealed no care items had been identified. Review of the Nursing Assessment revealed no documentation of the resident's [MEDICAL CONDITION] or the recent [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] Nebulizers were added per physician's orders [REDACTED]. Cross refers to F309 as it relates to Resident #3's need for emergency care. The facility staff failed to have necessary knowledge related to Resident #3 recent hospitalization and treatment for [REDACTED]. The facility admitted Resident #4 on 4/1/2011 with [DIAGNOSES REDACTED]. Review of the Incident Report dated 4/1/2011 at 9:10 PM, revealed Resident #4 ""was found on the floor in the bedroom by family. Resident lying on L (eft) side with blood on floor, face, elbow and hands."" Review of the summary sent to the State Licensing Agency revealed Resident #4 sustained a fracture to his nose. Review of the closed record revealed no nurse's notes. Further review revealed no assessment of the resident's injuries after the fall and no documentation of the resident before or after the fall. Review of the Nursing Admission Assessment revealed no notes written regarding the resident's condition pre or post fall. During an interview on 5/9/2011, the DON confirmed there were no nurse's notes in the medical record and there was no documentation of the resident's injury or the resident's condition after the fall. Cross refers to F309 as it relates to Resident #4's need for emergency care. Resident #4 fell at the facility and was injured on 4/1/11, there was no documentation regarding the injury or the resident's condition before or after the fall to provide evidence that necessary care and treatment was given to this resident.",2014-09-01
9921,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2011-05-09,309,G,1,0,16RU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record reviews and interviews the facility failed to provide the necessary care and services for 2 of 10 sampled residents. Resident #3 did not receive the appropriate interventions for respiratory distress. Resident #3 was not sent to the emergency room timely and did not have the necessary interventions put in place after his admission. There was no evidence that Resident #4 was assessed after a fall. Documentation reviewed from the report made to the State Licensing Agency revealed the resident sustained [REDACTED]. The findings included: The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #3 on [DATE] at 9:30 AM revealed the First Responders were arriving at the resident's room. The resident was observed to be pale and was pursed lip breathing. Resident #3 was observed to be on 5 L oxygen via nasal cannula. The resident's oxygen saturation was ,[DATE] %. The first responders placed a non-rebreather mask at 100 % oxygen. Resident #3's saturation slowly increased to ,[DATE]%. EMS arrived at 9:45 AM and transported the resident to the emergency room . Record review on [DATE] revealed Resident #3 did not have a Discharge Summary, Transfer Summary or History and Physical on record. The Director of Nurses located an envelope that included Transfer Orders and a Hospital Course Summary. Review of the Transfer Summary revealed Resident #3 was to have 5 L High Flow Nasal Cannula Continuously. Review of the Hospital Course Summary revealed Resident #3 had ""Acute on Chronic [MEDICAL CONDITION], status [REDACTED]. Review of the Nurses Notes revealed on [DATE] at 10:35 PM, Resident #3 was ""alert and pale O2 at 5 L, O2 sats ,[DATE]%. Daughter notified and agrees with resident to be sent to emergency room . Nurse Practitioner notified. Resident changed to mask and O2 sat increased to 90 %. Continues to fluctuate."" At 10:46 PM, ""First responders in to evaluate."" At 11:00 PM, ""EMS in to evaluate, O2 sats ,[DATE]% on 5 L. Resident alert and talkative, decision made per EMS, ER doc, and resident daughter and resident to remain in facility at this time."" At 4:00 AM, O2 sats ""fluctuating 70's and low 80's. NP notified new order received gave [MEDICATION NAME] per order. O2 sat increased to 88%."" [DATE] at 7:00 AM, ""vitals done on resident again O2 sats was (sic) low dtr (daughter) notified and she wanted him sent out to hospital for evaluation and treatment. Oxygen saturations were fluctuating...Ambustar called and awaiting their arrival."" At 0915 AM, Ambustar arrived O2 sats were 62% on high flow O2. I informed Ambustar that I would call EMS. EMS arrived around 9:,[DATE]:25 AM. They put O2 on the resident and sats increased to 93%...he was taken via stretcher to SRMC."" Review of the EMS paperwork dated [DATE] at 10:50 PM, revealed Nursing staff stated that earlier pt (patient) sat had dropped to 60 while they were changing his diaper and sheets... Partner called ER physician and Dr stated that if he was not showing any signs or symptoms then there was nothing he could do for him. After discussing with staff and pt and daughter we all determined that pt would not be transported unless something changed. Pt and staff was advised to call back if something changed."" Review of the Interim Care Plan revealed no care items had been identified. Review of the Medication Administration Record [REDACTED]. Further review revealed [MEDICATION NAME] Nebulizers were added. The administration times were 6 AM, 12 PM, 6 PM, and 12 AM. The 6 AM dose was initialed as given Review of the Nursing Assessment revealed no documentation of the resident's [MEDICAL CONDITION] or the recent [MEDICAL CONDITION]. During an interview on [DATE] at 10 AM, Registered Nurse #1 stated that she received report at 7 AM and she was informed that Resident #3 had dropped his O2 sats and EMS was called. RN #1 stated that she immediately went and assessed the resident. She stated that his saturations were low, in the 80's. RN #1 stated that she administered an [MEDICATION NAME] nebulizer. RN #1 stated that the resident's sats increased to 86%. She stated that she notified the Nurse Practitioner. An order was obtained to send the resident to the emergency department. The daughter and resident were in agreement. RN #1 stated that she then called Ambustar to transport the resident. RN #1 stated that the above events had taken place between 7 and 7:30 AM. RN #1 stated that after 45 min, Ambustar had not arrived and she called them back. They informed her they were in the parking lot. RN #1 then went and assessed Resident #3 again and his O2 sat was 62%. RN #1 stated that she then informed Ambustar that she would call 911. RN #1 stated that she called 911 at 9:15 AM and the first responders arrived at 9:25 AM. During an interview on [DATE], at 10:05 AM, the paramedic transporting the resident stated that if a resident dropped his oxygen saturations and had a history like Resident #3, then the resident should be transported to the ER via an ambulance not transfer service. During an interview on [DATE] at 10:10 AM, the Director of Nurses stated that she expected the nurses to have reported all of the resident's information to the nurse practitioner. The DON also stated that there should not have been a delay in time of getting Resident #3 to the ER. She also stated that residents with respiratory distress should be transported via EMS and not Ambustar. The DON also confirmed Resident #3 did not have an interim care plan developed and did not have the necessary care and services in place for Resident #3. The DON confirmed that RN #1 administered an [MEDICATION NAME] nebulizer without an order. During an interview on [DATE], the Nurse Practitioner stated that she was not aware of the resident's medical history. She stated that staff informed her that Resident #3 had a history of [REDACTED]. The NP stated that she gave the order to send the resident to the emergency room . The NP further stated that she was not aware until 4 AM on [DATE] that the resident did not go to the ER. She learned this when staff called her again. Staff reported that the resident did not go to the ER and that he was still dropping his saturations. The NP stated that she ordered [MEDICATION NAME] Nebulizers. The NP then stated that if she was made aware of the resident's history she would have been more ""insistent"" that he go to the ER and if needed to be sent to a different hospital for treatment. She confirmed that the nursing staff should relay all pertinent information. The NP also stated that 911 should be called for all emergencies and the Ambustar should not have been called to transport the resident to the ER. During an interview on [DATE], 4 nurses stated that if a resident exhibited respiratory distress then 911 would be called immediately. They stated that the resident would not be left alone. All four stated that if the resident's saturation dropped and was fluctuating then that would constitute an emergency and 911 should be called. All stated that Ambustar should not be called to transport a resident in distress. All four nurses stated that a resident with a change in condition should be reassessed every 15 minutes to assure that the condition did not deteriorate. Review of the facility's policy on Emergency 911 revealed the facility staff is to call 911 when the ""residents condition is life threatening, in accordance with his/her advanced directives. Qualified Staff initiates the appropriate procedures i.e. oxygen, CPR...Qualified staff attempt to stabilize and monitor resident until the advance medical team arrive."" The facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Incident Report dated [DATE] at 9:10 PM, revealed Resident #4 ""was found on the floor in the bedroom by family. Resident lying on L (eft) side with blood on floor, face, elbow and hands."" Review of the summary sent to the State Licensing Agency revealed Resident #4 sustained a fracture to his nose. Review of the closed record revealed no nurse's notes. Further review revealed no assessment of the resident's injuries after the fall and no documentation of the resident before or after the fall. Review of the Nursing Admission Assessment revealed no notes written regarding the resident's condition pre or post fall. During an interview on [DATE], the DON confirmed there were no nurse's notes in the medical record and there was no documentation of the resident's injury or the resident's condition after the fall.",2014-09-01
9922,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2011-05-09,323,D,1,0,16RU11,"On the day of the complaint inspection based on observation and interviews the facility failed to assure each resident's environment was free of accidents and hazards as was possible. During initial tour of Unit 3 a med cart was observed to have 3 capsules in a medication cup left unattended. The findings included: During initial tour on 5/9/2011 at 9:00 AM, the Unit 3 med cart was observed to have 3 capsules in a medication cup left unattended. No staff was visible in the area. Residents were observed in the immediate vicinity; however, no resident went near the medication. The cart was observed to be unattended from 9:00 AM to 9:30 AM. The surveyor requested the nurse assigned to the cart return to the cart. Registered Nurse (RN) #1 and the Director of Nurses confirmed the medication was left unattended on the med cart and confirmed there were resident's in the area. The medication was identified as Cran Caps 145 mg. RN #1 stated that she had run out and borrowed some from another cart. RN #1 stated that she knew the medication was not supposed to be left out. RN #1 stated that she was in a hurry and forgot to lock up the medication. The DON stated that medications were not supposed to be left unattended on a med cart. She stated that a plan of action would be implemented immediately.",2014-09-01
9923,UNIHEALTH POST ACUTE CARE - BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2014-07-24,323,F,0,1,J30P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policies titled ""Storage of Chemicals and Equipment indicated "". and ""Items Not Allowed in Resident Rooms"", the facility failed to store products in a secure manner that had the potential for harm if accessed by cognitively impaired residents. Storage areas containing these products were observed unlocked and unattended. There were six cognitively impaired, mobile residents currently residing in the facility but none were known to wander. The findings included: On [DATE] at approximately 10:30 AM, during the initial tour, the treatment room door was observed unlocked. The room contained (two) 16 ounce (oz) bottles of Hydrogen Peroxide labeled ""Keep out of reach of children"". The Housekeeping Closet between the nurses' station and the activity/day room was unlocked and contained: (5) cans of Lynx Orange Oil Furniture Polish labeled harmful or fatal if swallowed/keep out of reach of children. (12) 1.25 liter bottles of Provan Foaming Medicated Handwash labeled external use only-keep out of reach of children. One unopened case of Lynx Foaming tile and grout cleaner containing (12) 32 ounce containers per case An activity staff person was seated at a table in the activity room and had the potential to be able to observe the area. One (1) opened box of denture cleanser with 20 tablets remaining labeled keep out of reach of children was noted to be in a bedside stand outside room 16. Room 212, that was labeled as storage, was noted unsecured. The room contained a hot water tank, and maintenance tools including 6 screwdrivers and a hammer. Following the observation, the area was monitored for approximately 20 minutes without further concern. The information was then shared and observed with Licensed Practical Nurse # 1. At that time only the door to the hot water heater remaining unlocked. Licensed Practical Nurse (LPN) #1, stated that s/he was unaware of the denture cleanser and that the resident in that room did not have dentures. S/he removed the items from the drawer. S/he also stated the doors to the Housekeeping closet and storage room were supposed to be locked at all times. On [DATE] at approximately 12:22 PM, LPN # 1 was informed that a key was observed to be left in door of a storage room located across from nursing station, that previously had been locked. There were no resident's nor staff observed in the area at that time. The room contained personal care supplies including: Approximately 50 packs of 10 disposable razors with 4 packages opened ( 26) 16 oz containers of Skintegrity All Over Clean for Hair & Skin- labeled keep out of reach of children, if swallowed get help or contact poison control immediately ( 47) 4 oz Sparkle Fresh Mouth Wash labeled do not swallow, keep out of reach of children, (12) 8 oz containers of Provon Perineal Wash- labeled keep out of reach of children. ( 15) Hollister Odor Eliminator Drops- 8 oz- labeled keep away from children ( 1 box) of approximately 75 1.5 oz containers of Anti Perspirant - labeled keep out of reach of children (36) Nutrashield approximately (36) 4 oz tubes labeled keep out of reach of children. LPN #1 was observed to remove the key from door lock at approximately 12:25 PM. On [DATE] at approximately 2:55 PM, during an interview with the Maintenance Director, s/he stated s/he was not aware door to the room containing the hot water heater had been left unlocked. S/he stated it could be dangerous for residents if they entered room as the hot water heater was stored in the room. The Housekeeping Supervisor, when interviewed on [DATE] at approximately. 2:59 PM, stated that s/he did not know how long the doors had been unlocked. On [DATE] at 3:55 PM, observation of Room 118 revealed one bottle of contact lens cleanser in a box on the resident's bedside table. On [DATE] at 4:02 PM, observation of Room 122 revealed (1) 4 fluid ounce partially filled Nutrashield Cream and (1) 2 fluid ounce partially filled Nutrashield Repair Cream located on the resident's bedside table. Review of the Safety Data Sheets for the products identified as potential concerns stated: Anti Bacterial Denture Cleaning Tablets - Potential Health Effects:...Ingestion: Do not ingest tablets or place them in mouth. Symptoms may include: Damage to the esophagus, abdominal pain, burns, breathing problems, seizures, bleaching of tissue, blood in urine, internal bleeding, vomiting."" Dawnmist Roll-On Deodorant/Antiperspirant - Health Hazards...Ingestion: Call a physician or Poison Control Center immediately. Other information: Keep out of reach of children..."" Nutra Shield Cream"" - Emergency and First Aid Procedures:...Eye Contact: Flush with water. Get medical attention if irritancy persists. Ingestion: If large quantities are ingested, get medical attention..."" Provon Perineal Wash - First Aid Measures: Eye Contact: Do not rub eyes. Flush eyes thoroughly with water for 15 minutes. If condition worsens or irritation persist, contact physician...Ingestion: Do not induce vomiting. Contact a physician or Poison Control Center..."" Mouth Wash - Health Hazard Data...Ingestion...Seek medical attention if at least 20 ml (milliliters)/kg (kilogram) is ingested..."" Medline Protection Plus Body and Hair Shampoo - Health Hazard Data:...Ingestion: May cause oral and gastrointestinal irritation, vomiting, and diarrhea. Emergency and First Aid Procedures: Inhalation: Remove from exposure area to fresh air immediately. Keep affected person warm and at rest. Treat symptomatically and supportively. Contact physician or Poison Control Center. If breathing has stopped, give artificial respiration, and get medical attention immediately...Ingestion: Treat symptomatically and supportively. Maintain airway and respirations. If vomiting occurs, keep head below hips to prevent aspiration. Dilution by rinsing the mouth and giving water or milk to drink is generally recommended. Contact physician or local poison control center. Lynx Foaming Tile and Grout Cleaner - Hazard Identification; Emergency Overview: Danger: Corrosive. Do not get on skin. Harmful if swallowed or inhaled. Avoid breathing vapor or mists. Clear liquid with acid odor...Eyes: Can cause permanent eye injury. Symptoms may include stinging, tearing, redness, pain, blurred vision and eye burns. Skin: Corrosive to tissue. May cause redness, pain and moderate to sever burns. Inhalation: Breathing of this material is harmful. Mist or vapor inhalation can cause sever irritation to the nose, throat and upper respiratory tract. Ingestion: Harmful or fatal if swallowed. Corrosive- may cause sore throat, abdominal pain, nausea and sever burns of the mouth, throat and stomach. Keep out of reach of children. Lynx Orange Oil Furniture Polish: Hazard Identification: Emergency Overview: Danger: Harmful or fatal if swallowed. Aspiration hazard. Vapor Harmful. Can cause nervous system depression. Keep away from heat and flames. Content under pressure. Do not puncture or incinerate container. Eyes: May cause mild irritation. Symptoms include stinging, tearing and redness. Ingestion: Harmful or fatal if swallowed. Aspiration hazard - this material can enter the lungs during swallowing or vomiting and cause lung inflammation and damage. Handling and storage:Keep out of reach of children. EQ Disinfecting SYS listed the following: May cause skin, eye , and respiratory tract irritation, do NOT induce vomiting if ingested. Drink plenty of water. If symptoms persist, call a physician. Review of the facility provided policy entitled Storage of Chemicals and Equipment indicated ""...Storage/Supply Rooms: Storage and supply rooms should be locked at all times..."" Review of the facility policy on [DATE] titled ""Items Not Allowed in Resident Rooms"" revealed the following: No medications of any kind are allowed in resident rooms, whether prescription or over the counter, to include but not limited to lotions, powders, eye/ear drops, pills, liquids, vitamins, etc. At the time of the survey, the facility had six cognitively impaired mobile residents residing in the facility. However, none were known to wander. . The facility admitted Resident # 14 with [DIAGNOSES REDACTED]. On [DATE] at approximately 9:01 AM, medication administration was observed for Resident #14. Licensed Practical Nurse (LPN) #3 was observed to administer medications, giving them to the resident with regular water. The resident began coughing after drinking the water. During reconciliation, it was determined the resident had a physician's order for Honey Thick Liquids that was verified by LPN #3 at approximately 10:25 AM on [DATE]. S/he verified the resident was given regular water and not thickened liquids during med pass. Review of the Physician's Telephone Orders (TO) for Resident # 14 revealed the resident had been changed to a Pureed Diet with Honey Thick Liquids on [DATE]. There also was an order on [DATE] to obtain a FEES, (Fiberoptic Endoscopic Evaluation of Swallowing,) to further assess Pt's (patients) swallowing (secondary to) ST (speech therapy) screening results. The undated Speech Screening results indicated the resident was placed on Aspiration Precautions and required supervision during all oral intake by trained staff. The FEES was completed on [DATE] and the recommendations included: Pureed died with Honey Thick Liquids after test revealed ""...poor laryngeal sensation, and reduced airway closure resulting in penetration (deep, audible) aspiration (audible) of thin liquids via cup/straw, penetration (deep/silent)/aspiration (silent) of nectar- thick liquids via cup, and penetration (deep,silent)/aspiration of liquid portion of mixed solids during the swallow..."" On ,[DATE]//14 at approximately 11:30 AM, review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated that the resident had a BIMS (Brief Interview for Mental Status) of 3, indicative of cognitive impairment. The MDS also documented the presence of a swallowing disorder. Continued record review revealed the Resident's current care plan reflected the resident's swallowing difficulty and the [DATE] diet change and Honey Thick Liquids. The care plan also addressed the resident's decreased safety awareness due to cognitive deficits.",2014-09-01
9924,CONWAY MANOR,425121,3300 4TH AVENUE,CONWAY,SC,29527,2011-05-18,360,F,0,1,DJFV11,"On the days of the survey, based on observation and interview, the facility failed to have a three day supply of emergency food on hand. The findings included: Observations with the Dietary Manager on 3/18/11 at approximately 9:30am revealed the following supplies on hand which were identified for emergency use: 1 case (12 - #2 cans) Cream of Chicken Soup (approximately 120 1/2 cup servings), 1 case (6 - #10 cans) Chili con Carne (approximately 78 1 cup servings) , and 1 case (96 individual packs) Corn Flakes. 1 case (6 - 5lb (pound) tubs) Peanut butter, and 1 case (6 - #10 cans) Grape Jelly. Interview with the Dietary Manager (DM) at that time indicated that the above supplies were held for emergency use. There were pureed items in the freezer but the DM was not sure if the freezer and cooler were on the emergency generators. Further interview revealed the next delivery of food was the next day. The DM was not sure that there was not enough shelf stable food on hand between regular stock and emergency supplies to last for 3 days. When asked if the DM knew how much food should be on hand for emergency supplies, she stated she did not. At the time of the survey the census was 176 residents, however the facility is certified for 190 bed capacity.",2014-09-01
9925,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2010-12-15,225,D,0,1,GFU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to assure an allegation of physical/verbal abuse was thoroughly investigated and reported to the appropriate state agency. Resident #3, (1 of 6 residents reviewed for abuse and neglect) reported an alleged incident of physical/verbal abuse. There was no evidence the allegation was thoroughly investigated and reported to the appropriate state agency. The findings included: The facility admitted Resident #3 on 5/5/10 with [DIAGNOSES REDACTED]. On 12/1510 at 11:15 AM, an individual interview was conducted with Resident # 3 by this surveyor. During the interview, Resident #3 stated a facility staff member had been rude, yelled at her and had ""jerked"" her during care. During a subsequent interview with the Administrator on 12/15/10, she stated that the Ombudsman had visited with residents and that Resident #3 had reported to the Ombudsman the alleged incident which occurred around three months ago. The Administrator also stated that after talking with Resident #3, she was able to determine what staff member could have been involved. The staff member was employed only on an ""as needed"" basis. After speaking with the Director of Nursing, it was decided not to schedule that particular staff member again. When asked if the incident had been reported to the State Survey Agency - Certification, the Administrator stated, ""No."" Review of the facility policy titled ""Abuse Investigations"" listed the following: Policy Statement - ""All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 3) The Director of Nursing will complete and submit the Resident Abuse Report Form to the Office of Certification within 24 hours or next business day.""",2014-09-01
9926,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2010-12-15,441,D,0,1,GFU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview and review of facility policy for handwashing, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. During observation of a pressure sore treatment for [REDACTED]. Additionally, after placing biohazard material in the biohazard room, the staff member did not wash her hands. The findings included: The facility admitted Resident #1 on 11/29/10 with [DIAGNOSES REDACTED]. During observation of a pressure sore treatment on 12/14/10 at 11:27 AM, Registered Nurse (RN) #1 was observed to reach into a paper container of 4 x 4""s with her soiled gloved hand, thereby contaminating the clean dressings. After the treatment was completed, RN #1 bagged the trash in a biohazard bag, entered the biohazard room and discarded the contents. RN #1 exited the biohazard room, entered the resident's room and began to transport the resident to an activity without washing her hands. During an interview with RN #1 on 12/15/10 at 12:25 PM, she stated that hand sanitizer was used after tying up the soiled bag, but could not remember if she had washed her hands before entering the patients room after exiting from the biohazard room. The facility provided policy for Hand Hygiene stated: ""Hand hygiene continues to be the primary means of preventing the transmission of infection.....some situations that require hand hygiene.....before and after direct resident contact....""",2014-09-01
9927,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2010-12-15,156,C,0,1,GFU911,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete 3 of 3 mandated Liability Notices in a timely manner. The findings included: During review of residents' funds on 12-15-10 at approximately 2:45 PM with the Minimum Data Set (MDS) Coordinator, she confirmed 3 of 3 mandated Liability Notices reviewed had not been completed.",2014-09-01
9928,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-05-16,312,E,1,0,TEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record reviews, interviews and information provided by the facility, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 2 of 3 residents that were unable to care for their own needs. Resident #1 and Resident #2 failed to regularly receive showers that were routinely scheduled by the facility. The findings included: The facility admitted resident #1 on 5/8/2009 with [DIAGNOSES REDACTED]. Her Quarterly MDS (Minimum Data Set) of 5/4/11 and the annual MDS dated [DATE] scored the resident as having short and long term memory problems and severely impaired decision making abilities. The resident coded as requiring total assistance with her ADL's (Activities of Daily Living) for bathing and hygiene. During record review on 5/16/2011, it was noted the resident was scheduled for three (3) showers a week, Monday-Wednesday-Friday on the 3-11 shift. Review of the CNA (Certified Nursing Assistant) assignment sheets, had the resident's room and bed number listed for a shower. The assignment stated: ""Shower List: Please initial once the shower is completed! Inform nurse of any resident that refuses a shower."" The resident was scheduled for showers that were not initialed as having been completed on 4/1/11, 4/18/11, 4/20/11, 4/22/11, and 4/25/11. 5 showers for the month of April were not initialed as done. The facility readmitted resident #2 on 4/10/11 with [DIAGNOSES REDACTED]. A score of 8-12 is moderately impaired. He was coded as requiring extensive assistance with his ADL's of bathing and hygiene. During record review on 5/16/11, the resident was scheduled for Monday-Wednesday-Friday showers on the 3-11 shift. Review of the CNA assignment sheets had a space that stated, ""Place INT (initials) if shower given, R if refused, S if resident sick. The resident was scheduled for showers that were not initialed as having been completed on 4/2/11, 4/5/11, 4/7/11, 4/9/11, 4/12/11, 4/15/11, 4/16/11, 4/17/11, 4/19/11, 4/21/11, 4/22/11, 4/23/11, 4/26/11, 4/28/11, 5/2/11, 5/4/11, 5/6/11, 5/9/11, 5/11/11, and 5/13/11; 14 showers were not initialed in April and 6 showers not initialed in May, 2011. During an interview on 5/16/11 at 2:40 PM, the resident stated, ""I don't get my showers like I am suppose to. It's hit or miss. They give me a bed bath on 11-7 sometimes. I take my showers when I can get them."" During an interview on 5/16/11 at 2:30 PM, an RN (Registered Nurse) on the 300 unit stated, ""They (CNA's) are suppose to initial or sign when they give showers. They have not been signing for showers like they are suppose to."" The nurse confirmed that the CNA assignment sheets were the only place that the showers were documented. During the group interview on 5/16/2011 at 10:00 AM, 2 of the 8 residents in the group stated that they do not always get their showers when they are due. ""We are supposed to get 3 showers a week. Sometimes we only get 2, depending on how busy they are. All showers were given in the mornings and now they are changing them. Sometimes you get them in the afternoon.""",2014-09-01
9929,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,309,D,1,1,9D9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to assure a resident (#10) with physician orders for FSBS (Finger Stick Blood Sugar) before meals and at bedtime and Sliding Scale Insulin Coverage four times a day was treated per the physician's order. The order was changed without evidence of a physician's order to do so. Recommendations for the coordination of care between Resident # 10's kidney specialist and the facility were not recieved and acted upon in a timely manner to assure the resident recieved necessary care and services. The findings included: The facility admitted Resident #10 on 12/17/10 with [DIAGNOSES REDACTED]. On 2/8/11 at approximately 9:35 AM, review of the Physician Order Report for 01/01/2011 - 01/31/2011 revealed an order for [REDACTED]. No physician order for [REDACTED]. During an interview at 12:10 PM, Licensed Practical Nurse (LPN) #1 stated she was unable to locate an order changing the frequency of the FSBS from QID to BID and was unable to explain why the frequency had been changed on the Medication Flowsheet. On 2/9/11 at approximately 9:18 AM, further record review revealed on 2/4/11 at at 2:42 PM the facility received recommendations from the resident's Kidney Specialist. Howevever, the facility Physician was not notified until 2/8/11 at 9:50 PM . The recommendations included the following: 1. 1500 cc (cubic centimeter) fluid restriction 2. Nepro 1 can daily 3. Double meat portions at meal times 4. [MEDICATION NAME] 30 mg. (milligrams) Q HS (at bedtime) 5. [MEDICATION NAME] 800 mg. 3 (tablets) with meals TID (three times a day) and 2 (tablets) with snacks 6. Low Potassium Diet During an interview on 2/9/11 at 9:50 AM, the Director of Nursing (DON) stated that the facility has three fax machines, one on each unit and the copier also receives faxes. She stated there is no process for checking the copier, located in a separate room, for any faxes that may contain clinical information. The DON stated that all of the staff on all shifts have access to the copier. She verbalized that the facility had issues with missing lab results and records either not being filed or being filed on the wrong chart but that the facility had not written an formal QA (Quality Assurance) to address the issues.",2014-09-01
9930,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,441,E,0,1,9D9U11,"On the days of the Recertification and Complaint Surveys, based on interviews and observations, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Resident #14 was observed to have her Nebulizer mask attached to the side rail of her bed. There were additional random observations of three other residents with nebulizer masks which were uncovered, lying on the bedside tables or lying over a side rail and five random observations of oxygen tubing lying on the floor. The findings included: On 2/7/2011 during initial tour of the facility, five residents were noted to have oxygen tubing lying on the floor in their rooms. Four residents were observed with nebulizer mask either hooked on the side rail of their beds or lying uncovered on their bedside tables. On 2/8/2010 at 5:50 PM, Resident #14's uncovered nebulizer mask was observed to be hanging on her side rail. On 2/8/2010 at 6:20 PM, Licensed Practical Nurse (LPN) #3 verified that the resident's 14's oxygen tubing was on the floor and that her mask was not stored in a bag but hooked on her side rail. The LPN also verified that the resident's room mate had a nebulizer mask which was also uncovered and draped on her side rail.",2014-09-01
9931,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,286,D,0,1,9D9U11,"On the days of the survey, based on record review, observations and staff interviews, the facility failed to maintain resident's comprehensive assessments in the medical record or in a location that was accessible to all professional staff for all residents with comprehensive assessments. The findings included: During the days of the survey, the most recent comprehensive assessment (MDS) was not available on the medical record. At 2:00 PM on 2/8/2011 the ADON (Assistant Director of Nursing) was asked where the most recent MDS was located. The ADON stated that the MDS's were locked up and she would bring it. When asked if the MDS's were available to the staff, the ADON stated she thought they had a key to get them. At 4:00 PM on 2/8/2011, Licensed Practical Nurse (LPN) #3 was asked if she had a key to unlock the cabinet that contained the MDS. The LPN stated that she did not think so. The LPN was observed trying to open the cabinet. None of the keys on the key ring unlocked the cabinet. .",2014-09-01
9932,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,273,D,0,1,9D9U11,"On the days of the Recertification and Complaint Survey, based on record review and interviews, the facility failed to complete the Care Area Assessment (CAA's) as required for a Comprehensive Assessment or to complete the assessment within 14 days of admission for Resident #10. (1 of 14 charts reviewed for Comprehensive Assessments.) The findings include: The facility admitted Resident #10 on 12/17/2010. A Comprehensive MDS (Minimal Data Set), including CAA's, was required to be completed by 12/30/2010, day 14 of the resident's stay. Review of the record on 2/8/2011 at approximately 11:55 AM revealed the Assessment was signed as complete on 1/13/2011 and did not include the CAA's. During an interview on 2/8/2011, the MDS Coordinator stated the CAA's had not been done and confirmed that the assessment had been signed as complete on 1/13/2011, day 28 of the resident's stay and not within the 14 day time frame as required by the regulation. She further verified that, though signed as complete, the Comprehensive Assessment was not complete without the CAA's. The MDS Coordinator stated she believed that she had been instructed to not to sign the assessment as complete until the care plan had also been completed which is not due until day 21 of the resident's stay.",2014-09-01
9933,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,279,D,1,1,9D9U11,"**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 utilize the CAA's (Care Area Assessments) to develop a comprehensive care plan or to develop the care plan timely. The facility also failed to review and revise the care plan regarding [MEDICAL CONDITION] medications, Percutaneous Gastrostomy (PEG) Tube and [MEDICAL TREATMENT] to reflect the needs of Resident #10, 1 of 14 charts reviewed for care plans. The findings included: The facility admitted Resident #10 on 12/17/10 with [DIAGNOSES REDACTED]. The PEG was subsequently removed while she was hospitalized from [DATE] to 1/15/11 and the resident was no longer receiving any nutrition or hydration via her PEG. Review of the care plan for Resident #10 revealed it was dated 1/13/11 (while Resident #10 was in the hospital). The CAA's had not been completed and therefore had not been utilized in the development of the comprehensive care plan as required in the regulation. On 2/8/11 at 10:17 AM, review of the resident's care plan revealed a care plan for a therapeutic diet with interventions for tube feedings and flushes. It was not reviewed or revised upon the resident's return from the hospital reflecting the removal of the PEG. On 2/8/11 at 9:35 AM, review of Physician's Progress Notes revealed the resident was evaluated by the Psychiatrist on 1/31/11, diagnosed with [REDACTED]. Review of the January and February Medication Administration Record [REDACTED]. On 2/8/11 at 10:17 AM, review of the resident's care plan revealed no care plan for the potential for side effects/ adverse effects of [MEDICAL CONDITION] medications. On 2/8/11 at 9:35 AM, review of the Physician order [REDACTED]. per order."" During an interview on 2/8/11 at approximately 4:00 PM, the MDS (Minimal Data Set) Coordinator confirmed the PEG had been removed and that the care plan did not reflect the removal. She also confirmed the resident had been receiving [MEDICAL CONDITION] medications and that there was no care plan to monitor medication administration, side effects or adverse effects. The MDS Coordinator also verified that the resident was not on fluid restrictions and confirmed that the care plan included interventions regarding maintaining fluid restrictions. She stated she used pre-printed care plans due to time constraints and confirmed that they did not accurately reflect the resident's current status. The MDS Coordinator also confirmed that the care plan was not completed timely. Cross refer CFR483.20(b)(2) F273 Related to untimely and incomplete comprehensive assessment.",2014-09-01
9934,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,502,D,0,1,9D9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of Recertification and Complaint Survey, the facility failed to obtain a blood culture as ordered for Resident #10, (1 of 10 residents reviewed for laboratory services.) The findings included: Resident #10 was admitted on [DATE] with a [DIAGNOSES REDACTED]. (milligrams) 1 (tablet) PO (by mouth) daily x (times) 1 wk (week) then obtain blood cultures on completion of antibiotics. At 11:10 AM, review of the lab results in the record revealed no results for a blood culture. At 11:40 AM Licensed Practical Nurse (LPN) #1 was asked if any lab results were available but not yet filed to the resident's medical record. During an interview at 12:10 PM LPN #1 stated she was unable to locate any blood culture results for Resident #10. She stated that the nurse who receives an order for [REDACTED]. If the staff is still unable to obtain the sample, the Physician is then notified. She was unable to explain why the blood culture was not obtained. During an interview at approximately 1:10 PM, the Medical Records Director stated she was unable to locate the Lab sheets for the month of December and could not confirm that the blood culture had been obtained. During an interview at approximately 1:25 PM, the Wound Nurse, previously the Unit Manager, also stated she had been unable to locate the Lab sheets to confirm the blood culture had been obtained. At 10:40 AM on 2/9/11, the Director of Nursing verified there was no blood culture result in the record and was unable to explain why the blood culture had not been obtained.",2014-09-01
9935,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,333,E,0,1,9D9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to assure that Resident # 2 and Resident # 7 were free from any significant medication errors. Resident # 2 had admission orders [REDACTED]. Resident # 7 was ordered by the physician to receive two medications ([MEDICATION NAME] and KDur) and the order was not initiated for two days following the order. The findings included: The facility admitted Resident #7 on 7/16/09 with [DIAGNOSES REDACTED]. Record review on 2/8/11 at approximately 9:30am revealed physician's orders [REDACTED]. . .KDur 20 meq (milliquivalents) qd."" Review of documentation on the Medication Administration Record [REDACTED]. Interview on 2/8/11 at approximately 2:15 PM with Licensed Practical Nurse (LPN) #2 revealed, that after review of the physician's orders [REDACTED]. Further interview indicated the procedure for new medications was for a nurse to sign off the order, fax the order to the pharmacy, and to begin medication as soon as possible. LPN#2 confirmed that due to the procedure not being followed, the resident's medication was delayed by 2 days. The facility admitted Resident #2 on 11/19/2010 with [DIAGNOSES REDACTED]. Review of Resident #2's monthly physician's orders [REDACTED]. Review of the documentation on the back of the MAR indicated [REDACTED].",2014-09-01
9936,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-02-09,314,D,0,1,9D9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to assure that one of three sampled residents reviewed with pressure ulcers received necessary care and treatment. Hospital transfer orders for Resident # 2 were not implemented timely and there was no evidence the pressure ulcer was treated on two day per physician orders. The findings included: The facility admitted Resident #2 on 11/19/2010 [DIAGNOSES REDACTED].. Review of Resident #2's medical chart on 2/8/11 at 9:25 AM, revealed Hospital transfer orders which stated the resident required the use of a wound vac which needed to be changed on Monday, Wednesdays and Fridays, starting 11/22/2010. The Nursing Data Collection Tool dated 11/19/2010 documented the presence of a wound on admission. There was no documentation that the wound was measured or staged until 11/23/10 (date noted to be difficult to read). When measured on 11/23/10 undermining and tunneling depth assessments were not documented. When the wound was next measured on 12/2/10 there was no undermining but 4 centimeters of tunneling were noted. Physician's Telephone Orders (TO) dated 11/20/2010 stated that the resident's wound was to be cleansed with Cara Klenz and packed with moist gauze daily. The record contained documentation of the alternate treatment for 11/20 and 11/21/2010. On the days of 11/22 and 11/23/2010, the wound care was not documented as having been provided. On 2/8/11, during an interview with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse #2, they verified the discharge orders from the hospital included orders for a wound vac to be continued and changed on 11/22/10 which was not begun/signed as initiated until 11/24/2010. A Telephone Order dated 1/4/11 stated: "" When wound vac not in use may cleanse wound c (with) ns (normal saline), pack c (with) Silver Alginate, cover c (with) dry dressing & (and) secure c (with) tape. Change q (every) day and prn (as needed). When asked by the surveyor why the resident had an order for [REDACTED]. When the ADON was asked for a policy related to wound vac's, she stated that the facility did not have one and instead used the information provided by the wound vac company to train the nurses.",2014-09-01
9937,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,221,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on observations, record review, review of facility policy ""Physical Restraint"", and interview, the facility failed to adequately assess 2 of 3 residents with restraints for the effectiveness of those restraints and 1 of 3 residents was not assessed for a restraint. Resident #1 had bilateral hand mittens that she was able to remove and decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 had bilateral hand mittens as an intervention to prevent him from disconnecting himself from the ventilator. In spite of the interventions he was able to disconnect himself from the ventilator 5 times. Resident #3 decannulated himself 4 times and pulled out his central intravenous catheter. Resident #3 did not have adequate interventions put in place and was not assessed for the need of a restraint. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]."" Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE], she was noted to pull off her mittens frequently. On [DATE] Resident #1 expired after she removed her cannula. . Record review revealed no restraint assessment or reassessments were completed to determine the ineffectiveness of the mittens. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. In addition, Resident #2 had fallen out of bed twice. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was ""deserving of 1:1's."" The Attending Physician also agreed that there were more interventions that could be initiated. Record review revealed Resident #2 did not have a restraint assessment or reassessment completed that addressed the effectiveness of the restraint used. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC (Peripherally Inserted Central Catheter) line resulting in a [MEDICAL CONDITIONS]. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. The Medical Director stated that if a resident displayed self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. Review of the facility policy ""Physical Restraint"" on [DATE] revealed the following information under ""Policy"": ""....Physical restraints may be temporarily required as an intervention for emergent and/or therapeutic care when needed to treat a patient/resident's specific medical condition."" In addition: ""Physical restraints may only be utilized when the following criteria have been met and there is supportive documentation present in the patient/resident's clinical record."" The areas listed included; ""A completed Physical Assessment.......When the patient/resident's physical restraint has been determined to be used as an intervention for emergent and/or therapeutic care and treatment, the physical restraint will only be used for certain time periods and under specific conditions."" Listed under ""Physical Device Initial/Annual Assessment"" the following requirement for assessment was included under ""Admission..."" ""When the patient/resident's condition is suspect for potential use of a physical restraint"", and under ""Quarterly (in conjunction with the MDS (Minimum Data Set) cycle)-Physical Restraint Elimination Assessment. (#1) When the patient/resident currently has a physical restraint. (#2) When the patient/resident's condition is now suspect for potential use of a physical restraint."" Cross Refer to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to follow policy through ongoing assessment of the most appropriate and effective interventions to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9938,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,225,D,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on record review, interview and review of the facility's policy on Abuse and Neglect the facility failed to report timely one of one incident to the State Certification Agency. Resident #1 pulled off her mittens and decannulated herself on [DATE] resulting in her death. The facility failed to report the incident to Certification within 24 hours of the incident. The facility also failed to submit a 5 day report within the mandated 5 days. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE]. Resident #1 expired on [DATE] after she removed her cannula. Resident #1 was also noted to pull off her mittens frequently. Review of the reportable incidents revealed no report was made to the State Certification Agency within 24 hours of the incident and a 5 day report was not submitted to the State Certification Agency. During an interview on [DATE] at 3:45 PM, the Administrator stated that the incident on [DATE] was not reported to the State Certification Agency. She stated that she did not know the incident was a reportable incident. Review of the facility's policy on Abuse and Neglect revealed: ""Reporting: The Administrator and/or Designee will immediately notify the appropriate state agencies of the incident...""",2014-09-01
9939,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,280,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on record review, review of facility policy ""Ventilation, Mechanical"", review of facility policy ""Admission Behavior Logs"", and interview, the facility failed to assure 3 of 3 residents reviewed had their care plans reviewed and revised to reflect the current status of each resident. Resident #1's care plan did not reflect the 7 decannulations and was not updated with interventions to prevent the decannulations. Resident #2 disconnected himself from the vent 5 times. The care plan was not updated to reflect those incidents and was not updated to reflect interventions to prevent his behaviors. Resident #3's care plan was not updated to reflect his behaviors of self injury, decannulation or pulling out his PICC (peripherally inserted central catheter) line. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 pulled off her mittens and decannulated herself 7 times. She died on [DATE] after she removed her cannula Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and ""Patient has pulled [MEDICAL CONDITION] episodes of agitation and often picks and pulls at trach. Approaches included ""Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient [MEDICAL CONDITION] necessary and possible consequences of pulling it."" Another problem area identified on [DATE] ""limb restraints used to prevent pt from removing trach."" Approaches included ""apply limb restraint as ordered, review the continued need for limb restraint."" The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include revised interventions to prevent decannulation. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 disconnected himself from the ventilator 5 times and fell out of bed twice. Review of the Care Plan dated [DATE] and updated [DATE] revealed a Problem area of Combative Behavior. Approaches included ""monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection of patient and others."" Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included ""bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety."" Resident #2's care plan was not updated with his behavior of disconnecting from the vent. No new interventions were added to address the behaviors. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Review of the Care Plan revealed a Problem Area of Respiratory Distress. There was no care plan for the resident's behavior of decannulating self or pulling at the PICC line. The care plan was not updated to reflect the resident's 4 decannulations nor any interventions to prevent the behavior. On [DATE] review of the facility policy ""Ventilation, Mechanical"" revealed the following information: Listed under the title ""Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement."" Under the title of ""Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient. #3 The Interdisciplinary Team will develop a plan of care based on individual resident/patient needs. Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the ""initial interventions""...Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan."" During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9940,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,281,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on observations, record reviews, interviews, review of the facility policy ""Ventilation, Mechanical"", and review of the South Carolina Code of Ethics for Nurses, the facility failed to assure staff members provided services that met professional standards of quality for 3 of 3 residents reviewed. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. Staff members also failed to appropriately respond to alarms. The findings included: During initial tour of the facility on [DATE] at 9:45 AM, an alarm monitor was observed at the desk, several alarms were sounding. Licensed Practical Nurse #1 was observed to stand at the nurse's station and chart for 10 minutes. During those 10 minutes 4 vent alarms sounded and heart rate, oxygen saturation and respiratory rate alarms sounded. The nurse was observed to periodically glance at the monitor and then continue to chart. After 10 minutes, Certified Respiratory Therapist (CRT) #1 walked to the nurse's station, LPN (Licensed Practical Nurse) #1 informed the CRT #1 that the alarms were sounding. The CRT then went to check on those residents. During an interview on [DATE] at 11:00 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. On [DATE] review of the facility policy ""Ventilation, Mechanical"" revealed the following information: Listed under the title ""Equipment"" was ""#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used."" Under ""Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement."" Under the title of ""Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......"" The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE]. On [DATE] Resident #1 expired following her decannulation. Resident #1 was also noted to pull off her mittens frequently. Review of the Physician's Orders revealed a telephone order dated [DATE] for bilateral hand mittens. On [DATE] at 4:30 PM, [MEDICATION NAME] as needed was discontinued. On [DATE] an order was written for [MEDICATION NAME] 15 mg every night. On [DATE] at 10:55 PM, [MEDICATION NAME] 0.5 mg x 1 dose now was ordered. On [DATE] [MEDICATION NAME] was discontinued. On [DATE] [MEDICATION NAME] 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving [MEDICATION NAME] 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was [MEDICAL CONDITION] only. On [DATE] at 5 PM, [MEDICATION NAME] was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for [MEDICATION NAME] 25 mg as needed three times daily. On [DATE], [MEDICATION NAME] 15 mg as needed as ordered. On [DATE] at 11:30 AM, [MEDICATION NAME] and [MEDICATION NAME] were discontinued [MEDICATION NAME] mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed [MEDICATION NAME] on [DATE] for pulling at trach. (No corresponding notes were located). And on ,[DATE] received [MEDICATION NAME] at 11 PM after decannulating. Resident #1 received as needed [MEDICATION NAME] four times for increased anxiety. Review of the MAR indicated [REDACTED]. On [DATE] [MEDICATION NAME] was discontinued. No as needed [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. Resident #1 received as needed [MEDICATION NAME] on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. [MEDICATION NAME] as needed was not administered. [MEDICATION NAME] mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented ""No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented ""she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, [MEDICAL CONDITION]. We seem to have straightened things out by putting her on [MEDICATION NAME] 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day."" During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]."" The Attending Physician was asked if the interventions were effective and he stated ""Yes."" The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't ""know for sure but would have said three."" The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The Attending Physician was asked what other interventions could have been put in place and he stated that he ""honestly didn't know what else"" could have been done. He was asked about 1:1's or psychoactive medications; he stated that he could have tried other medications and that 1:1's would have been better for the patient. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #2 disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. Review of the Physician ' s Orders revealed no PRN (as needed) medication was ordered for agitation. During an interview on [DATE] at 11:40 AM, the Attending Physician agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's; however there were no negative outcomes as of yet for Resident #2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Physician's Orders revealed there was not a psychiatric referral made when Resident #3 began displaying behaviors. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director stated if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. Resident #1, #2 and #3 did not have new and effective interventions put in place to prevent the resident from displaying self injurious behaviors. During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. Review of the South Carolina Code of Ethics for Nurses revealed Provision 1, ""The nurse, in all professional relationships, practices with [MEDICATION NAME] and respect for the inherent dignity and self worth and uniqueness of every individual unrestricted..."" Provision 2 ""The nurse's primary commitment is to the patient..."" Provision 3, ""the nurse promotes, advocates for and strives to protect the health safety and rights of each patient."" Provision 4, ""the nurse is responsible and accountable for individual nursing practice."" Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9941,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,319,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on record review, interviews and review of the facility's policy on ""Behavior Logs"", the facility failed to ensure 3 of 3 residents displaying psychosocial difficulties received the necessary treatment and services. Resident #1 had a history of [REDACTED]. On [DATE] after decannulating herself she expired. Resident #2, care planned for the use of restraints, was able to disconnect from the ventilator 5 times. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. No appropriate interventions were put in place to address each resident's behaviors. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE]. On [DATE] Resident #1 expired after her decannulation. Resident #1 was also noted to pull off her mittens (restraints) frequently. Review of the physician's orders [REDACTED]. On [DATE] at 4:30 PM, [MEDICATION NAME] as needed was discontinued. On [DATE] an order was written for [MEDICATION NAME] 15 mg every night. On [DATE] at 10:55 PM, [MEDICATION NAME] 0.5 mg x 1 dose now was ordered. On [DATE] [MEDICATION NAME] was discontinued. On [DATE] [MEDICATION NAME] 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving [MEDICATION NAME] 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was [MEDICAL CONDITION] only. On [DATE] at 5 PM, [MEDICATION NAME] was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for [MEDICATION NAME] 25 mg as needed three times daily. On [DATE], [MEDICATION NAME] 15 mg as needed as ordered. On [DATE] at 11:30 AM, [MEDICATION NAME] and [MEDICATION NAME] were discontinued [MEDICATION NAME] mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed [MEDICATION NAME] on [DATE] for pulling at trach. (No corresponding notes were located). And on ,[DATE] received [MEDICATION NAME] at 11 PM after decannulating. Resident #1 received as needed [MEDICATION NAME] four times for increased anxiety. Review of the MAR indicated [REDACTED]. On [DATE] [MEDICATION NAME] was discontinued. No as needed [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. Resident #1 received as needed [MEDICATION NAME] on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. [MEDICATION NAME] as needed was not administered. [MEDICATION NAME] mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the physician's orders [REDACTED]. Resident #1 did not receive any PRN (give as needed) medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of documentation on the resident's Medication Administration Record [REDACTED]. Review of the Behavior Monthly Flow Record dated [DATE] revealed Resident #1 had 18 episodes of pulling at her trach. No other documentation was noted on the flow sheets. No other flow sheets were located at the time of the survey. Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and ""Patient has pulled [MEDICAL CONDITION] episodes of agitation and often picks and pulls at trach. Approaches included ""Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient [MEDICAL CONDITION] necessary and possible consequences of pulling it."" The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include adequate interventions to prevent decannulation. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented ""No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented ""she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, [MEDICAL CONDITION]. We seem to have straightened things out by putting her on [MEDICATION NAME] 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day."" During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]."" The Attending Physician was asked if the interventions were effective and he stated ""Yes."" The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't ""know for sure but would have said three."" The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The Attending Physician was asked what other interventions could have been put in place and he stated that he ""honestly didn't know what else"" could have been done. He was asked about 1:1's or psychoactive medications; he stated that he could have tried other medications and that 1:1's would have been better for the patient. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #2 had disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. Review of the Care Plan dated [DATE] revealed a Problem area of Combative Behavior. The care plan was updated on [DATE]. Approaches included ""monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection or patient and others."" No care plan was noted to address Resident #2's falls. No new interventions were put in place after either fall on ,[DATE] or ,[DATE]. Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included ""bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety."" No behavior monitoring flow sheets were located. Review of the physician's orders [REDACTED]. No as needed medication was ordered for agitation. Review of the Physician's Progress Notes revealed Resident #2 was seen last by a Psychiatrist on [DATE]. At that time the [MEDICATION NAME] was increased. Review of the Attending Physician's Progress Notes revealed on [DATE], Resident #2 ""remains on the ventilator and is wearing protective mittens so that he doesn't hurt himself. No changes in his therapy."" On [DATE] the Attending Physician documented ""he's comfortable on the ventilator, but he continues to need to wear mittens to protect him from hurting himself as he is frequently agitated, swinging his arms and grabbing at things."" During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was ""deserving of 1:1's."" The Attending Physician also agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's; however there were no negative outcomes as of yet for Resident #2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Review of the Care Plan revealed no problem area related to the resident's behavior of decannulating self or pulling at the PICC line. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Psychiatrist Note dated [DATE] revealed Resident #3 had previously been on [MEDICAL CONDITION] medications, however all medications were discontinued prior to his admission on [DATE]. Review of the physician's orders [REDACTED].#3 began displaying behaviors. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director stated if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the ""initial interventions""...The Charge Nurse will be responsible for observation, communication with other staff and documentation. Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan."" Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9942,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,323,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on observation, record review, review of facility policy ""Ventilation, Mechanical"" and interview, the facility failed to assure 3 of 3 residents were provided the adequate supervision to prevent accidents and failed to provide an environment as free of hazards as is possible. Resident #1's restraints were ineffective and she self decannulated 7 times. No new interventions were put in place to protect the resident. Resident #1 expired as a result of the self decannulation on [DATE]. Resident #2 wears bilateral mittens but still disconnects from the vent. Resident #2 fell twice with no interventions put in place after the second fall. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a DVT (deep vein thrombosis). No interventions were put in place to protect the resident. The findings included: During initial tour of the facility on [DATE] at 9:45 AM, an alarm monitor was observed at the desk, several alarms were sounding. Licensed Practical Nurse #1 was observed to stand at the nurses station and chart for 10 minutes. During those 10 minutes 4 vent alarms sounded and multiple heart rate, oxygen saturation and respiratory rate alarms sounded. The nurse was observed to periodically glance at the monitor and then continue to chart. After 10 minutes, Certified Respiratory Therapist (CRT) #1 walked to the nurses station, LPN #1 informed the CRT #1 that the alarms were sounding. The CRT then went to check on those residents. During an interview on [DATE] at 11:00 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. On [DATE] review of the facility policy ""Ventilation, Mechanical"" revealed the following information: Listed under the title ""Equipment"" was ""#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used."" Under ""Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for tracheostomy tube replacement."" Under the title of ""Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......"" The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 12 AM, ""Rs (Resident) pulling at vent tubes. Redirected resident."" [DATE] at 12 AM, ""Resident continues to pull ventilatory (sic) tubing off."" [DATE] at 10:40 AM, ""Resident pulled trachea out. No bleeding noted, respiratory therapist reinserted trachea. Resident was medicated for agitation. Trachea was reinserted without complications."" At 11:55 PM, ""Resident pulled trachea out again. Family member was notified. (Family) requested that doctor be called for an order for [REDACTED]. On [DATE] at 12:10 AM, Attending Physician ""notified of resident pulling out trachea times two without complications."" Attending Physician ""gave orders for hand mittens to both hands."" On [DATE] at 6 PM, Resident #1 was medicated for anxiety with 0.5 mg (milligrams) of Xanax. At 6:28 PM, Resident #1 ""slipped right hand out of mittens and pulled trach out. Resp (respiratory) therapist replace trach without any problem. On [DATE] at 6 AM, ""Resident pulled hand free from mitten and disconnected the vent from the trach."" On [DATE] at 12 AM, Resident ""asking staff to remove mittens so she can remove trach."" On [DATE] at 4 AM, Resident #1 ""has hand mittens in place, but she managed to disconnect vent tubing several times during the night."" On [DATE] at 2:45 AM, ""resident managed to remove one glove."" On [DATE] at 6 PM, Resident #1 had mittens off and decannulated herself. Family at bedside. Respiratory Therapist reinserted without any problems. On [DATE] at 9:15 PM and 10:15 PM, ""attempting to remove mittens."" On [DATE] at 12 AM, the nurse documented that Resident #1 did not ""appear to comprehend function and purpose of trach."" At 7:50 AM, ""writer entered resident's room and found resident with trach out. Non responsive to verbal stimuli. RT (Respiratory Therapist) notified and trach placed back in. Resident remained non responsive..."" Resident #1 was sent to the emergency room via ambulance at 8:32 AM. The resident was admitted to the hospital. On [DATE] Resident #1 was readmitted to the facility. On [DATE] at 12 AM, ""Resident managed to remove R (right) mitten."" On [DATE] at 12 AM, ""Resident attempting to pull trach. Mittens reapplied."" On [DATE] at 2:40 AM, Resident #1's mittens were removed per staff member, resident grabbed trach and removed halfway. At 7:30 AM, Resident #1 pulled the mittens off and was pulling at her trach. On [DATE], Resident continues to try to pull mittens off. On [DATE] Resident #1 was moved off of the vent hall. Resident #1 remained on continuous SPO2 monitoring as well as heart rate monitoring. ""Family member requested medications for anxiety. Vistaril 25 mg three times daily as needed was ordered."" Resident #1 was noted to be on a trach collar. On [DATE] at 1 AM, ""family requested something for anxiety."" On [DATE] at 6 PM, ""pt's (patient) family request that pts MD be called due to concerns of pt not resting at night. New order received for Restoril 15 mg at night as needed."" On [DATE] at 10:45 AM, ""Daughter requested for patient to have something routinely at bedtime for rest...new orders received."" (Vistaril and Restoril were discontinued and Ambien 5 mg was ordered.) On [DATE] at 2:45 AM, Resident #1 was observed to have her trach to trach collar at 4 L oxygen and mittens to bilateral hands in place. At 3:20 AM, ""Trach decannulation. RT called to room. Pt assessed, unresponsive to verbal stimuli, sternal rub. Vital signs checked, no pulse, no respirations. CPR started. EMS called. AED applied. Instructions to resume CPR. CPR continued until paramedics arrived."" At 3:45 AM, Resident #1 was transferred to the hospital. At 4:08 AM, Resident #1 was pronounced expired. Review of the Physician's Orders revealed a telephone order dated [DATE] for bilateral hand mittens. On [DATE] at 4:30 PM, Haldol as needed was discontinued. On [DATE] an order was written for Remeron 15 mg every night. On [DATE] at 10:55 PM, Risperdal 0.5 mg x 1 dose now was ordered. On [DATE] Lexapro was discontinued. On [DATE] Risperdal 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving Seroquel 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was on trach collar only. On [DATE] at 5 PM, Seroquel was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for Vistaril 25 mg as needed three times daily. On [DATE], Restoril 15 mg as needed as ordered. On [DATE] at 11:30 AM, Vistaril and Restoril were discontinued and Ambien 5 mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed Haldol 3 milligrams on [DATE] for pulling at trach. (No corresponding notes were located but the MAR had documentation the medication was effective). And on ,[DATE] received Haldol at 11 PM after decannulating. Resident #1 received as needed Xanax four times for increased anxiety. Review of the MAR dated [DATE] revealed Resident #1 received Xanax six times between [DATE] and [DATE]. On [DATE] Xanax was discontinued. No as needed Risperdal was administered. Review of the MAR dated [DATE] revealed on [DATE] Resident #1 received 2 mg Haldol one time dose. Resident #1 received as needed Vistaril on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. Risperdal as needed was not administered. Ambien 5 mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the Behavior Monthly Flow Record dated [DATE] revealed Resident #1 had 18 episodes of pulling at her trach. No other documentation was noted on the flowsheets. No other flowsheets were located at the time of the survey. Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and ""Patient has pulled out trach during episodes of agitation and often picks and pulls at trach. Approaches included ""Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient why trach is necessary and possible consequences of pulling it."" Another problem area was identified on [DATE] of ""limb restraints used to prevent pt from removing trach."" Approaches included ""apply limb restraint as ordered, review the continued need for limb restraint."" The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include new interventions to prevent decannulation. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented ""No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented ""she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, tolerating trach collar. We seem to have straightened things out by putting her on Seroquel 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day."" During an interview on [DATE] at 11 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. CRT #1 stated that she routinely cared for Resident #1 and stated that she had a history of [REDACTED]. During an interview on [DATE] at 12:40 PM, CNA (Certified Nursing Assistant) #1 stated that she cared for Resident #1. She stated that she was aware that Resident #1 had a history of [REDACTED].#1 stated that on the early morning of [DATE] she was sitting at the desk with 2 other nurses. One nurse notified LPN #2 that the alarm was sounding for Resident #1. LPN #2 then went to check on the resident. CNA #1 was walking down the hallway when LPN #1 called out for help and informed CNA #1 that Resident #1's trach was out. CNA #1 stated that she then went and got the Respiratory Therapist. During an interview on [DATE] at 12:55 PM, LPN #1 stated that she cared for Resident #1. LPN #1 stated that she did not hear an alarm sounding, however the vent nurse informed her of the alarm. LPN #1 stated that she went and checked on the resident and noted that she had decannulated herself and was non responsive. She stated that she called for help. The RT came to the room and reinserted the trach and CPR was initiated. LPN #1 stated that she knew the resident had a history of [REDACTED].#1 stated that she had last checked on the resident at 2:45 AM, 35 minutes prior to finding the resident non responsive and decannulated. During an interview on [DATE] at 1 PM, RT (Respiratory Therapist) #1 stated that on the morning of [DATE] at around 3 AM, she was at the desk charting. She stated that CNA #1 came to the desk and informed her that Resident #1's trach was out. RT #1 then went to the resident's room, reinserted the trach and started CPR. RT #1 stated that she knew Resident #1 had a history of [REDACTED]. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]."" The Attending Physician was asked if the interventions were effective and he stated ""Yes."" The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't ""know for sure but would have said three."" The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 had bed bolsters and bilateral mittens in place for safety prior to February 2011. On [DATE] at 4 AM, Resident #2 ""disconnected self from vent."" On [DATE] at 12 AM, Resident ""very agitated at times and pulls self off vent."" On [DATE] at 5 PM, ""upon entering room, I noted the resident in C bed lying on the floor, between the bed and the wall. Vent was unhooked. Resident was placed back on vent."" (On ,[DATE] a bed alarm was ordered). On [DATE] at 3:40 AM, ""found on floor between beds by RT who alerted nurse immediately. Vent alarm sounding, bed alarm working. Assisted back to bed, vent reconnected."" On [DATE] at 8 PM, Resident #2 was ""able to disconnect vent and turn self in bed with feet hanging out of bed."" Further review of the nurses notes revealed Resident #2 had noted self injurious behaviors, including biting and scratching himself. Resident #2 also had a history of [REDACTED]. Review of the Respiratory Therapy Notes revealed no entries related to the resident disconnecting himself from the vent. Review of the Care Plan dated [DATE] revealed a Problem area of Combative Behavior. The care plan was updated on [DATE]. Approaches included ""monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection of patient and others."" No care plan was noted to address Resident #2's falls. No new interventions were put in place after either fall on ,[DATE] or ,[DATE]. Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included ""bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety."" Review of the Physician's Orders revealed Resident #2 was receiving Seroquel three times daily and Depakene at bedtime. No as needed medication was ordered for agitation. Review of the Physician's Progress Notes revealed Resident #2 was seen last by a Psychiatrist on [DATE]. At that time the Seroquel was increased. Review of the Attending Physician's Progress Notes revealed on [DATE], Resident #2 ""remains on the ventilator and is wearing protective mittens so that he doesn't hurt himself. No changes in his therapy."" On [DATE] the Attending Physician documented ""he's comfortable on the ventilator, but he continues to need to wear mittens to protect him from hurting himself as he is frequently agitated, swinging his arms and grabbing at things."" During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was ""deserving of 1:1's."" The Attending Physician also agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 4 PM, ""Resident pulls at all devices. Pulled trach out..."" On [DATE] ""Res pulled out his PICC (Peripherally Inserted Central Catheter) to the R arm. Arm swollen three times the size. Called 911 to transfer to hospital. Called (Medical Director) about pt pulling out PICC line. (Resident #3 was diagnosed with [REDACTED]. On [DATE] at 5 PM, Resident #3 ""pulled out trach, resp called Trach #3 put back in."" On [DATE] at 6:40 PM, Pulmonologist consult for possible trach decannulation."" On [DATE] at 10:30 PM, ""pulled his trach out, respiratory but it back in."" On [DATE] at 7 PM, ""CNA called this nurse to res room. Res had trach lying on his throat, nursing attempted to replace and resp came into room with in two minutes, also attempted to replace trach...MD aware and order to send to (ER) for trach replacement."" The ER was unable to reinsert the trach and the resident was stable. The resident was sent back to the facility decannulated per the physician. Review of the Care Plan revealed a Problem Area of Respiratory Distress. There was no care plan for the resident's behavior of decannulating self or pulling at the PICC line. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Psychiatrist Note dated [DATE] revealed Resident #3 had previously been on psychotropic medications, however all medications were discontinued prior to his admission on [DATE]. Review of the Physician's Orders revealed there was not a psychiatric referral made when Resident #3 began displaying behaviors. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. During an interview on [DATE] at 5:15 PM, the Medical Director stated that he was not aware of the Resident #1's death nor was he aware of the events surrounding her death. The Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. He stated that 1:1's could be an intervention. The facility Medical Director stated that if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The facility Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9943,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,490,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection, based on record review, observations, interviews, and review of facility policies ""Physical Restraints"" ""Ventilation, Mechanical"" ""Admission Behavior Logs"", the Administration failed to administer effectively and efficiently to attain or maintain the highest practicable physical well being for 3 of 3 residents with tracheostomies, behaviors and/or restraints. The facility Administration failed to ensure staff monitored, evaluated, or adequately care planned the behaviors of the identified residents resulting in decannulation and disconnections from the ventilator. (Resident's #1, #2, and #3) The findings included: Resident #1 removed her mittens and decannulated herself 7 times. Resident #1 expired on [DATE] after she removed her cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. No assessments were completed related to the efficacy of the interventions and restraints. No new and effective interventions were put in place for either resident to prevent the decannulations/disconnections. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Adequate interventions were not initiated to address the resident's self injurious behaviors. The facility administration failed to monitor the care provided to residents with tracheostomies, behaviors and/or restraints. Review of the facility policy ""Physical Restraint"" on [DATE] revealed the following information under ""Policy"": ""....Physical restraints may be temporarily required as an intervention for emergent and/or therapeutic care when needed to treat a patient/resident's specific medical condition."" In addition: ""Physical restraints may only be utilized when the following criteria have been met and there is supportive documentation present in the patient/resident's clinical record."" The areas listed included; ""A completed Physical Assessment.......When the patient/resident's physical restraint has been determined to be used as an intervention for emergent and/or therapeutic care and treatment, the physical restraint will only be used for certain time periods and under specific conditions."" Listed under ""Physical Device Initial/Annual Assessment"" the following requirement for assessment was included under ""Admission..."" ""When the patient/resident's condition is suspect for potential use of a physical restraint"", and under ""Quarterly (in conjunction with the MDS cycle)-Physical Restraint Elimination Assessment. (#1) When the patient/resident currently has a physical restraint. (#2) When the patient/resident's condition is now suspect for potential use of a physical restraint."" ""A Restraint Committee will meet at least monthly. A Restraint Committee Coordinator will be appointed by the Administrator."" On [DATE] review of the facility policy ""Ventilation, Mechanical"" revealed the following information: Listed under the title ""Equipment"" was ""#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used."" Under ""Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement."" Under the title of ""Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......"" Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the ""initial interventions""...The Charge Nurse will be responsible for observation, communication with other staff and documentation. Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan."" Cross Refer to the following citations; 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of ""K."" It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of ""K."" Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of ""K."" The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of ""K."" Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of ""K."" The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-501 was identified at a scope and severity level of ""K."" The facility Medical Director, failed to ensure facility policies were developed and followed to meet the needs of the residents ensuring they were receiving services appropriate to their needs. 483.75 Quality Assurance F-520 was identified at a scope and severity of ""K"". The facility failed to identify deficient practice related to residents with tracheostomies, behaviors and/or restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9944,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,501,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on record review and interview, the facility's Medical Director failed to assure resident care policies were implemented appropriately and failed to assure each resident's medical care was coordinated. The findings included: Resident #1 had bilateral hand mittens that she was able to remove and decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Adequate interventions were not initiated to address the resident's self injurious behaviors. During an interview on [DATE] at 5:15 PM, the facility Medical Director confirmed that he was the medical director for the entire facility. He stated that the Pulmonologist (Attending Physician) was the ""medical director"" for the vent unit. The Medical Director confirmed again that he was over the entire facility and was responsible for residents and staff. The Medical Director stated that he was not aware of the Resident #1's death nor was he aware of the events surrounding her death. The Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. He stated that 1:1's could be an intervention. The Medical Director stated that if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]."" The Attending Physician was asked if the interventions were effective and he stated, ""Yes."" The Attending Physician was asked how many time the resident had decannulated herself and he stated that he didn't ""know for sure but would have said three."" The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one (prior to the resident's death). He was asked again if the interventions were effective and he replied no. Cross Refers 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of ""K."" It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of ""K."" Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of ""K."" The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of ""K."" Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of ""K."" The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-490 was identified at a scope and severity level of ""K."" The facility Administration failed to monitor/supervise the care provided residents with tracheostomies, behaviors and/or restraints. 483.75 Quality Assurance F-520 was identified at a scope and severity of ""K"". The facility failed to identify deficient practice related to residents with tracheostomies, behaviors and/or restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9945,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-05-31,520,K,1,0,3NDW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and extended inspection based on observations, record reviews and interviews the facility failed to identify and implement plans of action for concerns identified related to residents with tracheostomies, behaviors and/or restraints. The findings included: Resident #1 had bilateral hand mittens that she was able to remove and she decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the adequate interventions to prevent decannulation of their tracheostomies or disconnection from the ventilator. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of ""K."" It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of ""K."" Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of ""K."" The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of ""K."" Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of ""K."" The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-490 was identified at a scope and severity level of ""K."" The facility Administration failed to monitor/supervise the care provided residents with tracheostomies, behaviors and/or restraints. 483.75 Administration F-501 was identified at a scope and severity level of ""K."" The facility Medical Director, failed to ensure facility policies were developed and followed to meet the needs of the residents ensuring they were receiving services appropriate to their needs. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2014-09-01
9946,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,241,E,0,1,BTTI11,"On the days of the survey, based on observations and interviews, the facility failed to promote an environment that enhances each residents' dignity during dining. The findings included: During a random observation on 7/05/11 at 12:25 AM, a staff member was observed moving a resident from one dining table to place the resident at another table where a resident and her spouse were seated. A resident at the first table asked the staff not to move the resident because they wanted to eat together. The staff informed the resident that was moved that her food tray was available and she need to move her at the other table. The stafff member placed/positioned the resident at the corner of the table with the resident and her spouse. There was little interaction between the the married couple and the resident that was moved. Additionally, there was a table in the dining room ( near the large television) where three residents had been served and were observed to be eating while one resident was not served for 15 to 20 minutes later. A random dinner observation on 7/05/11 at 5:06 PM revealed a staff member seated in the large dining room feeding one resident while 7 to 8 residents were seated in dining room waiting to be served. Two of the residents were heard saying they were ready to eat while watching staff feed a resident in the dining room. An interview on 7/05/11 at 5:07 PM with CNA (Certified Nursing Aide) #2 confirmed she heard the residents saying they were ready to eat. An observation on 7/05/11 at 5:20 PM revealed a staff member moving a resident from one spot at the dining table to accommodate another resident that reportedly sat in that spot. The first resident had been observed sitting in the dining room for over 15 minutes not eating nor served before she was moved to accommodate the other resident whose food was delivered the dining table when she arrived. An interview on 7/05/11 at 5:33 PM with CNA (Certified Nursing Aide) #1 revealed the resident that was moved was new to the facility and the other resident had a special spot at the table. CNA #1 also acknowledged the resident that was moved did not get her food timely. A random observation of the supper meal on 7/5/11 revealed the staff serving residents randomly and not sequentially by tables. Another random observation was made of a staff member feeding a resident in the main dining room in front of 5-6 other residents. The resident was fed and tray removed while the other residents seated at the table were still waiting for their trays. A resident was observed being fed by staff in the larger of 2 dining areas. Other residents were noted to be sitting in the same dining area waiting on their evening meals. The residents waiting were not served their meals until after the resident being fed had completed her meal and was removed from the area. On 7/5/2011, during observation of the evening meal, at approximately 5:45 PM, a female resident was observed to be waiting on her meal for 10-15 minutes while 2 other residents at the same table had been served and were eating. This resident had been moved from her place at the table to another place at the same table for another resident to be seated there with her tray. Multiple residents were observed waiting on their food while other residents at their tables were served and eating their evening meal.",2014-09-01
9947,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,371,E,0,1,BTTI11,"On the days of the survey, based on observations and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Expired milk was noted to be in the milk cooler and the resident refrigerator. The findings included: During a random observation of the facility's kitchen on 7/5/2011 at 9:20 AM, after breakfast had been served, 78- 236 milliter (ml) containers of Buttermilk were noted to have an expiration date of 7/2/2011. There were also 42- 236 ml containers of Fat Free Skim Milk with an expiration date of 7/4/2011. The Dietary Manager verified the expiration dates and then placed a hand written note on the milk crates which stated do not use. At 9:50 AM on 7/5/11, 6-236 ml containers of Buttermilk with an expiration date of 7/2/2011 and 4-236 ml. containers of Fat Free Skim Milk with an expiration date of 7/4/2011 were observed in the resident's refrigerator on the Short Hall. During an interview with Certified Nursing Assistant (CNA) #1, she verified the expirations dates on the containers. When asked by the surveyor if these were given to the residents, she stated after the resident's diet was verified by the nurses, they did give the residents milk from the refrigerator. On 7/5/2011, at approximately 11:00 AM, the Regional Dietary Consultant stated that he had started an in-service related to checking for expiration dated on the containers of milk. He also stated that the weekend staff must not have checked them. On 7/05/11 at 12:40 PM during a random lunch observation, staff was observed delivering uncovered food trays down the hall to rooms 1 to 16. There was no food carts available. The residents food was delivered on a tray with the plates uncovered. On 7/05/11 at 5:40 PM ,during random dinner observation , staff was observed delivering food trays down the hall to rooms 1 to 16 with the dessert ( peaches) uncovered. An interview on 7/06/11 at 5:44 PM with CNA (Certified Nursing Aide) #2 confirmed the peaches were not covered during meal delivery.",2014-09-01
9948,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,156,C,0,1,BTTI11,"On the days of the survey, based on observation and interview the facility failed to display, per regulatory requirement, written information about how to receive a refund for previous payments covered by medicare and medicaid. The findings included: Initial tour of the facility on 7/05/11 at 9:30 AM revealed there was no posting in the facility related how to obtain a refund from medicare and medicaid. An observation and interview on 7/06/11 at 10:55 AM with the Director of Nursing confirmed the findings that there was no posting related to how to receive a refund for previous payments.",2014-09-01
9949,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,167,C,0,1,BTTI11,"On the days of the survey, based on observation and interview, the facility failed ensure the most recent survey was readily accessible to the residents and failed to post a notice of survey availability. The findings included: Initial tour of the facility on 7/05/11 at 9:30 AM revealed there was no posting in the facility related the availability of the most recent survey. An observation and interview on 7/06/11 at 10:55 AM with the DON (Director of Nursing) revealed there was no posting of the most recent survey. The survey was located on a bulletin board out of reach of the residents and there was no posting noted to identify the survey as the most recent survey as confirmed by the DON.",2014-09-01
9950,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-05-11,225,D,1,0,Y5Z911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record reviews, interviews and review of information provided by the facility, the facility failed to report to the state agencies an injury of unknown origin for 1 of 1 residents with an injury of unknown origin. Resident #1 sustained a fracture of her right clavicle and a dislocated right shoulder; the facility was unable to determine when or how the injury occurred. The findings included: The facility admitted Resident #1 on 1/6/09 with [DIAGNOSES REDACTED]. On 5/10/11 the resident's medical record was reviewed. The resident had been discharged on [DATE] at 5:00 AM. Review of the nurse's notes for 3/20/11, at 1:25 PM, stated that the nurse was informed the resident's roommate had reported the resident had fallen out the bed, ""she pitched off the bed as if reaching for something off the floor"". Resident #1 was medicated for pain at 8:29 AM, for complaint of her right shoulder hurting. The nurse wrote that at the time the pain medication was given she was unaware of a fall. The nurses note continued to say that the resident was given pain medication again at 12:00 PM, ""resident was able to move arm at that time without difficulty"". At 6:50 PM on 3/20/11, a nurse's note stated that the daughter had arrived and requested the resident be sent to the ER (emergency room ) for evaluation, treatment and an x-ray. On 3/21/11 a nurse's note timed for 3:00 AM, stated the hospital had notified the facility the resident had sustained a dislocated right shoulder and was transferred to another hospital in Aiken. A nurse's note for 5:00 AM stated the daughter had come in to ""retrieve mothers belongings, medications..."" The daughter informed the staff she had taken the resident home. The resident had [DIAGNOSES REDACTED]. The daughter also stated the doctor had informed her the resident's condition could have not just happened, it was an old fracture, ""perhaps occurred as far back as Friday."" Review of the facility investigation of the incident included a witness statement from Resident #3, the roommate of Resident #1. ""Resident stated she was awakened from a deep sleep with the sound of her roommate falling to the floor. States she was very sleepy but opened her eyes to see roommate on the floor and two persons came in and attempted to lift her and called for another person. She stated she could not identify persons in the room because she was sleepy and it was dark."" The resident did not witness the fall; she heard a noise that woke her. The facility admitted resident #3 on 10/3/08 with [DIAGNOSES REDACTED]. The medical record was reviewed on 5/10/11. Review of the Quarterly Minimum Data Set of 4/12/2011, the resident was coded an 11 for her BIMS (Brief Interview for Mental Status). A score of 8-12 indicated the resident was moderately impaired. Medication review revealed the resident was on multiple psychoactive medications. Nurse's Weekly Progress Reports dated 3/13/11 and 3/20/11 had the resident documented as ""Mentally Challenged. Under ""Disordered Thinking/[MEDICAL CONDITION]"": Ability Varies is checked on both of the weekly reports. On the 3/20/11 report, her decision-making ability was checked at Severely Impaired. On 5/10/2011 at 2:15 PM, Resident #3 was interviewed regarding the incident. When asked if she saw her roommate fall, the resident said, ""Yes, she fell . She was walking around the room. She slammed the door open and she fell ."" When asked if she remembered when her roommate had fallen, she stated, ""No. Isn't it enough she fell ?"" The resident had nothing more to say about the incident. During an interview with the Director of Nurses (DON) on 5/11/2011 at 1:30 PM, she stated she thought the roommates having said that they heard the fall, that it was a witnessed fall. She stated that she knew one of the roommates was unreliable but thought that one was reliable. She confirmed that the injury was not reported to the state agency as required for an injury of unknown origin. Review of the facility investigation revealed that no staff members witnessed the incident. None of the staff statements confirmed the resident had been picked up off the floor. Resident #3 stated she was awakened by the sound of the resident falling sometime early Sunday morning. During an interview with the Resident #3, she stated the resident had slammed the door open and fell . The resident complained of pain of her shoulder on 3/20/11 in the morning and at noon. There was no documentation to indicate there had been any incident or injury until 1:25 PM on 3/20/11. The time and the cause of the resident's injury were not determined by the facility. The facility did not report the injury of unknown origin to the State Agency as required.",2014-09-01
9951,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,363,F,0,1,KWBU11,"On the days of the survey, based on observation, interview, and facility policy related to Emergency Food Supply, the facility failed to maintain a separate emergency food supply to met the nutritional needs of the residents. The findings included: During a tour of the main kitchen on 12/8/10 from 10:30 AM to 11:45 AM, a request was made to observe the emergency food supply. The Food and Beverage Director stated that they had a 72 hour supply of food as part of their regular stock and he understood that was sufficient. He further stated that they could also order more food from their food purveyor in Columbia if needed. The plan for Emergency Food Supply was requested. The policy dated 3/15/10 documented ""A three day supply of staple food items will be kept on hand at all times. All foods are either canned or non-perishable and may be served without heating. Food for emergency menu is kept in a marked special area in the storage room.""",2014-09-01
9952,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,372,F,0,1,KWBU11,"On the days of survey, based on observation and interview, the facility failed to ensure garbage and refuse was disposed of properly in outside storage receptacles. The findings included: The compactor and cardboard and recyclable dumpsters were observed during the tour of the main kitchen on 12/8/10 at approximately 11:30 AM. There was a large amount of paper and plastic trash under the wooden steps leading up to the compactor as well as trash around the three containers. There was also trash scattered in the woods behind this area. An interview with the Food and Beverage Director indicated dietary was not responsible for keeping the area clean and trash-free.",2014-09-01
9953,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,362,F,0,1,KWBU11,"On the days of survey, based on Dietary observations and identified concerns and interview, the facility failed to ensure sufficient personnel were employed to carry out the functions of the dietary service. The findings included: The Food and Beverage Director was interviewed on 12/8/10 at 2:10 PM regarding the concerns related to the sanitary conditions in the Main and Health Care kitchens. When asked about sufficient staff, he stated that all employees had been on an eight hour furlough per week for the last two months. He also stated there was a hiring freeze and he had 8 positions to be filled, 6 dietary under staff and 1 Health Care Center Dining Room Manager, and 1 Sous Chef.",2014-09-01
9954,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,371,F,0,1,KWBU11,"On the days of survey, based on observations, interview, and facility documentation, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. The main kitchen that cooked for the entire campus including the Health Care Center as well as the serving kitchen in the Health Care Center were inspected and found to have numerous areas of unsanitary conditions. The current monitoring systems for cleaning/sanitation in both areas were not being utilized based on the findings. The findings included: During the initial tour of the kitchen on 12/7/10 at 8:40 and the extended tour on 12/8/10 from 10:30AM to 11:40 AM accompanied by the Food and Beverage Director the following conditions were found: A large grey plastic trash container uncovered by the kitchen door containing trash. Kitchen floor with dust, dried spills, and food remnants. Dust, black matter on 1/2 of the metal filters over the cooking area on both sides. Dust on the fan and mechanical parts behind the oven. During the extended tour of the main kitchen on 12/8/10 from 10:30AM to 11:40 AM accompanied by the Food and Beverage Director the following conditions were found:, Heavy grease build-up on the convection ovens inside and outside. Metal splash guard around the stove with soiling. Stored pots and pans over the pot and pan sink with soiling. Dried food spills/food crumbs/and or black substance around the floor drain rim, behind a majority of the cooking equipment, stainless steel shelving, drawers in the food preparation area near the meat slicer, table under the meat slicer, spice storage shelf, rice, sugar, and flour plastic bins, #10 can rack, shelves in cooler, black plastic bins holding lids, potato chip and croutons and the ceiling of the freezer. The floor throughout the kitchen, including under the pot and pan sink, behind tilting kettle, cooler, and freezer was observed with trash, dust, and dried food. Radios on shelves in kitchen and dishroom. Frozen fish was observed in a large plastic container on the floor next to a kettle, being defrosted with running water. Large frozen juice containers in the cooler were covered with frost, being stored over opened cartons of individual butters being defrosted. Sanitizer test of solution in red plastic bucket testing with 200 parts per million chlorine. Freezer with sprinkler system and food stacked higher than 18"" on the top shelves. Three tall grey stained trash/garbage containers uncovered near food preparation areas. During the extended tour of the Health Care Center (HCC) kitchen on 12/8/10 at 11:45 AM, the following conditions were found: A spray bottle of Chlorox bleach stored in the grey plastic cabinet with V-8 juice and individual puddings. There was also a purse on the bottom shelf next to the inside section of a mini dicer/chopper. A jacket was stored on a metal cart next to a bag of napkins The Air Conditioning/heating unit mounted on the wall above the microwave was observed with dust and smudges. Food crumbs/ spills/and or grease were identified in the condiment storage area, inside bottom of the plate lowerator, silverware bins, bottom shelf of the cart containing blue plastic plate covers, on the outside of the microwave shelf, four stainless steel drawers under the steam table, and dust on the vents above the doors on the upright refrigerator. Two employees serving food were observed wearing dangling earrings. Interview with the acting supervisor of the HCC kitchen revealed each employee had their own cleaning assignments. There were also Daily Equipment Cleaning Check list forms on the bulletin board (last one dated 12/6/10) initialed by the AM and PM supervisors. The instructions on this form included ""Employees are required to complete these tasks each and every shift AM & PM. Failure to complete tasks will result in disciplinary action"" The PM Supervisor, Executive Chef or the Sous Chef on duty will be responsible for final inspection and turning in sheet to the Director of F & B (Food and Beverage) daily"" Interview with the Registered Dietitian on 12/8/10 at approximately 1:30 PM revealed he did a Sanitation Survey of the main kitchen every two weeks which were provided. The findings were reviewed by him with with the Executive Chef, the Sous Chef and Administrator. The score for 10/1 was 97.6%; 10/8 was 97.7%; 10/14 92%; 11/5 90.3%, and 11/29 88%. The Food and Beverage Director presented ""Daily Cleaning Check Lists"" and ""AM/Daily Supervisor Checklists for DHEC policies."" The findings from the check lists resulted in a ""Food and Beverage Quality Assurance Review"" which was presented. The time frame was from about 3 months ago with a target date of 1/1/11. The section on Sanitation and Infection Control met the LCS/Community (facility)Standards. Inservices presented were as follows: QI (Quality Improvement) audit of tray line temperatures from 2/14-3/5/10 within acceptable standards. Inservices on 12/29/09 and 2/16/10 on the cleaning schedule. Dietary Meeting 4/13/09 ""Follow your cleaning list"" A Life Care Services policy dated 2005 for Daily Cleaning, Weekly Cleaning, Food Storage, and Garbage Disposal was presented when it was requested from the Director of F & B. A review of the infection control surveillance data from 1/10-11/10 and chart review of sampled residents revealed no pattern or outbreaks of Gastrointestinal concerns.",2014-09-01
9955,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,280,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to periodically review and revise the care plan for 1 of 9 residents reviewed. (Resident #1 was exhibiting behaviors of refusing care and diet which was not addresssed in the plan of care.) The findings included: The facility admitted Resident #1 on 9/10/09 with [DIAGNOSES REDACTED]. Record review on 12/7/10 revealed that the resident exhibited behaviors of refusal of meals, supplements, refused periods of rest and personal hygiene. Review of the Minimum (MDS) data set [DATE] listed the resident's cognitive status as a short term memory problem and moderately impaired cognitive skills for daily decisionmaking. The resident's weight chart revealed that the resident had lost weight over the past months and also had three Stage II pressure sores. Further review of the resident's care plan revealed that although the behaviors had been added to the care plan, interventions for the exhibited behaviors had not been incorporated into the resident's plan of care. During an interview with the Care Plan Coordinator on 12/8/10 at 10:35 AM, she stated that when the resident exhibited behaviors, the facility staff would call the resident's son or ask staff that had a good rapport with the resident to talk with him. At the time of the interview, the Care Plan Coordinator confirmed that she had not updated the resident's care plan to include interventions for the behaviors exhibited.",2014-09-01
9956,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,315,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, interview, and review of facility policy for Perineal Care, the facility failed to ensure appropriate perineal/incontinent care was provided for 1 of 1 residents observed for perineal/incontinent care. During perineal/incontinent care, the Certified Nursing Assistant(CNA) did not cleanse the perineal area properly, cleanse the resident's buttocks, and did not wash her hands during the procedure. (Resident #6) The findings included: The facility admitted Resident #6 on 11/15/02 with [DIAGNOSES REDACTED]. On 12/8/10 at approximately 4:40 PM, CNA #2 was observed providing perineal/incontinent care for Resident #6. After CNA #2 donned gloves, the resident's brief was unfastened and the resident was rolled to the left side. CNA #2 removed her gloves and donned new ones, a brief was placed, and the resident was rolled onto her back. CNA #2 changed her gloves and using different wipes, cleansed the creases of the right leg and then left leg. CNA #2 changed gloves and attempted to spread the resident's labia. Using a wipe, she wiped down the middle of the perineal area. CNA #2 changed gloves and repeated the cleansing process. After drying the resident, CNA #2 changed gloves and reapplied the resident's brief. CNA#2 removed her gloves and washed her hands. Review of the facility policy titled ""Perineal Care, General"" listed the following in the guidelines: "" e) Female: Wash perineal area (from pubis toward perineum) with disposable wipes. Discard disposable wipes after one use in trash liner/bag. g) Remove perineal pad. h) Dry perineal and anal areas. Apply clean dry perineal pad or under garments. Assist resident to comfortable position. i) Discard disposable items. Remove gloves and wash hands thoroughly."" CNA #2 was asked during an interview on 12/8/10 at 5:50 PM if she could identify anything that the surveyor may have been concerned during the treatment. She stated that she had done the procedure wrong related to the cleaning of the resident's perineal area.",2014-09-01
9957,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,367,E,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide the physician prescribed diet for 2 of 6 sampled residents reviewed for therapeutic diets. During the survey meal observations, Resident #1 did not receive Ensure with meals and Resident #6 did not receive whole milk with meals per physician orders. The findings included: The facility admitted Resident #1 on 9/10/09 with [DIAGNOSES REDACTED]. Record review on 12/7/10 revealed a physician's orders [REDACTED]. Further review of the Minimum Data Set(MDS) listed the resident's cognitive status as a problem with short term memory and moderately impaired cognitive skills for daily decision making. Review of the care plan noted the resident as refusing meals, supplements, periods of rest, and personal hygiene. An intervention listed on the care plan related to pressure sores was to adjust diet/supplements as indicated to reduce the risk of skin breakdown. Also, the care plan for potential weight loss related to poor po(oral) intake of meals listed as an intervention to provide nutritional supplements as ordered by physician and provide diet as ordered by physician Review of the nurse's notes listed only one time on 11/23/10 that the resident had received/or refused the Ensure supplement. Review of the nutritional assessment dated [DATE] listed significant weight loss and pressure ulcers as problems identified with recommendations to consider liberalizing diet to Regular Mechanical Soft with chopped meets and to change supplements to between meals rather than at mealtime to improve intake at meals. On 9/3/10, the Dietician again recommended to liberalize diet and to give supplements between meals. On 12/6/10, the Dietician recommended to continue diet and supplements. Review of the resident's weights were as follows: 1/10 -139.8, 2/10 - 154.5, 3/10 - 149.2, 4/10 - 139.4, 5/10 - 161, 6/10 - 159.2, 7/10 - 156, 8/10 - 157, 9/10 - 144, 10/10 - 143.5, 12/10 - 141.8. Observation of meals on 12/7/10 at 12:50 PM, 6:15 PM and 12/8/10 at 9:10 AM revealed that the resident did not receive Ensure as ordered during the three meals observed. Review of the placement card revealed that Ensure was not listed. Review of the list in the satellite kitchen revealed that Ensure was listed. The Medication Administration Record for the dates of 12/7-8/10 revealed that Ensure had been signed off as given. An interview on 12/8/10 with Licensed Practical Nurse #5 confirmed that the resident had not received Ensure but the MAR had been signed. She also stated that the family wished that the Ensure still be offered to the resident. LPN #5 stated that if the resident did not consume the Ensure that a circle should be placed around the nurse's initials to indicate that it was not given/consumed. The facility admitted Resident #6 on 11/15/02 with [DIAGNOSES REDACTED]. Record review of the current physician's orders [REDACTED]. Review of the resident's care plan revealed an intervention for weight loss was whole milk with meals. Review of the resident's weights were as follows: 1/10 - 131, 2/10 - 134, 3/10 - 123, 4/10 - 134, 5/10 - 130, 6/10 - 125.7, 7/10 - 127, 8/10 - 129, 9/10 - 128.7, 10/10 - 127.1, 11/10 - 133.9, 12/8/10 - 127.1. Observation of the meals on 12/7/10 at 12:45 PM, 6:10 PM, and 12/8/10 at 1:00 PM revealed the resident did not receive whole milk. Review of the placement card on the table revealed whole milk was listed. During an interview with Certified Nursing Assistant(CNA) #2, she confirmed that while assisting the resident at mealtime that the resident had not received whole milk. During an interview with a CNA sitting beside the resident during mealtime, she stated that the resident has too much to drink and would not drink the milk. During an interview with the Director of Nursing on 12/9/10 at 9:11 AM, she stated that the staff should encourage the residents at mealtime to eat and drink and that the CNA's should tell the nurse if the residents are not consuming the meals/drinks as ordered.",2014-09-01
9958,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,176,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews the facility failed to follow a procedure to ensure that an individual resident had been assessed by an interdisciplinary team for self-administration of drugs. The findings included: On 12/7/10 at approximately 9:38 AM during observation of medication pass, Licensed Practical Nurse (LPN) # 1 allowed Resident A to self-administer inhalations from a [MEDICATION NAME] Inhaler. Resident A did not shake the container as specified by the manufacturer and waited approximately 5 seconds between inhalations, instead of one minute as specified in Facts and Comparisons. During medication reconciliation, there was no physician's order for self-administration and there was not record of an assessment for self-administration. On 12/7/10 at approximately 3:30 PM, LPN # 1 stated that the resident was alert and oriented and was always allowed to self-administer the [MEDICATION NAME] Inhaler and that in spite of encouragement did not wait between inhalations. During an interview on 12/8/10 at approximately 9:25 AM, LPN # 2 (Care Plan Coordinator) stated that no assessment for self-administration had been completed on Resident A. During an interview on 12/8/10 at approximately 5:00 PM LPN # 4 stated that she did not allow Resident A to self-administer [MEDICATION NAME] Inhaler and that she waits one minute between inhalations.",2014-09-01
9959,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,425,E,0,1,KWBU11,"On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 1 of 1 medication rooms. The finding included: On 12/7/10 at approximately 12:25 PM, inspection medication room revealed the following: -An undated, opened foil pouch containing eleven vials of Xopenex Inhalation Solution 1.25mg. (milligram)/3ml. (milliliter) was found on the bottom shelf of the refrigerator. -An undated, opened foil pouch containing six vials of Xopenex Inhalation Solution 0.63mg. /3ml. was found on the bottom shelf of the refrigerator. The manufacturer label on each of the foil pouches stated: "" Once the foil pouch is opened, the vials should be used within 2 weeks "". -Four Povidone Iodine Prep Pads, Lot 5B94, expiration 2/08 were found atop the treatment cart. -One Povidone Iodine Prep Pad, Lot 3M11, expiration 12/06 was found atop the treatment cart. On 12/7/10 at approximately 12:35 PM LPN (Licensed Practical Nurse) # 5 stated that all nurses used products from the treatment cart and confirmed that the Xopenex vials and Povidone Iodine Prep Pads were expired.",2014-09-01
9960,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,332,E,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of a medication error rate of five percent or greater. The medication error rate was 7.3% (percent). There were 3 errors observed out of 41 opportunities for error. The finding included: -ERROR # 1: On 12/7/10 at approximately 9:38 AM, during observation of medication pass on Sweet Bay, Licensed Practical Nurse (LPN) # 1 handed a [MEDICATION NAME] Inhaler to Resident A without shaking the inhaler or providing instruction to Resident A. Resident A took two puffs from the inhaler with approximately 5 seconds between puffs. During medication reconciliation on 12/7/10 at approximately 2:00 PM, the physician's order [REDACTED]. However, the Drug Facts and Comparisons states that the [MEDICATION NAME] Inhaler should be shaken for 10 seconds before administration and in reference to administration technique for aerosol inhalers: "" Allow greater than or equal to 1 minute between inhalations (puffs). "" On 12/7/10 at approximately 3:30 PM LPN # 1 verified that the [MEDICATION NAME] Inhaler had not been shaken, that no instruction had been given to Resident A and that Resident A had not waited a sufficient amount of time between inhalation. During an interview on 12/8/10 at approximately 5:00 PM, LPN # 4 stated that she administers [MEDICATION NAME] Inhaler to Resident A and that she waits a minute between inhalations. -ERROR # 2: On 12/7/10 at approximately 4:47 PM, during observation of medication pass on Sweet Bay, LPN # 2 stated that she would not administer [MEDICATION NAME] 6.25 mg. (milligrams) to Resident B due to a low blood pressure reading of 102/61. During medication reconciliation on 12/7/10 at approximately 5:00 PM, the physician's order [REDACTED]. During an interview on 12/7/10 at approximately 5:10 PM, the Director of Nursing stated that a medication hold order due to low blood pressure would be a parameter of the physicians order. On 12/7/10 at approximately 6:10 PM LPN # 2 verified again that the dose had been withheld from Resident B due to the low blood pressure reading. -ERROR # 3: On 12/8/10 at approximately 8:45 AM, during observation of medication pass on Sweet Bay, RN # 1 poured Polyethylene [MEDICATION NAME] 3350 Powder into a medicine cup and measured the powder to the 25 ml. (milliliter) mark. RN # 1 poured approximately 6 oz. (ounces) of water into a plastic cup, dissolved the powder in the water and administered to Resident C. During medication reconciliation on 12/8/10 at approximately 8:50 AM, the physician's order [REDACTED]. of water once daily. "" On 12/8/10 at approximately 8:55 AM RN # 1 verified that the order read to measure 17 Gm. (grams) or one capful of the powder and mix with 8 ounces of water. She measured one capful of powder using the Polyethylene [MEDICATION NAME] 3350 graduated cap at the 17 Gm. mark, poured it into a medicine cup and noted that it read 30 ml. RN # 1 verified that the plastic cup used to measure the water was a 7-ounce cup and that it had not been poured completely full with water.",2014-09-01
9961,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,441,D,0,1,KWBU11,"On the days of the survey, based on observation and interview, the facility failed to assure Personnel must handle, store soiled linens so as to prevent the spread of infection. Soiled linen was observed stored uncovered and over-flowing the storage container. The findings included: During initial tour on 12/7/10 at approximately 8:40 AM a white overloaded soiled linen container was observed in the Sweet Bay Soiled Utility Room. The soiled linen container was uncovered and over-flowed approximately 18-inches above the top of the container. Repeated observations on 12/7/10 at approximately 11:30 AM, 12:45 PM, 3:10 PM and 3:55 PM found that the overloaded soiled linen container remained uncovered and had not been removed from the Soiled Utility Room. During interviews on 12/8/10 at approximately 6:50 PM, the DON (Director of Nursing) stated that soiled linen containers should be covered and the Administrator stated that the Laundry is responsible for removing soiled linen daily at 8:00-8:30 AM and 1:30-2:00 PM.",2014-09-01
9962,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,156,C,0,1,KWBU11,"On two days of the survey, based on observations, interview, and review of ""Residents Rights"" in the facility's Admission Packet, the facility failed to prominently display written information on how to receive refunds for previous payments of Medicare benefits. The findings included: On two days of the survey, written information of how to receive refunds for previous payments covered by Medicare benefits had not been prominently displayed. Random observations on 12-07-10 and 12-08-10 of a posting observed on the bulletin board in the facility entrance foyer revealed no information on how to receive refunds for previous payments covered by Medicare. During an interview on 12-08-10 at approximately 1:40 PM with the Director of Social Services, she revealed she did not know refund information for previous payments of Medicare benefits had to be prominently displayed. Review of ""Residents Rights"" in the facility's Admission Packet stated,""The facility must prominently display in the facility written information and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits"".",2014-09-01
9963,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,279,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to develop an Initial Care Plan that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 new residents. Resident #4 did not have an Initial Care Plan developed. The findings included: The facility admitted Resident #4 on 12-01-10 with [DIAGNOSES REDACTED]. Record review on 12-08-10 at approximately 1:00 PM revealed an Initial Care Plan had not been developed. During an interview on 12-08-10 at 1:15 PM with Licensed Practical Nurse (LPN) #2, she, after record review, confirmed an Initial Care Plan had not been developed. She further revealed she was responsible for developing the Initial Care Plan and stated, ""I'll write one right now"".",2014-09-01
9964,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,281,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to clarify an allergy discrepancy for 1 of 9 residents reviewed for admission criteria. Professional standards of quality were not met for admission criteria for Resident #4 when nursing failed to identify The findings included: The facility admitted Resident #4 on 12-01-10 with [DIAGNOSES REDACTED]. Record review on 12-07-10 at 5:25 PM of Resident #4's record revealed the record did not have an allergy sticker. Review of the Face Sheet revealed in the Allergy section ""No allergies"". Record review of the History and Physical dated 12-01-10 revealed documentation of allergies to [MEDICATION NAME] ([MEDICATION NAME]), Horse Serum, and Anti-Depressants. During an interview on 12-07-10 with the Assistant Director of Nursing (ADON), she, after chart review, confirmed the allergies were not listed on the Face Sheet. Record review of the Patient Transfer Form dated 12-01-10 revealed documentation in the section ""Important Medical Information"" of allergies to Horse Serum and Antidepressants. Additional record review revealed documentation of allergy to [MEDICATION NAME] on the ...... Regional Medical Center Transfer Medication Summary dated 12-01-10. Record review on 12-08-10 at 4:00 PM of the Treatment Record and Medication Administration Record [REDACTED]. During an interview on 12-08-10 at 4:00 PM with the ADON, she, after chart review, confirmed the above findings. She further stated she was responsible for ensuring allergies were listed correctly on the Face Sheet. The ADON proceeded to put an allergy sticker on the chart with documentation of all of Resident #4's allergies and to update the Face Sheet for allergies.",2014-09-01
9965,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,325,D,0,1,KWBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status related to body weight. The facility failed to document the percentage of snack intake daily for Resident #2 with trending weight loss. The findings included: The facility admitted Resident #2 on 11-19-10 with [DIAGNOSES REDACTED]. Record review on 12-07-10 at approximately 3:21 PM of the physician's orders [REDACTED]. Record review of the Dietary Progress Notes dated 11-24-10 revealed ""5 Day Assessment. Weight 136.9 pounds (#) at admission. Per os (PO) 25-50 percent (%). Per nursing-not eating well"". Record review of the Nutrition Risk assessment dated [DATE] revealed Skin Condition as ""Stage 2: Coccyx, Sacrum area"". The Nutrition Risk Assessment further noted current body weight as 132.1 # and usual body weight as 136.9# at admission. The Weight Trend revealed a trend of ""Weight Loss"". The Comments section noted ""Per os (PO) limited. Weight (wt) trending down. Noted alteration in skin integrity"". Record review of Resident #2's Nutrition assessment dated [DATE] revealed ""Weight Goal: prevent further loss"". In the Nutrition [DIAGNOSES REDACTED]. The Nutrition Assessment further noted in section ""Nutritional Goals: Weight decreased 3.5% since admission. Interventions in place for wounds, poor appetite-on [MEDICATION NAME], receiving Multivitamins and Med Pass. Record review on 12-08-10 at 11:15 AM of the Medication Administration Record [REDACTED]"". The following was revealed: 12-03-10: no documentation, 12-04-10: no documentation, 12-05-10: no documentation, and 12-06-10: no documentation. During an interview on 12-08-10 at 12:45 PM with the ADON, she, after chart review, verified the above findings and stated, ""I'll check into this"".",2014-09-01
9966,HALLMARK HEALTHCARE CENTER,425326,255 MIDLAND PARKWAY,SUMMERVILLE,SC,29485,2011-05-25,309,E,0,1,EDKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of the Hallmark Healthcare and Rehabilitation Center Nursing Information Manual the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents reviewed for care and services. A recommendation for a consultation with a nephrologist was not carried through for Resident #1. A physician order [REDACTED].#4. Med Pass was not provided as ordered for Resident #10, . The findings included: The facility admitted Resident #10 on 4/4/03 with [DIAGNOSES REDACTED]. Record review on 5/23/11 at 5:20 PM revealed a nutritional assessment dated [DATE] with recommendations by the Registered Dietician for MedPass 60 cc(cubic centimeters) twice a day - aid in weight maintenance. An [MEDICATION NAME] level was drawn on 2/25/11 which revealed a low level of 2.9 (normal range 3.5 - 4.7). A physician's orders [REDACTED]. Review of the cumulative orders for March 2011, April 2011, and May 2011 revealed that MedPass was not included on the orders. MedPass not listed on MAR or TAR and no there was no documentation presented to indicate that it was given. During an interview on 5/25/11 at 3:20 PM, with the Assistant Director of Nursing, she confirmed that the MedPass had not been given as ordered for the months of April and May 2011. During the interview, she also confirmed that the pharmacy had never received a copy of the order. She stated that once an order was received, the procedure was to facsimile the order to the pharmacy for processing. The ADON also stated that during changeover, physician orders [REDACTED]. Review of the cumulative orders revealed that they were reviewed by two nurses but the discrepancy was not identified. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 5/23/11 at approximately 2:45pm revealed a Discharge Summary from Trident Medical Center which stated - ""She is to follow up with Dr...... in Nephrology in 1 to 2 weeks and . . ."". Further review of Physicians Orders and Nursing Notes revealed no documentation of the follow up being ordered or that it was scheduled. Interview with Licensed Practical Nurse (LPN) #1 at approximately 3:20pm indicated that staff had attempted to call Dr..... but could not find the name in the phone listings. They then called hospital, and the hospital not aware of this particular Dr. LPN # 1 confirmed that there was no documentation that this was done or that the facility Dr. was made aware of situation at that time. A second interview on 5/24/11 with LPN #1 at approximately 9:30am indicated that no attempt was made to schedule appointment with a different physician. The facility admitted Resident #4 on 05-06-11 with [DIAGNOSES REDACTED]. Record review on 05-23-11 at 3:15 PM of the Physician's Telephone Orders dated 05-06-11 revealed the following: ""Monitor oxygen (O2) saturations (Sats) every (q) shift. Notify Doctor of Medicine (MD) if less than (<) 90 percent (%)"". Additional record review on 05-24-11 at 9:45 AM of the May 2011 Medication Administration Record (MAR) revealed it had not been updated to reflect the Physician's Telephone Orders of 05-06-11 to monitor O2 Sats every shift. During an interview on 05-24-11 at 12:15 PM with the Unit Manager, she, after record review, verified the Physician's Telephone Orders dated 05-06-11 to monitor O2 Sats every shift had not been transferred to the May 2011 MAR and subsequently the O2 Sats had not been monitored. The Unit Manager stated, ""the shift nurse is responsible for putting the physician's orders [REDACTED]. Review of the Hallmark Healthcare and Rehabilitation Center Nursing Information Manual on 05-24-11 at 4:00 PM revealed the section titled ""Nursing Administration (Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (Unit MGR), Weekend Supervisor"" stated ""Check MAR daily for accuracy and record results on monitoring tools"". Further review revealed the section titled ""Unit Managers/Weekend Supervisors"" stated ""Check all new orders daily (responsible for follow-up of new orders, notification and documentation) by 11:30 PM"".",2014-09-01
9967,HALLMARK HEALTHCARE CENTER,425326,255 MIDLAND PARKWAY,SUMMERVILLE,SC,29485,2011-05-25,315,D,0,1,EDKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the facility policy titled ""Indwelling Catheter Care"", the facility failed to provide appropriate care and services to prevent urinary tract infections for 1 of 1 sampled resident reviewed for Foley Catheter care. During Resident #12's Foley Catheter care, the staff member contaminated clean areas and failed to re-clean the area. The findings included: The facility admitted Resident #12 on 04-28-11 with [DIAGNOSES REDACTED]. On 05-24-11 at 11:24 AM, Certified Nursing Assistant (CNA) #1 entered Resident #12's room to provide Foley Catheter care. Observation revealed CNA #1 spread Resident #12's labia, cleansed with a downward motion on the right side, released the labia, obtained additional disposal wipes, and after spreading the labia again, continued with the Foley Catheter care without re-cleaning the contaminated area. During an interview on 05-25-11 at 2:15 PM with CNA #1, she verified she had failed to keep the labia open as she obtained additional disposable wipes and had continued with the Foley Catheter care without re-cleaning the contaminated area. Review of the facility policy titled, ""Indwelling Catheter Care"" revealed Procedure #6 stated ""Spread labia on female (keep labia spread open until procedure is complete)"".",2014-09-01
9968,THE LAKES AT LITCHFIELD SNF,425380,120 LAKES AT LITCHFIELD DRIVE,PAWLEYS ISLAND,SC,29585,2011-05-03,371,F,0,1,VT2H11,"On the days of the survey, based on observations, interviews and review of the facility's check list for kitchen cleaning, the facility failed to prepare and serve food under sanitary conditions. 3 of 3 ovens observed were observed soiled with grease, burned on spills and debris. The findings included: On 5/2/2011 at 8:40 AM, during a tour of the facility's kitchen, the single oven had dried food stains on the door. The oven also had other dried spills on the ledge of the door and the oven floor. The oven handle was covered in an oily substance which had dripped down the door and onto the floor. The facility's double ovens both had thick burned on spills on the oven floors with dried spills on both inner door areas. Review of the facility's kitchen cleaning schedule indicated that during the week of 4/11/11 the ovens had been signed as cleaned 4 times. The week of 4/18/11 they had been cleaned 5 times. Per the Certified Dietary Manager (CDM) there was no cleaning form available for review since the week of 4/18/11. In an interview with the Kitchen Manager and the CDM, they both verified the surveyors observations. At 2:30 PM on 5/2/2011, the kitchen was observed a second time. The single oven and the lower oven soiled areas remained unchanged. The cook was cleaning the upper oven and made the comment that he had been ""chiseling"" all day.",2014-09-01
9969,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,441,F,1,1,QFX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to consistently document types of infection or analyze data to track infections and identify trends to help prevent the spread of infections within the facility. The findings included: On 2/15/11 at 9:10 AM, review of the facility's Acquired (In House) Infection Log revealed multiple infections listed, over the last 3 months for which data had been compiled, for which the infectious organisms were not documented. The Nosocomial Infection Summaries for the same time period was compiled revealing an infection rate of 20.53% in October, 18.6% in November and 19.9% in December. For the months of October, 2010 through December, 2010, 26 Urinary Tract Infections (UTI's) were listed on four units for which Culture and Sensitivities (C&S) had been done but the organism(s) had not been listed on the Infection Log. One infection was listed for the Williams Pavilion for which a wound culture had been done in November but the result of the C&S (culture and sensitivity) was not listed on the Infection Log. Further review revealed that identified the culture was positive for MRSA (Methicillin Resistant Staphylococcus Aureus.) In addition, a resident on the Elliott Pavilion who was positive for MRSA was not included on the Infection Log. One additional resident was identified with a MRSA infection on January 7, 2011 on the Williams Pavilion. All three of the infections listed educating staff as an action taken related to the problems identified. In addition, there was a MRSA UTI infection on Elliott Pavilion in December for which no Infection Control Investigation was done. During an interview on 2/16/11 at 10:07 AM, the Assistant Director of Nursing (ADON) confirmed that the infectious organisms were not consistently documented on the Infection Log. He verified that he was responsible for the implementation of the Infection Control Program and stated that he was familiar with the content of the Infection Control Regulation requirements. He stated he had not had any special education or in-services regarding infection control and none were planned in the future. He further stated that the Director of Nursing (DON) and the ADON were responsible for identifying trends. The Staff Development Coordinator (SDC)would then provide in-services to the direct care staff. He further stated that the SDC also provided annual in-services for handwashing. He verbalized that every morning he reviewed the lab results for any cultures during rounds and that he reviewed handwashing monthly with the unit staff. He confirmed that he did not use the Infection Log to identify trends but stated that he looked in residents charts for results of cultures to identify trends. The ADON also stated that he did not keep a list of residents with MDRO (Multi-Drug Resistant Organisms). The ADON stated that when a new case of MRSA was confirmed, the resident was placed on contact precautions and that he in-serviced the staff on all 3 shifts related to handwashing and contact precautions. He was then asked to provide copies of the employee in-service signature sheets for the residents diagnosed with [REDACTED]. An Educational In-Service Sign In sheet dated 11/10/10 for MRSA contact precautions for one shift and the annual handwashing competency for handwashing done by the SDC over over a 3 month period (October through December) were provided. No in-service sign in sheets were provided for the second and third shift for November and none were provided for the cases in December or January. The ADON was asked to provide infection control logs for the month of January 2011. None were provided prior to exit from the facility. On 2/16/11 at 10:55 AM an interview was conducted with the DON. When asked how the tracking of infections was done to identify trends utilizing the Infection Log data, the DON stated she ""had no idea."" She confirmed that the organisms were not consistently listed on the Infection Log for tracking infections. She further confirmed that identifying trends with the current data collection system would not be possible.",2014-09-01
9970,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,156,B,0,1,QFX311,"On the days of the survey , based on administrative record reviews and interview, the facility failed to provide the mandated 48 hour expedited Notice of Medicare Provider Non- Coverage for 2 of 3 residents who had been determined by the facility to no longer be eligible for Medicare coverage. Resident #6 was notified the day the services ended and Resident B was notified only 24 hours prior to the services ending. The findings included: On 2/16/11 at 10:05 AM, a review of 3 random Notices of Medicare Provider Non-Coverage and an interview with the Director of Admissions, who prepared the notices, was completed. The review revealed that Resident #6's services were to end on 2/1/11 and the documentation revealed the resdient's daughter was notified on 2/1/11. Resident B's services were to end on 4/9/10 and the documentation revealed the resident's daughter was notified by phone on 4/8/10. During the interview with the Director of Admissions, she stated that there had been some communication problems between departments which resulted in the untimely notifications.",2014-09-01
9971,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,322,D,0,1,QFX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation and interview, the facility failed to maintain a continuous feeding via Gastrostomy Tube ([DEVICE]) for one of three [DEVICE]s observed. Resident #16 was observed to not have his continuous [DEVICE] feeding running for five hours. The findings included: The facility admitted Resident #16 on 4/22/10 with [DIAGNOSES REDACTED]. Record review on 2/14/10 at 3:30 PM showed a physician order [REDACTED].' Observation of the resident on 2/15/11 at 11:05 AM revealed the resident to be sitting up in his wheel chair in his room in front of the feeding pump. The [DEVICE] feeding was not connected to the resident and the feeding pump was turned off. The Glucerna 1.2, 1000 ML (milliliters) was noted to have been hung on 2/15/11 at 2:00 AM and there was approximately 600 ML remaining in the bottle. At 11:15 AM the RCT (Resident Care Technician) assigned to Resident #16 came into the room and returned the resident to his bed. The [DEVICE] feeding continued to be disconnected from the resident. Further observations at 1:05 PM, 3:00 PM and at 4:15 PM showed the resident to be in bed and the [DEVICE] feeding still disconnected. Approximately 600 ML of Glucerna 1.2 remained in the bottle. At 4:20 PM this surveyor asked LPN #1 (Licensed Practical Nurse) to come to the resident's room. When we entered the room the LPN did not identify that the [DEVICE] feeding was not connected to the resident nor that the feeding pump was not running. When questioned further, LPN # 1 stated that she had planned to put his feeding pump on the wheel chair so that the resident could go out of his room earlier in the day and that things just got ""away from her.""",2014-09-01
9972,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,278,D,0,1,QFX311,"**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 assess one of one resident's for self catheter care. The facility was unaware that Resident #1 performed his own catheter care. The findings included: The facility admitted resident #1 on 9/14/2010 with [DIAGNOSES REDACTED]. Upon entering the resident room for catheter care, the resident stated that he did his own catheter care and did not understand why the CNA was going to perform catheter care. The resident gave permission for the CNA to perform catheter care. During observation of catheter care on 2/14/2011 at approximately 9:40 AM, the resident was observed pulling on his catheter and instructing the CNA (Certified Nursing Assistant) on how he wanted his care given. The resident pulled on his catheter and pushed down on his penis. He instructed the CNA to clean down further into his urethra. The resident stated that he did his own catheter care and used a ""Q-tip"" to clean. The catheter care was stopped by the surveyor. During the catheter care both the CNA and the Staff Development nurse stated that they were not aware that the resident performed his own catheter care. The Staff development nurse was to check for an assessment or check off of the resident performing self catheter care. Neither was provided during the survey. The medical record was reviewed on 2/15/11. There was no assessment on the medical record for the resident to perform self catheter care. The resident's care plan addressed the resident having a catheter but did not address the resident performing his own care. On 2/15/11 at 1:00 PM, RN #1 stated that the resident had been assessed for self administration of medications, but no assessment for the self catheter care was located. Review of the facility's ""Administration Policy & Procedure Directive"", under: I. Policy: A. Self- administration of medications or treatments by residents is permitted by a physician order [REDACTED]. B. The head nurse manager or team leader assesses resident competency to self administer for one week..... D. Obtain an order from the physician. Record in the MAR and Resident Profile. There was no evidence provided during the days of the survey that an assessment for self catheter care had been completed by the facility.",2014-09-01
9973,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,428,D,0,1,QFX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, and interviews, the facility failed to provide necessary pharmacy services to ensure that residents received medications as prescribed by their physician for 1 of 18 residents reviewed for medications, (Resident #10.) The findings included: The facility admitted Resident #10 on 1/5/2011 with [DIAGNOSES REDACTED]. On 2/15/2011 during record review, there was a telephone order dated for 1/6/2011. The order was for Femara, one by mouth qd (daily) ""[DIAGNOSES REDACTED]"" and for Albuterol MDI (Multi Dose Inhaler) 2 puffs inhaler every 6 hours prn (as needed). The Drug Information Handbook for Nursing 2010 states, Femara is classified as a Antineoplastic Agent. given for treatment of [REDACTED]. There were no records/documentation of the resident receiving the medications for 24 days. A Pharmacist Progress Note/Drug Regime Review form was on the medical record. The Pharmacist review was dated for 1/27/2011. There was nothing documented by the pharmacist regarding the medication orders of 1/6/2011. There was no indication that the pharmacist had noted that the medications had not been transcribed to the MAR indicated [REDACTED] On 2/16/2011 at 9:30 AM, the ADON, Assistant Director of Nurses was interviewed. The ADON stated that the pharmacist reviewed the resident's charts monthly. The ADON stated that he/she did not know why the Pharmacist had not noted the missed orders. On 2/16/2011 at 9:40 AM, the Pharmacist was interviewed. The Pharmacist stated that he/she was not aware that there was a problem ""until yesterday"" (2/15/2011). He/she stated they had done the drug review on 1/27/2011. ""When I do the review for the new residents I check for lab work that may be needed. I don't check the current MAR. I don't check the orders to see if they have been transcribed. I feel that is the nurses responsibility to check."" The Pharmacist also stated when she did the monthly drug review and checked the MARs that she checked the previous month's MARs. (The resident had been admitted on January the 5th.) By the MAR, the resident missed 24 doses of the prescribed medication during the month of January which was not identified during the pharmacy review. Cross refer to F 333 as it relates to a significant medication error.",2014-09-01
9974,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,333,E,1,1,QFX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, and interviews, the facility failed to ensure Resident # 10 remained free from a significant medication error. The facility failed to transcribe and administer two physician orders, resulting in the failure of the resident to receive medications per Physicians orders. (1 of 18 records reviewed for medication errors) The findings included: The facility admitted Resident #10 on 1/5/2011 with [DIAGNOSES REDACTED]. On 2/15/2011 during record review, there was a telephone order dated for 1/6/2011. The order was for [MEDICATION NAME], one by mouth qd (daily) ""[MEDICAL CONDITION]"" and for [MEDICATION NAME] MDI (Multi Dose Inhaler) 2 puffs inhaler every 6 hours prn (as needed). The Drug Information Handbook for Nursing 2010 states, [MEDICATION NAME] is classified as a Antineoplastic Agent. given for treatment of [REDACTED]. There were no records/documentation of the resident receiving the medications for 24 days. On 2/15/11 at 1:00 PM, Registered Nurse (RN) #1 was asked if she could see where the physician's orders [REDACTED]. On 2/16/2011 at 9:30 AM, the ADON, Assistant Director of Nurses was interviewed. The ADON confirmed that the order had not been transcribed to the January MAR.",2014-09-01
9975,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,329,G,1,1,7PCF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility administered medications to Resident # 5 without following the physicians parameters for administration and in the presence of potentially significant adverse side effects of the medication. Resident #15 received [MEDICATION NAME] without an order for [REDACTED]. The findings included: The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. The resident was ordered by the physician to recieve three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER (extended release) 300 mg, and [MEDICATION NAME] 320 mg) for the treatment of [REDACTED]. The instructions for administration were clearly identified on the MAR (Medication Administration Record). Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift using the following code: D (Day) E (Evening) N (Night) on a Vital Sign Record sheet. The findings from the Vital Sign Record sheets were then carried forward onto the NN (Daily Skilled Nurses Notes). However, 5 of 6 nurses notes were not fully completed. Review of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg were administered. The B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 96/56, E 93/58, N blank No pulse recorded for night shift. 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 75/48, E 72/46, N blank. Evening shift pulse was 50. 5-24-11 No pulse recorded for evening shift. It appeared that five different nurses had documented the medications were administered without following the physician ordered parameters for administration. Additionally, the time the vital signs were obtained were not documented. It was unable to be determined if the vital signs were obtained immediately prior to the administration of the medications. Further review of the medical record revealed a Pharmacy Consult had been completed on 5-18-11. During a phone conversation on 5-25-11 at approximately 10:00 AM with the Consultant Pharmacist, he reported that he had notified the facility on 5-20-11 via fax the following recommendation: ""---- (Resident # 5 ) has multiple order to hold meds (medications) per parameters. Please make sure these are being checked and documented prior to each dose of medication being given."" During a subsequent interview with the Director of Health Services, she stated that she had received the recommendation on 5-20-11, however, there was no evidence of interventions put in place to ensure the recommendations were followed. There was no indication that the pharmacist had taken immediate action upon the discovery that the physician's orders [REDACTED]. Observations of Resident # 5 over the course of the survey, revealed he was in bed sleeping during the initial tour at approximately 10:50 AM on 5-23-11. At 1:10 PM Resident # 5 was observed in bed with his meal on the over the bed table untouched. Resident # 5 replied slowly to questions asked and appeared lethargic. At 5:40 PM Resident # 5 was still in bed with eyes closed, but he responded to conversation talked slowly and appeared confused when asked simple questions. He stated that he had not eaten lunch and was not hungry. When asked if he needed help to eat, he stated ""yes"", then after a few minutes he said ""no, I don't want to eat now."" On 5-24-11 at approximately 11:00 AM, wound care was attempted, however Resident # 5 stated he was in pain, so mediation was given and wound care was delayed. Resident # 5 again seemed lethargic and was slow to respond to questions by the nursing staff. On 5-24-11 at approximately 3:00 PM during a telephone interview with the Primary Physician, who was also the Medical Director of the facility, this surveyor conveyed concerns related to Resident # 5 displaying lethargic behavior and medications given to the resident when the Systolic Blood Pressure was below 110. The Medical Director stated that he was unaware that the blood pressure medications were being given when the Systolic Blood Pressures were below the parameters which he had ordered. On 5-25-11 at approximately 7:30 AM, the Medical Director assessed Resident # 5. The nurses note documented: ""Upon revaluation, noticed resident to be lethargic (with) pinpoint pupils. VS (vital signs) taken (with) machine B/P 57/29 T(temperature) 98.2 HR (heart rate) 67 RR (respiratory rate) 20. B/P rechecked manual 60/40 HR 64. Resident stated that 'I feel awful.' Last pain medication [MEDICATION NAME] 7.5/325mg given at 2:30AM on 5/25/11.... Order recieved from Dr.... to have resident transported to ... for evaluation."" This surveyor asked the facility Director of Health Services for information related to Resident # 5's condition at the hospital but none was supplied before the survey ended. Review of the Drug facts and Comparison which is updated monthly revealed the following statement about the [MEDICATION NAME] and [MEDICATION NAME] on page 438b: ""Carefully monitor blood pressure during initial administration. Closely observe patients already taking antihypertensives."" The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes dated 4/12/11 at 9:15 PM stated, ""Resident was given liquid [MEDICATION NAME] and liquid [MEDICATION NAME] as ordered. MD was notified that previous [MEDICATION NAME] order was given and not Roxinol (sic). Roxinol was held per physician... D/C previous [MEDICATION NAME] order per MD..."" The nursing documentation for 4/14/11 (not timed) stated, ""N.O. (new order) [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) 0.5 ml Q (every) 4 hours, order noted and faxed. At 9:00 PM on 4/14/11 the Daily Skilled Nurses Notes stated, ""9 PM meds (liquid MSO4, [MEDICATION NAME]) given as ordered..."" Review of the Physician's Interim Orders revealed the following: ""4/11/11 (untimed) Schedule Roxinol drops 2 cc po q 4 4/12/11 (untimed) Hold 9 PM, D/C [MEDICATION NAME] 4/14/11 (untimed) D/C [MEDICATION NAME] tabs, D/C [MEDICATION NAME] 2:30 Order Clarification: [MEDICATION NAME] SO4 20 mg/ml 0.5 mls po Q 4 hr"" Review of the United Pharmacy Services, Controlled Drug Report for Resident #15's [MEDICATION NAME] 100 milligrams/5 milliliters take 1 ml to 2 ml po q 3 hrs (hours) prn (as needed) pain showed the resident continued receiving [MEDICATION NAME] 2 milliliters on 4/13/11 at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM; on 4/14/11 at 1:00 AM and 5:00 AM. Review of the United Pharmacy Services, Controlled Drug Report for Resident #15 dated 4/14/2011 for [MEDICATION NAME] Solution 20 mg/ml 0.5 ml (10 mg) by mouth every 4 hours documented the resident received [MEDICATION NAME] 0.5 ml on 4/14/11 at 9:00 PM. Review of the Medication Record (MAR) for April 2011 documented ""Roxinol gtts (drops) 20 mg/ml 2 cc po q 4 hours"" given on 4/12/11 at 5:00 PM and held at 9:00 PM; on 4/13/11 [MEDICATION NAME] was given at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM; on 4/14/11 [MEDICATION NAME] was given at 9:00 AM only. No order was written to discontinue the [MEDICATION NAME]. No order was written to clarify the dose or indication for the ""Schedule Roxinol drops 2 cc po q 4 hours"" order written 4/11/11. On 4/14/11 an order was written to clarify how Resident #15 was to receive pain medication. The order stated, ""[MEDICATION NAME] 20 mg/ml give 0.5 ml po Q 4 hours"". The [MEDICATION NAME] was given as ordered on [DATE] at 1:00 PM, 5:00 PM, and 9:00 PM. [MEDICATION NAME] 0.5 mg IM (intramuscular) or liquid Q 4 hours r/t (related to agitation) was given on 4/11, 4/12, 4/13/11 at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. [MEDICATION NAME] 0.5 mg was given on 4/14/11 at 9:00 AM and 1:00 PM. There was no written physician's orders [REDACTED]. There was no documentation in the MAR indicated [REDACTED].",2014-09-01
9976,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-05-25,514,E,1,1,7PCF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection the facility failed to maintain clinical records on each resident that were complete and accurately documented for services provided. Three of Nine residents reviewed (Residents #1, #5, & #15) for adequate delivery of care and services had documentation that was missing or not available for review. The findings included: Resident # 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Discontinue use and notify Occupational Therapy if redness / irritation persist greater than 30 minutes after taking off- remove for personal care"" ; Left knee orthotic to be worn 3-6 hours 7-3 shift every day- discontinue use and notify Physical Therapy if redness persists greater than 30 minutes after removing""; ""Cleanse peg tube site with normal saline pat dry and apply dry dressing change every day"". Review of the May Treatment Record showed a lack of documentation that the treatment(s) were completed to the elbow on 05/07/11, 05/08/11, and 05/17/11; the treatment to the Peg tube site for 05/14/11 and 05/15/11; the treatment to the left upper extremity for 05/08/11 and 05/17/11; and the treatment for [REDACTED]. The facility admitted Resident # 5 on 5-12-11 with [DIAGNOSES REDACTED]. Review of Resident # 5's medical record revealed that three medications ([MEDICATION NAME] 5 mg (milligrams), [MEDICATION NAME] ER (extended release) 300 mg, and [MEDICATION NAME] 320 mg) used for the treatment of [REDACTED].< (less than) 110."" The instructions for administration were clearly identified on the MAR (Medication Administration Record). Further review of the medical record revealed that Resident # 5 was having his BP (blood pressure) and other vital signs checked each shift using the following code: D (Day) E (Evening) N (Night) on a Vital Sign Record sheet. The readings from the Vital Sign Record sheets were brought forward onto the NN (Daily Skilled Nurses Notes), however, review revealed 5 of 6 NN were not fully completed. Additionally, it was unclear if the blood pressure was obtained immediately prior to the administration of the medications as the time was not documented. Comparison of the NN and the MAR indicated [REDACTED] 5-16-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] 320 mg were administered. The B/P was listed on MAR indicated [REDACTED].) 5-17-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 73/52, E 99/62, N 94/58 5-19-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D blank, E 76/53, N 82/51 5-22-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 96/56, E 93/58, N blank 5-23-11 [MEDICATION NAME] 5 mg, [MEDICATION NAME] ER 300 mg, [MEDICATION NAME] 320 mg were administered. The BP's in the nurses notes were D 75/48, E 72/46, N blank. The facility admitted Resident #9 on 12/25/10 with [DIAGNOSES REDACTED]. Review of the medical record on 5/25/11 revealed a current physician's orders [REDACTED]. Further review of the medical record indicated a telephone order dated 3/03/11 for Prostat 101 30 ml daily. Record review noted that Resident #9 had pressure ulcers to the sacrum and heel and continued to receive treatment for [REDACTED]. Review of the May 2011 Medication Record (MAR) revealed blanks on the MAR for 5/23/11 and 5/24/11 indicating Resident #9 did not receive Prostat on those dates. The scheduled time for Prostat administration was 9 AM, and all other 9 AM medications on 5/23/11 and 5/24/11 were documented by staff as administered per orders. Review of the back of the MAR indicated [REDACTED]. The above findings were shared with the Staff Development Coordinator on 5/25/11 at approximately 10:30 AM. The facility afterward provided a handwritten statement from staff indicating Resident #9 ""did receive Prostat on May 23 & 24. Medication administration was not documented on MAR.""",2014-09-01
9849,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,164,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility policy entitled ""Enteral Feeding via Gastrostomy Tube"" dated 11.09.02, the facility failed to provide privacy for Resident #10 during two tube feeding flushes for 1 of 2 residents observed for privacy during tube feeding flushes. The findings included: Resident #10 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 5/16/11 at 4:00 PM, a tube feeding flush was attempted by the Licensed Practical Nurse (LPN) #4. The LPN did not close the door or the blinds in the window while checking residuals prior to starting tube feeding flush. On 5/17/11 at 12:10 PM, a tube feeding and tube feeding flush was conducted by the LPN #5. The LPN did not close the window blinds throughout the procedure. On 5/18/11 at 12:00 PM, an interview with the Director of Nursing (DON) was conducted. She stated that the expectation is that staff closes the door and the blinds during a tube feeding flush. Per review of the facility policy entitled ""Enteral Feeding via Gastrostomy Tube"" dated 11.09.02, which states ""5. while maintaining privacy, expose the feeding tube.""",2014-10-01
9850,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,241,D,0,1,B6NE11,"On the days of the survey, based on observation and interview, the facility failed to maintain an environment that enhances each resident's dignity during dining in 2 of 12 cottages observed for dining. Staff was observed eating their meal while a resident waited to be served. Two CNA's (Certified Nursing Aide) were observed standing while feeding a resident. The findings included: On 5/17/11 at 11:55 AM, it was observed that a resident was reading a newspaper while two staff members sat on each side of the resident eating sandwiches. The resident was waiting to be served lunch. A random observation on 5/16/11 at 5:23 PM revealed a CNA (Certified Nursing Aide) standing while feeding a resident in the dining room of the Jasmine Cottage. The Resident was observed attempting to eat food from her plate with her fingers. The CNA remained standing and encouraged resident to use a spoon to eat. The CNA then picked up the resident's plate and continued to feed the resident while standing. A random observation on 5/18/11 at 9:30 AM revealed a CNA (Certified Nursing Aide) standing while feeding a resident in the resident's room. The resident was in bed with the bed in the highest position. The resident was observed attempting to feed himself with a spoon and the CNA stood by the resident bed using a different spoon to feed the resident. An interview on 5/18/11 at approximately 9:45 AM with CNA #7 revealed that she stood because she preferred to stand. The CNA further stated ""I like standing, I cannot sit long"".",2014-10-01
9851,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,248,E,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, 5 of 14 sampled residents had no structured activities observed. (Residents #1, #4, #6, #8, and #13) Random observations of 10 of 12 cottages revealed structured activities per the posted Activity Calendar were not provided to residents during the days of the survey and 6 of 7 participants in the Group Interview voiced concerns related to the lack of activities. The findings included: During initial tour of Forsythia Cottage, on 5/16/11 at 11:37 AM, the Activities Calendar was noted to be at standing eye height level, printed on 8 1/2 by 11 inch paper and difficult to read from chair height. The facility admitted Resident #1 on 2/26/10 and readmitted her on 5/10/11. Her [DIAGNOSES REDACTED]. On 5/18/11 review of the 2/11/11 Life Enhancement Assessment for Resident #1 indicated that the resident was interested in playing Uno (a card game), enjoyed large and small groups and structured activities but needed encouragement. There was no documentation in the notes that card playing had been offered as an activity to this resident. Review of the Life Enhancement Notes revealed documentation of the residents limited participation in only 10 activities since the beginning of January. The facility admitted Resident #8 on 6/24/09 with [DIAGNOSES REDACTED]. On 5/18/11 review of the 9/13/10 Life Enhancement Assessment for Resident #8 indicated that the resident was comfortable in large and small groups and with 1 on 1 sensory activities. Activity Interests and Preferences indicated that the resident needed encouragement and Participation Patterns indicated that she was a passive participant with activities. During the days of the survey, Resident # 1 and # 8 were not observed engaged in any structured activities. Both were observed in their room or in the day area with the television playing. Both resident's engaged in conversation with other residents and self propelled their wheel chairs throughout the cottage. There was no structured activity observed being provided in Azalea or Forsythia Cottages on all days of the survey. During an interview on 5/18/11 at approximately 10:30 AM, the Activities Director (AD) stated that Activity Calendars were posted in all cottages but confirmed that the calendars were printed on 8 1/2 by 11 inch paper and posted too high to read from a wheel chair. She stated that worship services were scheduled on Tuesdays and Thursdays in different cottages each week. She stated group activities were scheduled at least weekly in the community room. The AD further stated that during inclement weather, the Certified Nursing Assistants (CNA's) were responsible for providing activities to the residents in each cottage. The AD confirmed that the CNAs were aware of their responsibility to provide meaningful activities. She verbalized that she had not been monitoring the activities being provided by the CNAs. The AD stated the CNAs ""claim they don't have time."" She confirmed no recent in-services had been conducted for the CNAs related to the types of activities that should be provided to low functioning residents. During the interview, the Nursing Home Administrator (NHA) stated she came to the facility in December, 2010. She stated she had identified a problem with the Activity Program in February, 2011. She presented a plan to the Performance Improvement Committee in February. The NHA also stated that all CNAs were trained at the Technical College on Life Enhancement and that cooks and housekeepers had been hired to allow time for the CNAs to provide activities to the residents in their assigned cottage. She further stated progress had not occurred as hoped and confirmed that no changes had been made to the plan to improve the Activity Program. On all days of the survey, no ongoing program of structured activities was observed being provided for the residents of the Lilac or Rhododendron Cottages. An interview was conducted with the Activity Director and Administrator on 05/18/11 at approximately 10:30 AM . They confirmed that the Life Enrichment Program ""did have problems"" at this time. Random observations in the Jasmine Cottage on 5/16/11 and 5/17/11 revealed 12 resident housed in the cottage with no structures program of activities in place. A television was noted in the living area of the cottage and 2 to 3 residents were noted in the living area in front of the television. The activity calendar indicated a 3 PM movie would be presented in the Community Room at the facility. Upon arrival to the Community Room to observe the posted activity, it was noted that the activity did not take place. On 5/17/11 at approximately 10:45 AM a group meeting with 7 interview-able residents was held in the Jasmine Cottage. Six of the 7 interview-able residents expressed concerns about the lack of on going activity program. Three of the 7 residents stated the activities presented are not age appropriate for them. The three residents stated ""play doh"" or ""clay"" was presented as an activity. Two group members stated that they did not like playing with a big ball as an activity. One group member stated she does exercises independently and stated she would like to have other participants to encourage her. One resident from a different cottage stated a Wii game was available in his cottage. Four of the group member then commented- ""How do we get a Wii game?"" Review of the Activity Calendars for March, April and May revealed a 7 PM activity everyday called ""Sleepy Tea"". The surveyor asked the group members, What is sleepy tea? The group members stated they were not sure and one group member said- ""You tell us, we do not know."" Four of the 7 group member stated they had requested age appropriate activities but there had been no changes. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An interview was conducted with Resident #4 on 5/16/11 at 3:30 PM. The resident stated that the facility does have activities at the community building but there are not activities in Magnolia Cottage. She stated that she has complained about the lack of activities for a year and a half with no changes. On 5/16/11 and 5/17/11, random observations were done in Magnolia Cottage and Holly Cottage. There were no activities observed throughout the survey in these cottages. The facility admitted Resident #6 on 4-29-11 with [DIAGNOSES REDACTED]. On 5-18-11, review of the 5-6-11 Enhancement Assessment revealed Resident #6 enjoyed playing cards/games/puzzles, working with cloths, listening to semi-classical music, and reading newspapers and magazines. Spiritual services were also very important to her. The assessment also revealed the resident was comfortable with large groups, small groups and that she needed encouragement in participation of activities. During the days of the survey, Resident #6 was not observed in any structured or individualized activities other than watching television. During the days of the survey, observation revealed no structured activities were being provided to any residents in the Rose Cottage. On the days of the survey, the facility failed to provide structured activities in Tea Olive Cottage. On 5-16-11, review of the Activities Calendar for the cottage revealed that at 11:00 am, ""Ball Toss"" was scheduled and there was no ball toss activity observed. On 5-16-11 at 3:00 PM the Activities Calendar revealed ""Movie Matinee"" as the activity. It was observed that there was one resident at the television asleep and the volume was not on. During an interview on 5-16-11 at 3:33 PM, Certified Nursing Assistant (CNA) #1 checked the calendar and stated that she was unaware that a movie was to take place. On 5-17-11, there were no planned activities scheduled in the Tea Olive Cottage per the Activity Calendar, and there were no structured activities observed. On 5-18-11, the Activities Calendar in Tea Olive Cottage noted that at 11:00 AM, ""Price is Right ON TV 7"" was the scheduled activity. It was observed that no residents were participating in this activity. During an interview on 5-16-11 at 11:15 AM, Resident #13 stated, ""I am lonely and (have) nothing to do"".",2014-10-01
9852,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,366,F,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the facility menus, the facility failed to make residents aware and provide substitutes at meals with similar nutritive value for residents that refused food. Resident #4 expressed concerns about alternate foods being available at meals. Resident #12 was not provided an acceptable alternate meal when she refused the vegetables offered. Six of seven residents during group expressed concerns regarding alternates being available at meals. The findings included: Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An interview was conducted with Resident #4 on 5/16/11 at 3:30 PM. The resident stated that during meals only an alternate meat is offered. She stated that if she does not want the meal offered she can get peanut butter crackers or a milk shake. She stated that no other alternates are provided. On 5/16/11 at 5:05 PM, an interview with the Food Service Director was conducted. He stated that a meat alternative is offered at each meal. He stated that they to have canned vegetables in stock and can microwave if they know a resident does not like a particular food prior to the meal based on the residents likes or dislikes. He stated that an alternate vegetable is not available on the steam table at meals. He stated that each kitchen has bread, peanut butter, jelly, and pimento cheese. The facility admitted Resident #12 on 12/18/09 with [DIAGNOSES REDACTED]. Record review revealed a care plan last reviewed on 5/03/11 that indicated the resident was to receive vegetables or organic foods and that she had a problem with milk (dairy). An observation on 5/17/11 at 12: 20 PM revealed the lunch provided was pork loin or chicken, green peas casserole or carrots and a roll. Resident #12 requested the pork lion and stated she did not want the carrots. CNA (Certified Nursing Aide) #7 informed the resident that cheese (dairy) was in the pea casserole and offered the resident the carrots again. The resident informed the CNA she did not want the carrots. The resident received a piece of meat (pork loin) and a roll. The CNA did not call the kitchen to request a different vegetable for the resident. An interview on 5/17/11 at 12:35 PM with CNA #7 revealed the carrots was the other vegetable available. On 5/17/11 at 10:45 AM during group interview the 6 of 7 group members stated they were not aware of alternate meals being provided.",2014-10-01
9853,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,371,F,0,1,B6NE11,"On the days of the survey, based on observation, interview, and review of the policies entitled ""Reheating Food to Serving Temperature"", ""Kitchen Set-Up for Preparation and Production"", and ""Preventing Contamination of Food during Preparation and Serving"", the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The findings included: On 5/16/11 at 10:35 AM, a tour of all the Cottage kitchens was conducted with the Food Service Director. In the Jasmine Cottage it was observed that a plastic bag with pancakes was not labeled or dated. The microwave contained rust on the inside of the door and in the inside back corners. The small refrigerator contained a cup with a thickened liquid that was not labeled or dated. In the Camellia Cottage it was observed that the microwave had rust on the inside of the door. The ice machine contained a pink substance around the screws on the top inside the ice machine and a rust colored substance on the metal in the back of the ice machine. In the Dogwood Cottage it was observed that a bag of fries in the freezer had slits in the bag. There was a pan on the counter covered with foil containing a pork loin. The microwave contained rust on the inside door and the paint of the inside top was bubbled up. In the Azalea Cottage it was observed that a container of sausage in the freezer was not labeled or dated. The microwave contained rust on the inside of the door and on the inside rim. In the Forsythia Cottage it was observed that the microwave had rust on the inside door and on the inside rim. One of the plastic lids on the steam table was broken and had a crack in the front. The reach in freezer in the dry storage area had ice build up on the bottom shelf of the freezer with boxes placed on top of the ice. In the Rose Cottage, an open bag with frosting was observed in the reach in refrigerator. The microwave had rust on the inside door. Both ovens contained dried food on the doors. The Food Service Director stated that neither oven had been used that day. The freezer in the dry storage area had ice build up on the bottom shelf and a bag of biscuits that was opened and not labeled or dated. In the Tea Olive cottage it was observed that there was mold like substance in the ice machine. One of the plastic lids on the door of the refrigerator was cracked in the middle. In the freezer in the dry storage there was ice build up on the bottom rack with boxes placed on top of the ice. In the Rhododendron Cottage it was observed that a pitcher of tea was dated 5/11. There was two pans of biscuits in the freezer not covered properly. A container of watermelon was in the refrigerator not labeled or dated. Three pots of food were on the stove, the stove was not on. The pots contained beef tips, rice, and mixed vegetables. In the Lilac Cottage it was observed that the microwave had rust on the inside door and on the inside rim. Both ovens contained dust around the inside edges. A broom and a dust pan were observed in the dining room not being used. The freezer in the dry storage had ice build up on the bottom shelf. In Magnolia Cottage it was observed that a container of chopped strawberries were not labeled or dated. A bag of strawberries were opened and not labeled or dated. In the small refrigerator there was cantaloupe dated 5/8 and a container of cantaloupe dated 2/30. There was a bag of food dated 5/12. On 5/16/11 at 4:30 PM, during dinner meal observation in Tea Olive Cottage it was observed that the cole slaw was not offered to any of the residents at the meal. An interview with Certified Nursing Assistant (CNA) #1 was conducted. She stated that she forgot to serve the cole slaw at the meal. On 5/16/11 at 5:05 PM, during dinner meal observation in Magnolia Cottage it was observed that staff changed gloves 4 times and did not wash hands at any time between glove changes. On 5/17/11 at 10:50 AM, it was observed that a bottle of sanitizer was left on the shelf in dining room. On 5/17/11 at 12:00 PM, during meal temperatures in Azalea Cottage, it was observed that the chicken was 120 degrees Fahrenheit. The CNA reheated the chicken in the microwave to a temperature 145 degrees Fahrenheit and then served the chicken to residents. On 5/17/11 at 12:20 PM, during observation of lunch meal in Forsythia Cottage it was observed that the CNA serving food from the steam table was not wearing a hairnet while plating food. On 5/18/11 at 10:00 AM, an interview was conducted with the Food Service Director. He confirmed findings. Per review of the facility policy entitled ""Reheating Food to Serving Temperature"" dated 08.03.05, it revealed that ""Potentially hazardous food that is cooked and cools to a temperature below 140 degrees Fahrenheit will be reheated. The food will be reheated to an internal temperature of 165 degrees for 15 seconds"". Per review of the facility policy entitled ""Kitchen Set-Up for Preparation and Production"" dated 08.01.03, it revealed that ""1. Put on hairnet or hair restraint."" Per review of the facility policy entitled ""Preventing Contamination of Food During Preparation and Serving"" dated 20.05.02, it revealed ""Disposable gloves may be used for only one task... Hands will be washed before putting on gloves and after disposal of gloves"". On 05/16/2011 at 5:00 PM, during observation of the dinner meal in Tea Olive Cottage, Certified Nursing Assistant (CNA) #1 put on gloves in the dining area without washing her hands and prepared drinks. She went to the kitchen area, opened the refrigerator and removed pitchers containing tea and lemonade. The CNA returned to the dining area, prepared more drinks and served them to the residents. She removed her gloves and, after completing several tasks, disposed of her gloves and donned new gloves without washing her hands, then prepared drinks. She touched supplement cans and opened straws touching the mouth tip. She removed her right glove and held it in her left hand while assisting residents. She reapplied the right glove, then removed the left glove and removed sandwich relish from the refrigerator. The CNA reapplied the soiled left glove, untied the hamburger bun wrapper, opened the buns and reached in with her soiled gloved hand, removed a hamburger bun and placed it on a resident's plate. CNA #1 proceeded to touch the tops of the steamer containers and used utensils to dip french fries and serve residents. During the same meal service, CNA #2 donned gloves without washing her hands. She was also observed to handle utensils, container tops and food items while serving residents. She then removed her gloves, applied alcohol-based hand sanitizer and donned new gloves before serving plates to the residents. After touching serving utensils, the CNA proceeded to the buffet and removed spoons and forks, touching mouth tips. She touched chairs and residents, then served residents from the steam table with the soiled gloves.",2014-10-01
9854,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,249,E,0,1,B6NE11,"On the days of the survey, based observations and interview, the facility failed to ensure that the Activity Director implemented and monitored the provisions of the activity program for residents to assure that was on-going and met the needs of the residents. The findings included: An interview on 5/18/11 at approximately 10:30 AM with Activity Director (AD) and the facility's Administrator revealed the facility attempts to have weekly worship services at the cottages. The AD stated trying to maintain a program of activities has always been difficult at the cottages. The AD further stated the CNAs (Certified Nursing Aides) in each cottage had the responsibility of providing a program of activities. The surveyor asked the AD when was the last time an in-service was provided to the CNAs related to structured program of activities in the cottages? The AD stated the last in-service was provided at the end of 2009 and the early part 2010. The AD was asked if she had been able to monitor the program of activities in the cottages to determine if they were being provided. The AD stated ""no"". The AD further stated she did not have anyone to assist her in providing a ongoing activity program in each cottage. The AD was asked about the posted ""Sleepy Tea"" activity that was to occur every day at 7 PM. The AD stated the ""Sleepy Tea"" was when the staff would give the residents tea to ""help them from being anxious"". The AD stated it was like to ""study"" to seem if it would calm the residents down. The AD stated the activities in each cottage were the same. The AD stated games, cards and books are provided for the residents. However, based on repeated observations on the days of the survey, there were no structured activities observed to be in place.",2014-10-01
9855,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,328,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure that a resident using an oxygen concentrator received proper treatment and care. The filters on both sides of the oxygen concentrator were not clean. (1 of 3 residents observed with oxygen concentrators) The findings included: Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. On 5/16/11 at 10:40 AM, during initial tour of the Magnolia Cottage, Resident #17 was observed receiving oxygen via a nasal cannula and plastic tubing which was connected to an oxygen concentrator. The oxygen concentrator had an air filter on the right and left sides of the machine. Both filters were observed to have heavy dust buildup which easily became airborne when scraped with a fingernail. Additional observations on 5/16/11 at 6:23 PM, 5/17/11 at 3:29 PM and 5/18/11 at 8:55 AM revealed both filters in the same condition. On 5/18/11 at 9:51 AM, during an and interview and observation with the Director of Nursing (DON), the DON agreed that the filters were heavily soiled with dust and needed to be cleaned. She stated that she would have to check the cleaning schedule and would ""get back with me on that"". On 5/18/11 at 11:15 AM, the DON stated that Clinical Engineering from Greenville Memorial Hospital services the oxygen concentrators and that the person she spoke to apologized for not cleaning the filters on that machine when he serviced the other concentrators earlier this month.",2014-10-01
9856,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,152,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on interviews and record reviews, the facility failed to obtain two Physician's signatures for statements of competency in accordance with state law in the Health Care Consent Act of South Carolina for 2 of 14 residents reviewed. The findings included: The facility admitted Resident #1 on 2/26/10 and readmitted her on 5/10/11. Her [DIAGNOSES REDACTED]. Record Review on 5/16/10 at 3:50 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated September 10, 2010. Review of the resident's MDS (Minimal Data Set) dated 3/2/10 revealed she had short and long term memory problems and required cueing for decision making. Review of the 2/10/11 MDS revealed a BIMS (Brief Interview for Mental Status) score of 6, indicating severely impaired cognition. The facility admitted Resident #8 on 6/24/09 with [DIAGNOSES REDACTED]. Record review on 5/16/11 at 2:35 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated 12/16/10. Review of the 9/14/10 annual MDS revealed she had short and long term memory problems and required assistance for decision making. Review of the 3/10/11 MDS revealed a BIMS score of 7, severely impaired cognition. During an interview at 3:30 PM on 5/17/11, the Social Services Supervisor stated that the Physicians rely on the the Social Workers to assist with resident's cognitive assessment to determine competency. She further stated that the Social Workers rely on the Physicians to sign the competency certificates. She confirmed that the Physician Certificate Ability or Inability to Consent to Admission or treatment for [REDACTED]. In addition, the Social Services Supervisor confirmed that the facility had no process in place to ensure that the competency certificates were signed by two physicians. Review of the South Carolina Code of Laws, Chapter 66, Adult Health Care Consent Act, Section 44-66-20 (6) states ""A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient.""",2014-10-01
9857,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,280,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, the facility failed to review/ revise the care plan for Resident #8 related to exit seeking behaviors, elopement and the placement of a Roam Alert bracelet. (1 of 5 residents reviewed for revision of the plan of care related to exit seeking/ Roam Alerts.) The findings included: The facility admitted Resident #8 on 2/26/10 and current [DIAGNOSES REDACTED]. On 5/17/11 at 9:50 AM, review of the Social Services Notes revealed the resident had eloped on 3/16/11 and that the resident had exhibited exit seeking behaviors on 2/21/11. A physician's orders [REDACTED]. Further review revealed that during the investigation of the elopement, staff reported that the resident did ""exhibit intermittent exit-seeking behaviros (sic.) of kicking at the doors and pushing at the doors stating that she wants to go out."" The Social Services Notes also revealed a note dated 2/11/11 revealing the resident also had a history of [REDACTED]. At 10:03 AM on 5/17/11, review of the Nurses Notes revealed a note dated 3/5/11 at 10:58 PM that stated the resident ""used repetitive statements through evening and did exit seek."" Another Nurses Note dated 2/21/11 at 11:13 AM revealed the resident wanted ""to visit mother and go home. Banging on doors and kicking doors saying that she is a prisoner."" On 5/17/11, review of the computerized and hard copy care plan revealed there was no care plan addressing the resident's behaviors, exit seeking, elopement or placement of the Roam Alert. During an interview on 5/18/11 at 11:45 AM, the Director of Nursing confirmed that the care plan did not address the resident's exit seeking behaviors, the placement of the Roam Alert bracelet or elopement risk. During an interview on 5/18/11 at 12:20 PM, RN #4, MDS (Minimal Data Set) Coordinator stated she was unaware of the resident's exit seeking behaviors or elopement.",2014-10-01
9858,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,323,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Survey, the facility failed to provide adequate supervision to prevent The facility failed to minimize the risk for accidents by failing to stabilize the oxygen cannister for Resident #2 ( 1 of 3 residents observed with oxygen.) Resident # 13, a known fall risk, was observed to be left unattended in the bathroom. ( 1 of 6 residents reviewed for falls) The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. On 5-16-11 at 3:00 PM review of the resident's records revealed a history of falls on 5-7-10, 5-24-10, 9-11-10, 9-12-11, 11-7-10, 3-26-11, and 4-5-11. Further review revealed a physician's orders [REDACTED]."" The 4/30/11 Care Plan approaches included use of a ""Pressure pad alarm in wchair (wheel chair) as safety devise (sic.)"" for a noted problem of ""I need reminders to call for assist with transfers (Parkinson's, Dementia, Debility). I have hand tremors, lean forward in my wchair & arthritis pain. I want to maintain my independence so may not use my call light for assist. I tire in the eve. (evening) & lack safety awareness. Hx (history) falls."" It was observed on 5-17-11 at 10:45 AM that Resident #13 was left unattended on the toilet in the bathroom while (CNA) #6 was in the day room. During multiple observations (on 05/16/2011 at 10:40 AM, 2:30 PM, 3:30 PM, and 5:45 PM; on 05/17/2011 at 9:00 AM and 3:25 PM; and on 05/18/2011 at 8:55 AM, 9:05 AM, and 10:55 AM), an unsecured oxygen (E) tank was noted on the floor at the head of Resident #2's bed. During an interview on 05/17/2011 at 4:10 PM, Licensed Practical Nurse (LPN) #6 verified that the oxygen tank was unsecured. On 05/18/2011 at 9:05 AM, Certified Nursing Aide #6 verified that the oxygen tank was on the floor and had never been in a stabilizer. No intervention was implemented until, on 05/18/2011 at 10:50 AM, LPN #1 again verified that the oxygen tank was unsecured and placed it in a stabilizer. Review of the facility Respiratory Care Policy and Procedure, provided by the Director of Nursing on 05/18/2011, stated: ""VI .SAFETY CONSIDERATIONS-FOR ALL CYLINDERS. A. All free standing cylinders, whether empty or full, shall be properly chained or supported, as in a cylinder stand, cart, or carrier.""",2014-10-01
9859,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,322,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of the facility policy entitled ""Standard Infection Precautions"", the facility failed to provide Resident #10 with a bolus feeding appropriate to prevent contamination of feeding in 1 of 2 residents observed for tube feeding flushes. The findings included: Resident #10 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 5/17/11 at 12:10 PM, a tube feeding and tube feeding flush was conducted by LPN #5. The LPN dropped the syringe onto the floor. She picked up the syringe with her gloved hand and went into the bathroom to rinse the syringe in the sink. The LPN returned to the resident to continue with placing formula into the syringe. The LPN did not change her gloves nor wash her hands before returning to continue with the tube feeding flush. Per review of the facility policy entitled "" Standard Infection Precautions"" dated 20.06.01, which stated... ""change gloves between tasks and procedures on the same elder and after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another elder. Clean hands each time gloves are removed"".",2014-10-01
9860,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,274,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, and interviews, the facility failed to identify significant physiological changes and complete significant change assessments for one of fourteen residents reviewed for Minimum Data Set (MDS) accuracy. Resident #13 had noted declines in activities of daily living (ADL) functions and no significant status change assessments were completed. The finding included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-17-11 at 11:30 am revealed the annual MDS assessment completed on 4-28-10 showed that a significant change assessment should have been completed on 7-22-10 based on data obtained under Section G of the assessment document, when compared to the quarterly MDS assessment completed on 7-22-10. Significant changes (declines) were noted on 4-28-11 in bed mobility which was coded ""0"" or ""independent"", compared to 7-22-10, which was coded as ""3"" or ""extensive assistance"". Also the resident's ability to transfer on 4-28-11 was coded ""0"" or ""independent"" compared to ""3"" or ""extensive assistance"" on 7-22-10. The quarterly MDS completed on 7-22-10 revealed a significant change assessment should have been completed on 10-13-10 based on data obtained under Section G of the assessment document, compared to the quarterly MDS completed on 10-13-10. Significant changes were noted on the 7-22-10 assessment in dressing which was coded as ""2"" or ""limited assistance"", compared to ""3"" or ""extensive assistance"" on 10-13-10. A decline was noted on 10-13-10 in toilet use from 7-22-10, which was coded as ""2"" or ""limited assistance"", compared to ""3"" or ""extensive assistance"" on 10-13-10. The quarterly MDS completed on 10-13-10 revealed a significant change assessment should have been completed on 1-10-11 based on data obtained under Section G of the assessment document, compared to the quarterly MDS completed on 1-10-11. Significant changes were as follows: the 10-13-10 MDS noted the resident's ability to walk in room was coded ""2"" or ""limited assistance""; locomotion on the unit was coded ""1"" or ""supervision""; locomotion off the unit was coded ""1"" or ""supervision""; personal hygiene was coded ""2"" or ""limited assistance"". The 1-10-11 MDS noted that the resident's ability to walk in room was coded ""3"" or ""extensive assistance""; the ability to walk in the corridor was coded ""3"" or ""extensive assistance""; locomotion off the unit was coded ""3"" or ""extensive assistance""; personal hygiene was coded ""3"" or ""extensive assistance"". During an interview on 5-18-11 at 9:45 am, Registered Nurse (RN) #4 reviewed the MDS assessment records for 4-28-10, 7-22-10, 10-13-10, and 1-10-11. RN #4 stated she had conferred with other MDS coordinators and stated that significant changes did occur between April, 2010 and July, 2010 and October, 2010 and January, 2011 for Resident #13 which should have prompted significant change assessments.",2014-10-01
9861,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,282,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and observations, the facility failed to follow care plan directives to monitor the use of chair safety alarms for one of six residents reviewed for alarm implementation. Resident #13's Care Plan for use of a pressure pad alarm was not followed. The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-16-11 at 3:00 PM revealed that the 4/30/11 Care Plan approaches included ""Pressure pad alarm in wchair (wheel chair) as safety devise (sic.)"", for a noted problem of ""I need reminders to call for assist with transfers ([MEDICAL CONDITION], Dementia, Debility). I have hand tremors, lean forward in my wchair & arthritis pain. I want to maintain my independence so may not use my call light for assist. I tire in the eve. (evening) & lack safety awareness. Hx (history) falls."" Further review revealed a physician's orders [REDACTED]."" On 5-16-11 at 10:45 AM during the Initial Tour with Certified Nursing Assistant (CNA) #4, Resident #13 was observed with the pressure pad alarm in place, but it was turned off as indicated by the switch in the ""off"" position. During an interview at this time, CNA #4 was asked about the need for the pressure pad alarm and identified that it was turned off. She stated that Resident #13 had a history of [REDACTED]. On 5-16-11 at 5 PM, Resident #13 was observed in the dining area with other residents. No staff members were in attendance and the resident's alarm was again in the ""off"" position.",2014-10-01
9862,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,309,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide services as ordered by the physician for one of fourteen sampled residents reviewed for care and services. The facility failed to perform weekly weights as ordered for Resident #2. The findings included: The facility admitted Resident #2 on 03/10/2011 with [DIAGNOSES REDACTED]. Record review on 05/16/2011 at 4:15 PM revealed a physician's orders [REDACTED]. Further review revealed no weekly weights were recorded. During an interview on 05/18/2011 at 10:00 AM, Licensed Practical Nurse (LPN) #1 verified the physician's orders [REDACTED]."" Review of the summaries revealed no reference to weights. During an interview on 05/18/2011 at 12:20 PM, LPN #1 stated, ""Dietary keeps up with the weekly weights and they never bring them back so that is why we have no record of the weekly weights."" During an interview on 05/18/2011 at 1:05 PM, the Director of Nutritional Services, accompanied by the Director of Food Services, stated, ""We did not do weekly weights.""",2014-10-01
9863,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2011-05-18,367,D,0,1,B6NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, and interviews, the facility failed to provide the diet as ordered by the physician for one of the three sampled residents reviewed for mechanically-altered diets. Resident #13 was provided solid foods on a mechanically-altered diet. The findings included: The facility admitted Resident #13 on 6-5-08 with [DIAGNOSES REDACTED]. Record review on 5-16-11 at 3:00 PM revealed physician's orders [REDACTED]."" Also, in the 4-30-11 Care Plan, the resident's problem stated: ""I eat a regular diet with my meat and other foods cut into small pieces because it's had (sic.) for me to chew some foods. I'm (sic.) might get constipation."" The Approaches included: ""Make sure I get the diet right"". Record review also revealed that the resident was evaluated by Speech Therapy and treated for [REDACTED]. The Speech Therapy Treatment Plan discharge summary on 12-9-10 revealed an order for [REDACTED]. Diet modification-Res. (Resident) to tolerate least restrictive diet consistency w/o (without) s/s (signs or symptoms) aspiration: Res. able to return to regular diet consistency. Staff instructed to cut food into small pieces."" On 5-16-11 at the 5:00 PM meal observation, Resident #13 was served a fish sandwich and french fries. The resident's meal was not chopped into small pieces. The resident stated, ""Sometimes I get help eating"", and ""Sometimes they make my food into smaller pieces."" It was observed that the resident struggled with cutting the fish sandwich and eventually removed the fish from the bun and ate it with her hand. She placed large pieces in her mouth, and after being unable to handle them, removed them and placed them back onto the plate. On 5-16-11 at 5:40 PM, a note was observed above the resident's bed instructing staff to chop food into small pieces and assist with all meals.",2014-10-01
9864,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2011-06-23,323,G,1,0,T7TE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interviews, the facility failed to provide supervision to prevent accidents for 1 of 3 residents reviewed for incidents/accidents. Resident #1 sustained a fall from her bed while receiving care from Certified Nursing Assistant (CNA) #1, certified on 1/24/2011 and employed by the facility 2/23/2011. CNA #1 was still in orientation when the incident occurred. The findings included: The facility admitted Resident #1 on 5/29/2009 with [DIAGNOSES REDACTED]. The resident's annual MDS (Minimum Data Set) dated 3/18/2010 and 3/18/2011 coded the resident as requiring total assistance with transfers and bed mobility with 2+ persons for support during those activities. She was coded as requiring total assistance with dressing, hygiene and bathing. The resident was coded as cognitively impaired with difficulty in decision-making. Review of the comprehensive care plan initiated 8/19/2010, failed to include in the approaches that the resident required 2-person assist with bed mobility. The approaches for the Activities of Daily Living (ADL) only included, ""dependent on staff to bathe shower; dependent on staff with daily hygiene, grooming, dressing oral care; Mechanical lift."" Review of the resident's nurse's notes dated 3/18/11 at 11 PM stated, ""Resident fell out of bed and onto floor while CNA was providing care. CNA stated she rolled the resident to change her sheet and she kept rolling and fell to the floor face down... Resident was bleeding from laceration on corner of left eye... and hematoma on left side of forehead... MD (Medical Doctor) notified. Ordered Vitamin K shot in left thigh. Patient was sent out to hospital on 911 call."" Resident #1 returned from the emergency roiagnom on [DATE] at 5:30 AM with a sutured laceration at the corner of her left eye. The physician progress notes [REDACTED]. Sent out to ER (emergency room ) due to head trauma while on Coumadin... 1. Hematoma L (left) forehead 2. Laceration to L forehead sutured by ER (emergency room ) 3. Hematoma to R (right) thigh."" Review of the facility's conclusion of the investigation of the incident revealed, ""...The CNA turned the resident to face the window. The CNA had the clean linen and brief underneath the resident's back. The CNA then walked around to the other side of the bed to turn the resident over. The resident rolled off the bed onto the floor... On 3/21/11 the CNA provided a demonstration of the incident. The ending result was the CNA did not ensure that there was enough room on the side once she turned the resident... The resident returned to the facility the same day with 4 sutures to the eye laceration. The resident was also placed on a wider mattress..."" Review of CNA #1's employee file, revealed the CNA was certified on 1/24/2011 and hired by the facility on 2/23/2011. During an interview with the Administrator on 6/23/2011 at 9:00 AM, she stated the CNA was in orientation at the time of the incident. The Administrator stated the CNA's orientation had been extended to ensure the CNA met the facility's expectation related to patient care. In an interview with the surveyor on 6/30/2011at 7:45 AM CNA #1 confirmed that she was in training at the time of the incident. She stated that the CNA responsible for her training her was not in the room at the time of the incident. There were no witnesses to the incident. CNA #1 stated that Resident #1 was on her back and that she positioned her on her right side. ""I was on her left side, as I was going around the right side, she rolled out of bed."" CNA #1 was a newly certified CNA in orientation at the facility. At the time of the incident the CNA was not supervised when providing care for Resident #1 identified by the facility as needing the assistance of 2 people for bed mobility.",2014-10-01
9865,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2011-06-23,280,G,1,0,T7TE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure 1 of 3 resident's care plans were reviewed and revised with adequate interventions to prevent falls/injuries from occurring. Residents #1's care plan was not updated with adequate interventions to prevent injuries. The findings included: The facility admitted Resident #1 on 5/29/2009 with [DIAGNOSES REDACTED]. The resident's annual MDS (Minimum Data Set) dated 3/18/2010 and 3/18/2011 coded the resident as requiring total assistance with transfers and bed mobility with 2+ persons for support during those activities. She was coded as requiring total assistance with dressing, hygiene and bathing. The resident was coded as cognitively impaired with difficulty in decision-making. Review of the resident's nurse's notes dated 3/18/11 at 11 PM stated, ""Resident fell out of bed and onto floor while CNA was providing care. CNA stated she rolled the resident to change her sheet and she kept rolling and fell to the floor face down... Resident was bleeding from laceration on corner of left eye... and hematoma on left side of forehead... MD (Medical Doctor) notified. Ordered Vitamin K shot in left thigh. Patient was sent out to hospital on 911 call."" Resident #1 returned from the emergency roiagnom on [DATE] at 5:30 AM with a sutured laceration at the corner of her left eye. Review of the comprehensive care plan initiated 8/19/2010, failed to include in the approaches that the resident required 2-person assist with bed mobility. The approaches for the Activities of Daily Living (ADL) only included, ""dependent on staff to bathe shower; dependent on staff with daily hygiene, grooming, dressing oral care; Mechanical lift."" The CNA care tool failed to address the need for 2-person assist with bed mobility. Cross Refers to F-323 as it relates to the facility's failure to review and revise the care plan with appropriate interventions to prevent injuries.",2014-10-01
9866,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2011-06-23,226,D,1,0,T7TE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review, interviews and review of the facility Abuse, Neglect and Misappropriation of Patient Property Prevention policy, the facility failed to implement written policies and procedures to prevent neglect. Resident #1 was injured during care on 3/18/2011. The incident was not reported until 4/21/2011. The findings included: The facility admitted Resident #1 on 5/29/2009 with [DIAGNOSES REDACTED]. The resident's annual MDS (Minimum Data Set) dated 3/18/2010 and 3/18/2011 coded the resident as requiring total assistance with transfers and bed mobility with 2+ persons for support during those activities. The resident's nurse's notes dated 3/18/11 at 11 PM, stated, ""Resident fell out of bed and onto floor while CNA was providing care. CNA stated she rolled the resident to change her sheet and she kept rolling and fell to the floor face down... Resident was bleeding from laceration on corner of left eye... and hematoma on left side of forehead."" Review of the facility investigation of the incident included a fax face sheet dated 4/21/2011, over a month after the incident occurred, reporting the incident to the State Agency Certification. The fax sheet contained a note that stated, ""Ombudsman stated should have been reported to certification."" Review of the facility Abuse, Neglect and Misappropriation of Patient Property Prevention policy revealed the following: ""Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."" ""Reporting: The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures (including to the state survey and certification agency)..."" During an interview with the administrator on 6/23/2011, she confirmed the incident was not reported to the State Survey Agency.",2014-10-01
9867,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,253,E,0,1,7GFL11,"On the days of the survey through observation and interview the facility failed to provide a comfortable interior for 3 of 5 units shower rooms, chairs in the 400 unit dining room area were soiled, Geri chairs and a wheel chair presented with cracked arms, dust-like material was noted on the air conditioning vents on the 400 day/dining room area and chipped tile was observed in and around the sink in a whirlpool room. Shower rooms and baseboards were noted with scrapes and holes in the walls. The findings included: Unit 100 - Observations on 7-26-2011 at 2:40 PM revealed large holes in walls and baseboards in both of the shower rooms. Additionally, there was rust/corrosion at the bottom of a door frame that led from the shower area to a toilet. Unit 300 - Observations on 7-26-2011 at 3:15 PM revealed large holes in baseboards and broken tiles in the shower rooms. During environmental rounds with the Maintenance Director on 7-27-2011, he confirmed the observations and indicated that this damage was probably due to wheelchairs hitting up against the walls and baseboards. During initial tour of the 400 Unit on 7/25/11 at approximately 9:45 AM, the following was observed: 1) Four chairs noted in the day/dining area with soiled/stained seats. 2) Air condition vents on each side of the day/dining area with gray build-up noted on the vents. 3) Observation of the whirlpool room on Hall 2 with one Geri-chair with a hole in the right armrest. A chipped area around the sink with what appeared to be loose grout. Upon entering the whirlpool room, the wall to the left was observed with scraped areas. 4) A Geri-chair outside of room 418 was observed with cracked areas along the upper portion of the chair with a torn area on the right armrest. On 7/27/11 at approximately 9:00 AM, the above was again observed with three additional soiled/stained chairs in the day/dining area and a wheelchair sitting outside of room 418 with cracked/torn armrests. On 7/27/11 at 9:40 AM, RN #1 confirmed the above during environmental rounds on the 400 unit.",2014-10-01
9868,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,309,E,0,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and record review, the facility failed to provide necessary care and services related to following physician's orders [REDACTED].( 1 of 1 sampled residents reviewed care and services related to following physician orders [REDACTED].) Resident # 21 had specific physician orders [REDACTED]. The findings included: The facility admitted Resident # 21 on 7-13-07 with [DIAGNOSES REDACTED]. During record review on 7-27-11 at approximately 10:45 AM, the following orders were noted on the physician's orders [REDACTED].& pulse Monitor and record before /after [MEDICAL TREATMENT] (M-W-F)."" Further review of the Medication Administration Record [REDACTED]. When reviewing the I & O records from May 2, 2011 to July 24, 2011, it was noted that the record had places for each shift to record fluid intake for a total of 219 possible entries during that period. Only 43 entries were made related to fluid intake. In the Output column there was only 1 entry for the 219 possible entries. This information was confirmed with the Director of Nursing on 7/26/11 at approximately 11:30 AM. During the Medication Pass Observation on 7/26/11 at 8:45 AM Licensed Practical Nurse (LPN) #1 applied a [MEDICATION NAME] to Resident # 21. When questioned about the patch, the LPN stated "" I only put it on the left or right shoulder or the middle of the shoulders"". The Physician orders [REDACTED]. Remove old patch. (Rotate site and do not repeat site for 14 days). The MAR indicated [REDACTED]. The March 2011 MAR indicated [REDACTED]. Site 16 (upper right chest) was used once, site 8 (left deltoid) was used once, site 7 (right deltoid) was used once, site 9 (right arm) and 10 (left arm) were alternated for the rest of the month. In April 2011, May 2011 and June 2011 the MAR indicated [REDACTED]. Additionally, in June 2011, nurses documented the date as the application site for June 20th, (site 20), 21 (site 21), 22 (site 22) etc. through the 26th. The application site codes on the back of the MAR indicated [REDACTED]. During a interview with LPN #1 on 7/26/11, she stated "" I thought the patch had to be rotated every 24 hours."" The Consultant Pharmacist stated on 7/27/11 at 9 AM "" the patch is rotated to prevent skin issues, but if the Physician ordered it that way, it should be given that way or changed"".",2014-10-01
9869,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,322,D,0,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and record review the facility failed to provide appropriate treatment and services for 2 of 4 resident observed for gastrostomy tube ([DEVICE]) flush. Gastric tube placement nor residual were checked for Resident # 5 prior to administering medications. The findings included: The facility admitted Resident # 5 on 12-1-04 with a [DIAGNOSES REDACTED]. During observation of administration of medications via [DEVICE] on 7-26-11 at approximately 11:20 AM, Licensed Practical Nurse (LPN) # 5 entered the room, and identified herself . LPN # 5 then washed her hands, applied gloves and looked around the room for her stethoscope. When she could not find one in the room, she stated she had given the resident a tube flush at 8:00 AM this morning and that it was only necessary to check the [DEVICE] for placement and residual once on each shift. LPN # 5 then administered the medications via the gastrostomy tube to Resident # 5. Review of the medical record revealed a physician's orders [REDACTED].""check placement before/after meds/flushes."" On 7-27-11 at approximately 11:30 AM, a telephone interview was conducted with LPN #5, in the presence of the Director of Nursing. At that time, LPN # 5 confirmed that she had not checked for placement nor residual during the tube flush. During a subsequent conversation with the Director of Nursing at that time, she stated LPN # 5 should have checked for residual and placement before giving medications. The facility admitted resident #1 on 12/31/09 with the following Diagnosis: [REDACTED]. During the observation of the tube flush and feeding on 7/25/11 at 4:30 PM Licensed Practical Nurse #3 failed to aspirate gastric contents to check for tube placement/residual. When questioned, on 7/26/11 at 3:30 PM, he stated "" I was nervous."" The DON (Director of Nursing) stated on 7/26/11 at 3:15 PM: "" The nurse should check placement by air bolus, auscultate bowels sounds and should aspirate to check for residual.""",2014-10-01
9870,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,334,C,0,1,7GFL11,"On the days of survey, based on record review and interview, the facility failed to ensure each resident or resident's legal representative received education regarding the benefits and potential side effects of the influenza immunization for 3 of 5 sampled residents. (Residents #1, #4, and #5). The findings included: Chart review of three residents revealed influenza immunizations were given to Residents #1, #4, and #5 in October 2010. Further review revealed no documentation that the residents or their representatives were given education regarding risks or benefits. In an interview with the Director of Nursing (DON) on 7/26/11 at 10:00 PM, she stated that the documentation would be located in the nursing notes. Review of the nursing notes did not reveal this information. When further documentation was requested, it could not be provided.",2014-10-01
9871,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,428,E,0,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews the facility failed to act upon Pharmacist report and recommendation for Resident # 13 related to increasing Aricept or changing to another drug. Resident # 2 had no pharmacy reviews in the current medical record. (Two of fifteen sampled residents reviewed for consultant pharmacy reviews.) The findings included: The facility admitted resident # 13 on 4/29/10 with the following Diagnosis: [REDACTED]. Start Aricept 10 mg hs (bedtime) for Dementia or change to Exelon to avoid GI (Gastro Intestinal) issues (history of ulcerative colitis and rectal bleeding). Under the Physician Response to Recommendation/Finding: The Physician checked the box next to ""I Agree: please write order (s)"". The Physician signed the form. No Physician order was written and the MAR (Medication Administration Record) through July 2011 continued to document that Aricept 5 mg was given every hs. During a interview with Licensed Practical Nurse #4 on 7/26/11 at 2:00 PM she stated "" the unit manager handles those"". At this time, the DON (Director of Nursing) stated "" the form should be given to the Physician and if he agrees or doesn't, the nurse manager or supervisor should carry it out like a regular order, write it, and call the family. The nurse should sign the consult form and file it under consult in the chart"". The DON confirmed that the process had not been followed which resulted in the resident continuing to receive the medication the physician ordered to be changed. The facility admitted Resident #2 on 8/28/09 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. During record review on 7/25/11 at 2:15 PM, no documentation of pharmacy reviews were noted. On 7/26/11, the DON(Director of Nursing) was informed that the drug regimen review could not be found. At that time the DON stated that *** performed the drug regimen review and she would contact them. On 7/27/11, one drug regimen review was presented to the surveyor dated 4/26/11. No other drug regimen reviews were provided during the survey process.",2014-10-01
9872,JOHN EDWARD HARTER NURSING CENTER,425103,185 REVOLUTIONARY TRAIL,FAIRFAX,SC,29827,2011-01-19,274,D,0,1,RCCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews, the facility failed to perform a significant change assessment for 1 of 1 residents (Resident #7) receiving Hospice services. The facility did not conduct a Significant Change Assessment for Resident #7 who was admitted to Hospice Services for a terminal illness. The findings included: The facility admitted resident #7 on 11/02/2010 with [DIAGNOSES REDACTED]. Review of the medical record revealed the facility had completed a care plan on 11/18/2010. On 11/24/2010 the resident was admitted to Hospice services. During record review on 1/19/2011, there was no Significant Change Assessment on the medical record following admission of the resident to Hospice services. The DON (Director of Nursing) was interviewed on 1/19/2010 at 11:40 AM. The DON stated that she was not aware that a Significant Change Assessment had to be completed when a resident was admitted to Hospice services. LPN (Licensed Practical Nurse) #1 was interviewed on 1/19/2011 at 11:55 AM. LPN #1 was responsible for completing the Comprehensive Assessments. She stated that she had not been aware that a Significant Change Assessment was required when a resident was admitted to Hospice Services.",2014-10-01
9873,JOHN EDWARD HARTER NURSING CENTER,425103,185 REVOLUTIONARY TRAIL,FAIRFAX,SC,29827,2011-01-19,309,D,0,1,RCCL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews, the facility failed to coordinate a plan of care for 1 of 1 residents (Resident #7) receiving Hospice services. The findings included: The facility admitted resident #7 on 11/02/2010 with [DIAGNOSES REDACTED]. Review of the medical record revealed the facility had completed a care plan on 11/18/2010. On 11/24/2010 the resident was admitted to Hospice services. A Hospice Care Plan was dated for 12/1/2010. The facility did not update their plan of care to include Hospice Services and the Hospice Care Plan did not address the services that would be performed by the facility. The Hospice Service reviewed and updated their Plan of Care on 12/6/2010, 12/14/2010, 12/28/2010, and on 1/5/11. There was no evidence of facility involvement in the Hospice care plan. RN (Registered Nurse) #1 was asked on 1/19/2011 at 10:50 AM, ""What does the 2m, 3m, 8 prn mean on the Hospice Face Sheet""? RN #1 stated that she did not know but that the Hospice Nurse could be called"". A call was placed to the Hospice nurse, who spoke to the Surveyor. The Hospice Nurse explained, ""The 2m-3m means 2-3 visits a month and 8 visits as needed."" The DON (Director of Nursing) was interviewed on 1/19/2010 at 11:40 AM. She agreed that there was no evidence of coordination of the resident's plan of care between the facility and the Hospice service. She stated that the facility had a care plan and Hospice had a care plan. LPN (Licensed Practical Nurse) #1 was interviewed on 1/19/2011 at 11:55 AM. She stated she was unaware if the Hospice Service was providing a CNA (Certified Nursing Assistant) or not. Although both the facility and the Hospice Service had a plan of care, there was no plan of care coordinated between the two entities. There was nothing to identify what care the facility would be responsible for or what the Hospice would be responsible for. The facility had one problem noted on their plan of care dated 11/16/2010 of Death/Dying issues that included an approach to refer pain to Hospice care plans. However, Hospice did not admit the resident to their services until 11/24/2010.",2014-10-01
9874,HERITAGE HEALTHCARE CENTER AT THE PINES,425113,413 LAKESIDE COURT,DILLON,SC,29536,2010-10-20,315,D,0,1,TQ5V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review and review of the facility's policy for Catheter Care, one of two resident's observed for catheter care received inappropriate care during the treatment. The Certified Nurses' Assistant CNA anchored the catheter tubing distally and cleansed the tubing moving from the distal portion back to the proximal end of the tubing. The findings included: The facility admitted Resident # 19 on 06/17/2008 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident received [MEDICATION NAME] 50 milligrams at bedtime as a maintenance dose of antibiotic for urinary tract infections. During the catheter care treatment on 10/20/2010 at 9:45 AM, CNA #1 held the catheter tubing distally from the urinary meatus and with a disposable wipe cleansed the tubing as she moved the wipe up the tubing to the proximal end of the tubing at the opening of the meatus. In an interview with CNA #1, she confirmed that she did hold the tubing distally and that she did move the wipe towards the meatus instead of away from the meatus opening. Review of the facility's Catheters: Care and Anchoring, Changing of policy revealed in item 11.) ....cleanse catheter from insertion site to four (4) inches; outward.",2014-10-01
9875,HERITAGE HEALTHCARE CENTER AT THE PINES,425113,413 LAKESIDE COURT,DILLON,SC,29536,2010-10-20,456,E,0,1,TQ5V11,"On the days of the survey, based on observation, record review, policy review, and interview, the facility failed to maintain 1 of 2 unit refrigerators in safe operating condition. The North nutrition refrigerator maintained an inside temperature higher than the recommended acceptable parameters. The findings included: Observation of the North Unit nutrition refrigerator on 10/20/10 at 2:15 PM, revealed contents of Med Pass, soft drinks, and applesauce. The inside refrigerator temperature was 56 degrees. The Dietary Manager and Maintenance Director confirmed that the temperature was above the recommended parameters. Review of the refrigerator log for October 2010 revealed temperatures ranging from 42 - 62 degrees. Review of the facility policy titled ""Refrigerator Temperatures"" revealed that temperatures should be maintained at or below 40 degrees. During an interview with the Director of Nursing on 10/20/10, she stated that the night nurse was responsible for checking and documenting the temperature and should have reported that the temperatures were out of the acceptable range.",2014-10-01
9876,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2011-01-19,315,D,0,1,FW0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and the facility provided Policy and Procedure for Catheter Care, Perineal Care (Female) and Competency for Peri-Care, facility staff performing catheter care for Resident #8 failed to position legs apart and bent, separate labia, and anchor tubing at the meatus before cleaning down the catheter tubing. Staff did not separate labia and wiped back to front while providing perineal care for Resident # 18. ( One of one catheter care observed and one of one perineal care observed.) The findings included: The facility admitted Resident #8 on 12/28/10 with [DIAGNOSES REDACTED]. During catheter care observation on 1/18/11 at 3 PM, CNA #1 (Certified Nursing Assistant) prepared the room and resident, washed her hands, and applied gloves. The resident was placed in a supine position ( flat on back with legs touching each other and straight out in front of resident.) The alert resident was not instructed to separate or bend her legs for the procedure. The CNA took a disposable wipe and wiped down right side, left side, and center disposing of the wipe after each stroke. The labia was not separated. The CNA then anchored the catheter tubing approximately 4 inches from the meatus, and using a disposable wipe, cleansed from the meatus down to where the tube was held/anchored. Following the procedure the CNA verified the surveyors observations. During an interview with the DON (Director of Nursing) on 1/19/11 at 3:15 PM, the DON stated that the resident should have been positioned on her side or lying on her back with legs up. When questioned if the CNA would be able to clean with the resident who was lying on her back with legs straight out in front of her and together, the DON replied: ""No- you can't clean unless the legs are apart."" When questioned as to where she would you expect the CNA to anchor the tubing, the reply was: ""...She should anchor near the body (meatus)."" . The facility admitted Resident #18 with the following Diagnoses: [REDACTED]. During an observation of Perineal (Peri)-Care for Resident #18 on 1/19/2010 at 12:10 PM, Certified Nursing Assistant (CNA) #2 cleansed the groin/thigh area of the body on each side of the resident wiping front to back. The resident's right leg was slightly bent at the knee toward the right, the left leg was straight. CNA #2 then wiped front to back down the center of the perineal area one time with out spreading the labia. Resident #18 was then positioned to her right side. The CNA, using a clean wipe each time, wiped the left and right buttock back to front. She continued by wiping the center back to front. The CNA did not spread the buttocks to clean the perianal area. The resident was repositioned to her left side and cleansed again in the same manner, wiping back to front and not cleaning the perianal area. At 12:20 PM on 1/19/2011, during an interview with CNA #2, the surveyor asked if she thought she should have done anything differently? CNA #2 stated that she ""would not."" The surveyor's observations were reviewed with the CNA. The CNA did not dispute the observations and stated that she had been trained to complete the care the way she had demonstrated it to the surveyor. On 1/19/2011 at 3:15 PM, during an interview with the Director of Nursing (DON), the surveyor asked how she would expect a CNA to perform Peri-Care on a female resident? The DON stated that she would expect a CNA to position the resident on her back, bend her knees and clean the area between the thighs and body. The CNA should spread the labia and cleanse each side and the center wiping front to back with a clean wipe for each area. The DON also stated that the resident should then be positioned on her side and the buttocks and peri-anal area should be cleaned front to back with a clean wipe for each area. Review of the facility's Competency for Peri-Care included: ""...open labia with one hand and hold until complete: Cleanse one side of the labia front to back-dispose of wipe. Cleanse the other side of labia front to back-dispose of wipe. Cleanse middle area-dispose of wipe. Cleanse the peri-anal area front to back-dispose of wipe..."" Review of the facility's Perineal Care Policy (Female) included: ""...7. Clean perineal area with wipes-open labia with one hand and hold until complete: a. Cleanse one side of labia front to back-dispose of wipe. b. Cleanse the other side of labia front to back-dispose of wipe. c. Cleanse middle area-dispose of wipe...f. Cleanse the buttocks front to back using a clean wipe for each stroke. g. Cleanse the peri-anal area front to back-dispose of wipe...""",2014-10-01
9877,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2011-01-19,441,E,0,1,FW0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews and review of the facility's policies entitled Gastrointestinal Infections, Clostridium Difficile (C-Diff), Infection Control Definitions and Contact Precautions, the facility failed to establish an Infection Control Program under which it assessed the need for and promptly initiated transmission based precautions to prevent the spread of infection. Resident #7 and Resident # 12 were potentially symptomatic/receiving treatment for [REDACTED]. The findings included: The facility admitted Resident #7 on 10/8/2008 and readmitted her on 11/23/2010 with [DIAGNOSES REDACTED]. During initial tour on 1/18/2011 at 11:00 AM, Licensed Practical Nurse (LPN)#1 stated that Resident #7 was admitted to the facility with a history of Clostridium Difficile and was currently having diarrhea. She also stated that the resident was being treated with Questran. Resident #7 was observed to be in a semi-private room with a roommate. Resident #7 was not on transmission based precautions at the time of the tour. Review of the resident's medical record on 1/18/2011 at 2:40 PM revealed that on 12/06/2010, Resident #7 had been ordered Vanco ([MEDICATION NAME]) 200 mg (milligrams)- 1 by mouth (po) qid (4 times a day) times 14 days for a [DIAGNOSES REDACTED]. 1/10/2011 The resident had been incontinent of stool with no loose stools noted. 1/12/2011 The resident had an incontinent episode with a loose stool. 1/13/2011 The resident was incontinent of bowel on 3 occasions. 1/14/2011 The resident was also noted to be incontinent. 1/16/2011 The resident had a temperature of 99.7 and 3 episodes of loose stools documented at 3:00 PM. At 10:45 PM, incontinent care was provided per documentation with no indication of whether it was due to bowel or bladder other that [MEDICATION NAME] Cream was applied to buttocks. 1/17/2011 the Nurses Notes documented that at 2:00 PM, the resident was incontinent of B&B (bowel and bladder) with incontinent care as needed. Resident #7 also had incontinent episodes on 11/18/2011 at 3:00 AM with no description of the stool. On 1/18/2011 at 12:30 PM, the resident left the facility for an appointment with a physician. Upon return to the facility the resident had an order for [REDACTED]. The resident was placed back into her room which she shared with a roommate. At 3:15 PM the resident had another episode of incontinence of bowel and bladder. An observation at 3:30 PM revealed that Resident #7 had not been placed on isolation for possible[DIAGNOSES REDACTED] and continued to share a room. In an interview with LPN #2 at 3:35 PM, when asked by the surveyor what steps she would follow with a resident suspected of having[DIAGNOSES REDACTED]? She stated that she did not know but would find out. When LPN #2 returned, she stated that at the first sign of fever or diarrhea she would isolate the resident. LPN #2 stated that she was not aware that Resident #7 had had a fever or diarrhea. However, the Unit Coordinator for the [MEDICATION NAME] Unit acknowledged Resident #7 had been having diarrhea. The Director of Nursing (DON) further stated that a resident would be isolated until a culture for[DIAGNOSES REDACTED] was obtained and came back negative. The surveyor asked if a resident had a history of [REDACTED].? The DON stated, ""Yes, until the results of a culture were obtained."" The surveyor asked the DON and LPN #2 at 3:45 PM, if they were aware that Resident #7 had an order for [REDACTED].? Both nurses stated that they were not aware of this information. Review of the facility's policy entitled Gastrointestinal Infections:...Procedure: 1. Criteria for infection include 3 or more watery stools in a twenty-four hour period that is not normal for a resident...Contact Precautions revealed""...Procedure: It is the intent of this living center to use contact precautions for residents known or suspected to have serious illness easily transmitted by direct resident contact or by contact with items in the resident's environment...1. Resident Placement. Resident may be placed in a private room..."" The policy entitle Infection Control Definitions revealed:""...Cohorting: Practice of grouping residents infected or colonized with the same infectious agent together to confine their care to one area...The policy entitled Clostridium Difficile indicated...1. Residents with diarrhea caused by [DIAGNOSES REDACTED]icile should be in private rooms or in the same room with other residents with [DIAGNOSES REDACTED]icile..."" Review of the facility's in-service which included Infection Control revealed that LPN #2 had been in-serviced on[DIAGNOSES REDACTED] on June 3,2010 and isolation on August 12,2010. The facility admitted Resident # 12 on 11/23/10 .During record review on 1/18/11, a 1/17/11 physician's orders [REDACTED]. On 1/18/11 there was a physician's order to d/c (discontinue) check stool for[DIAGNOSES REDACTED]. No documentation could be found in the medical record as to why the order had been written or why it was discontinued. There was no documentation noted of the resident having loose stools or diarrhea. On 1/19/11 at 8:40 AM an interview with RN #1 (Registered Nurse) revealed the resident had been having loose stools. The staff was unable to obtain a stool for a culture on 1/17/11, so they had discontinued the order. The nurse further stated the resident had two loose stools ""this morning"" (1/19/11), and she was getting another order for a stool culture. RN# 1 confirmed Resident # 12 was in a room with another resident and she stated she really wasn't sure how long the resident # 12 had been having loose stools. The residents shared the same bathroom. No precautions were noted to be in place other than universal handwashing. There was no documentation in the nurses notes of loose stools. Review of the RCT (CNA's) Flow Sheet for January revealed the resident had been sporadically having 2-3 stools per day since 1/8/11. There was no documentation as to the consistency of the stools. Prior to 1/7/11 the records had been maintained on the computer, but the computer program had been changed. Copies of these records were requested but not provided. During an interview with Resident #12 on 1/19/11 at 8 AM she stated she had ""three loose stools already this morning."" The resident recalled having some loose stools the week before but was unable to recall beyond last week.",2014-10-01
9878,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2011-01-19,225,D,1,1,FW0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and complaint survey based on record reviews, interviews and review of the facility policy on Abuse and Neglect, the facility failed to report timely, an allegation of verbal abuse. Two Certified Nurse Aides reportedly heard staff yelling at a resident in room [ROOM NUMBER] on 12/05/2010 and two (2) licensed nurses were informed of the incident on 12/05/2010. Documentation revealed the State survey and certification agency was notified on 12/13/2010 that Resident #6 was allegedly abuse verbally by a Certified Nurse Aide. The CNA was overheard using inappropriate language when speaking to Resident #6. (1 of 14 sampled residents reviewed) The findings included: The facility admitted Resident #6 on 10/15/09 and readmitted him on 5/12/10 with [DIAGNOSES REDACTED].#6 indicated that on 12/05/2010 at 11:00 PM two CNAs standing at the time clock, near Resident #6's room heard another CNA yell at a resident and state, ""I'm not going to take anymore of your --, you hear me! You always give me --!, I am not putting up with your crap tonight."" After hearing the yelling CNA #5 reported the incident to Licensed Practical Nurse (LPN) #3 who with Registered Nurse (RN) #3 entered room [ROOM NUMBER] and asked CNAs #3 and #4 if they heard anything out of the ordinary. In an interview on 1/18/2011 at 1:50 PM the Director of Nursing (DON) stated the incident occurred on 12/05/2010 and the nursing staff was aware of the incident on 12/05/2010. The DON further stated the nursing staff did not inform her of the incident until 12/12/2010 after a nurse called about the follow-up related to the allegations. The DON stated the staff was inserviced related to the reporting of abuse and neglect. The DON confirmed the allegation was not submitted to the State Survey and Certification Agency timely.",2014-10-01
9879,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2011-01-19,280,D,1,1,FW0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on record reviews, interviews, and review of the facility's Smoking Policy, the facility failed to review and revise care plans for 1 of 2 sampled residents reviewed who desired to smoke while residing in the facility. Resident #6 had been identified as a smoker by the facility and was not care planned with interventions related to smoking. The findings included: The facility admitted Resident #6 on 10/15/09 and 5/12/10 with [DIAGNOSES REDACTED]. Further record review revealed a care plan updated on 10/13/10 that did not address problem/need, goals and approaches for the resident being a smoker. In an interview on 1/18/11 at 4:50 PM the Social Services Director (SSD) stated the resident was a smoker. She confirmed he was not care planned for smoking but should have been care planned. In an interview on 1/18/11 at 5:05 PM Registered Nurse (RN) #2/Care Plan Coordinator confirmed the resident was a smoker, and that he was not care planned for smoking at the facility. Review of the facility's ""Smoking Policy"" revealed under ""Procedure: #3 Residents will be assessed by using the ""Smoking Screen"" form on admission, significant change and quarterly thereafter. Resident's smoking choice to be care planned appropriately.""",2014-10-01
9880,LANCASTER CONVALESCENT CENTER,425155,2044 PAGELAND HWY,LANCASTER,SC,29721,2011-06-22,315,D,1,1,MCJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility policies titled ""Catheter Care (Indwelling Catheter)"" and ""Policy on Prevention of Catheter-Associated Urinary Tract Infections"", the facility failed to provide appropriate care and services to prevent urinary tract infections for 1 of 1 sampled resident observed for Foley Catheter Care and 1 of 3 resident closed records reviewed (Resident #24). During Resident #7's Foley Catheter Care, the facility staff member failed to re-cleanse the meatus after releasing it to obtain additional cleansing cloths. The staff member further failed to obtain a leg strap to secure the catheter tubing and allowed the privacy bag to come into contact with the floor. The findings included: The facility admitted Resident #7 on 03-21-11 with [DIAGNOSES REDACTED]. On 06-21-11 at approximately 3:46 PM, Licensed Practical Nurse (LPN) #2 entered Resident #7's room to provide Foley Catheter Care. LPN #2 closed the Resident's room door, washed her hands, donned clean gloves, and proceeded to provide Foley Catheter Care. Observation revealed LPN #2 failed to re-cleanse the meatus after releasing it to obtain additional clean wipes. After completing the Foley Catheter Care, LPN #2 further failed to obtain a leg strap to secure the catheter tubing and allowed the privacy bag with the catheter drainage bag inside to come into contact with the floor. The bag appeared to be almost folded in half touching the floor with urine observed inside the drainage bag. During an interview on 06-22-11 with LPN #2, she stated, ""I know I let go. I know not to do that. I've been [MEDICATION NAME]. I was nervous. I normally don't stand on that side of the bed"". LPN #2 further confirmed a leg strap had not been present and the privacy bag touched the floor. Review of the facility policy titled ""Catheter Care (Indwelling Catheter)"" revealed Procedure #9 stated ""Spread the labia preferably using your thumb and ring finger; take the first no rinse wipe and wash down one side of the labia; dispose in the open trash bag at the foot of the bed. Then take the 2nd no rinse wipe and wash down the other side and dispose. Take the 3rd no rinse wipe, wash down the middle, then dispose. Take the remaining fingers and hold the catheter tubing between them while you keep the labia spread. Do not hold the catheter with the same fingers used to separate the labia. Take the 4th no rinse wipe and wash about 4 to 6 inches up the catheter tubing, going from the meatus up, taking care not to pull on catheter or advance further into the urethra"". Procedure #10 stated ""Remove gloves and put in trash bag. Place on clean gloves and secure the catheter with a leg strap"". Review of the facility policy titled ""Policy on Prevention of Catheter-Associated Urinary Tract Infections"" revealed ""Indwelling catheters are properly secured to the leg or abdomen after insertion to prevent movement of the catheter which may lead to urethral traction and bladder trauma"". Further review of facility policy revealed ""The collection bag and/or tubing are not allowed to touch the floor or other contaminated objects such as the wheels of wheelchairs"". Review of the facility policy ""Catheter Care (Indwelling Catheter)"" employee acknowledgement of understanding of Catheter Care and return demonstration per facility policy revealed LPN #2 signed this statement on 03-15-11. The facility admitted Resident #24 on 2/24/11 with [DIAGNOSES REDACTED]. Review of the closed medical record on 6/21/11 revealed the resident had a Foley catheter in place at the time of admission to the facility. Review of the April 2011 Physician's Orders indicated an order for [REDACTED]. Review of the Report of Consultation dated 4/27/11 indicated Resident #24 was seen by the Urologist on that date. Review of the consultation report indicated a [DIAGNOSES REDACTED]. The Director of Nursing documented in the Nurses Notes dated 4/27/11 at 12:00 PM which indicated that upon return from the Urologist's office, the Director of Nursing (DON) reviewed the physician's findings and assessed the resident with the Staff Development Coordinator. According to the notation, ""...the head of the penis did appear red and slightly swollen. Upon further review the nurse on the unit stated she had performed cath care prior to the resident leaving the facility for his appointment and forgot to pull the foreskin back into place. The DON then called the Urology office and spoke (with) the nurse regarding the appointment...The DON specially (sic) asked (sic) we should be doing anything different here at the facility and she stated, No just make sure the foreskin is returned after cath (catheter) care."" During an interview on 6/22/11 at approximately 3:30 PM, the DON stated the redness and swelling observed on 4/27/11 resolved. Record review revealed no further documentation related to this occurrence after the 4/27/11 documentation. Review of the Policy and Procedure related to Catheter Care provided by the facility on 6/21/11 revealed the policy addressed the Procedure for Performing Catheter Care on a Male Resident. The policy consisted for 4 steps with step #5 being blank. This policy was revised on 12/03/07. On 6/22/11 at approximately 3:30 PM, the surveyor asked if the facility had another policy related to catheter care. The facility provided another copy of this same policy on 6/22/11 at approximately 6:00 PM. Review of this policy indicated the same information with the addition of a handwritten notation under step #5 that stated, ""Return foreskin over head of penis."" The Administrator indicated at that time that this handwritten notation was added because the facility felt this information should be a part of their policy on catheter care.",2014-10-01
9881,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-06-16,323,G,1,0,IP8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, observations, interviews, and review of the facility's investigative materials related to a resident's fall from bed and an injury of unknown origin, the facility failed to ensure the residents received adequate supervision and assistance devices to prevent accidents, and failed to properly supervise staff to ensure compliance with safety measures for 1 of 1 resident reviewed who sustained a serious injury from a fall (#1) and for 1 of 1 resident reviewed for a fracture of unknown origin (#3). On the night of 4/27-28/11, the staff failed to ensure Resident #1 had both side rails raised on her bed, and failed to ensure the bed was in the lowest position. At approximately 1:45 AM, the resident fell from the bed and sustained an abrasion to the forehead, and hematomas to the forehead, and upper lips and philtrum. There was also a questionable fracture at the base on the left hand fifth digit. Certified Nursing Assistant (CNA) #1 saw the side rails down when she began her shift and ""assumed"" the order for them had been changed. On 5/10/11, Resident #3 was found to have right ankle swelling and discoloration. An x-ray showed a fractured distal fibula. The facility's investigation revealed CNA #2 transferred the resident on 5/8/11 without using the required sit to stand lift and without the assistance of a second person. The resident's ankle became twisted in the CNA's legs during the transfer. CNA #2 acknowledged knowing he was supposed to use the lift but did not use it with the resident on 5/8/11. The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident Minimum Data Sets for 4/19/10 and 4/7/11 showed the resident had short and long term memory problems with severely impaired decision making ability. The resident rarely understood communication, and others rarely understood the resident. She required total care from the staff for all activities of daily living. Neither assessment showed any falls. Review of the Nurse's Notes on 5/2/11 showed an entry for 4/28/11 at 1:45 AM saying: ""resident noted on floor (with) tube feeding connected but beeping flow error noted lying on her back (with) head tilted back blood noted to forehead and floor swelling noted to (R) eyebrow redness and swelling noted to (L) forearm bed noted in mid air and side rails on each side of the bed noted to be down after assisting resident (with) the assist of the CNA resident transferred to bed cleaned resident's forehead (with) NS (normal saline) to assess where bleeding was coming from slit noted to forehead actively bleeding ask other nurse to get me a gauze and some tap (sic) and placed a dressing on forehead left other nurse and CNA (with) resident notified MD (medical doctor) of resident's condition and what occurred and received order to send resident to ER (emergency room ) call 911 to transport resident to ... and started neurocheck notified family of occurrence and order to send resident to ER for evaluation of condition."" Nurse's Notes for 4/28/11, other than the late entry above, began at 3 PM and noted swelling and discoloration to the resident's forehead and eyes. Edema and discoloration was also noted to the left forearm. The 10 PM nurse's note included: "" ... Side rails are up on both side and bed in low position. ..."" Resident #1's physician examined her on 4/28/11 and noted ""Pt (patient) fell out of bed last (Wed) nite suffered hematoma to forehead & upper lips & philtrum. X-rays of (L) hand -? fx (fracture) at base of 5th digit. ... Swelling & discoloration to forehead (with) central abrasion. ... upper lip & philtrum (with) bluish discoloration & swelling. ... (increase) pain meds to Tylenol #3 cool compress applied x24 (hours)"" The resident was observed on all days of the complaint inspection to have both side rails raised when she was in bed. Her bed was kept in a mid-height position, not at the lowest position. Review of the resident's care plan dated 7/20/10 showed a problem of potential for falls and injuries related to impaired mobility, total care, and seizure disorder. ""Has side rails (up times) 2 for bed parameters & safety (secondary to) seizures."" The approaches to this problem included having the side rails up on each side of the bed. On 4/14/11, the care plan was reviewed and revised. It continued to show the problem of potential for falls and injuries. Approaches to this problem included the Falling Star Program and both side rails raised on the bed. Review of a Physical Restraint assessment dated [DATE] showed the resident required the use of bilateral bed rails due to seizure precautions, and because the resident fidgeted, was restless, and leaned while in bed. Review of the resident's cumulative physician's orders [REDACTED]. (diagnosis) seizures."" Review of the Assignment sheets used by the CNAs at the time of the resident's fall showed the resident was to have side rails up on both side of the bed. At the bottom of the assignment sheets was the message: ""ALL BEDS MUST BE IN LOWEST POSITION!"" Review of the facility's investigation showed the following information: CNA #2, who was assigned to the resident on the 3-11 shift, stated he made last rounds on the resident at approximately 10:15 PM and side rails were ""completely up."" CNA #2 continued to say that both side rails were up at all times when he was on duty. CNA#1, who was assigned to the resident on the 11-7 shift said she saw the resident at approximately 11:15 PM and both side rails were down. She checked on the resident again at 12:45 PM and the resident appeared ""OK."" CNA #1 heard the tube feeding pump alarm and entered the room to see the resident on the floor. She summoned the nurse. CNA #1 reported in her interview with the Social Worker, ""... that she was unaware of resident required to have side rails up, and could not find it in the book."" LPN #6 responded to CNA #1's call and found the resident lying on the floor face down. There was blood on the floor. The resident was turned to her back, examined, and then lifted back to bed. According to the statement written by the Social Worker who interviewed LPN #6: ""Nurse asked CNA if the side rails were down, and CNA stated 'yes.' The CNA stated the side rails were down when she completed her rounds, and assumed it was an order in place to have the side rails down."" LPN #1 went to the resident with LPN #6 and noted the resident in the same condition. The ADON (Assistant Director of Nurses) wrote in her interview notes: ""... Mr. (NAME REDACTED) stated he talked to (CNA #1) shortly after the incident & she stated that she noticed (resident's) side rails to be down but did not think much of it & thought that maybe there had been a change."" LPN #2, who wrote the late entry nurse's note, said in her interview with the Social Worker that the resident was on her back by the time she entered the room. ""... Transferred Resident to bed (with) CNA's and nurse, side rails noted to be already down when Resident found (with) air mattress inflated and bed in mid air."" Interviews conducted during the complaint inspection revealed the following information: LPN #1, the 11-7 nurse, said he had not done rounds on the resident before being summoned to the resident's room. He confirmed that the bed was not in the lowest position. When asked about the side rails, he thought one was not up, on the side where the resident fell from the bed. LPN #1 thought CNA #1 knew the side rails were down but she thought they were discontinued so she did not say anything to the nurses. LPN #2 stated when she entered the room both side rails were down. She acknowledged the side rails were supposed to be raised on both sides of the bed. CNA #1, who was employed with the facility since 2005,stated in her interview that she found the side rails down on first rounds and the resident was ""fine."" The resident continued to be ""fine"" on second rounds. CNA #1 checked the book for a side rail order and did not find a paper for 11-7 (the assignment sheet). Because both side rails were down, she thought it could not be that a CNA forgot to raise them but the order for the side rails must have changed. She acknowledged that she did not check any of the other shift assignment sheets to see what devices the resident might need. When asked if she consulted the nurses about the side rails, CNA #1 stated she did not. CNA #1 stated the bed was not in its lowest position but was at ""standard"" height. She said the bed was always supposed to be in the lowest position but it was never kept in the lowest position. CNA #1 said she used ""poor judgment"" that night. Resident #3 with [DIAGNOSES REDACTED]. Review of the resident assessment Minimum Data Sets of 8/31/10 and 5/20/11 showed the resident required extensive assist of two people for transfer with a mechanical lift on the earlier assessment, and was noted to require the total assist of two people for transfer on the later assessment. Review of the Nurse's Notes showed an entry on 5/10/11 at 12:30 PM saying the resident complained of pain in her right ankle. The ankle had swelling, and was warm and painful to touch. When asked what happened, the resident stated her bed fell on her foot. The resident's roommate reported that Resident #3 hit her foot when being put to bed ""last night."" An X-ray showed a fractured distal fibula. The facility's investigation revealed Resident #3 was transferred to bed on 5/8/11 by CNA #2, without the sit to stand lift and without the assistance of a second person. CNA #2 reported to the Administrator on 5/10/11 that: ""when putting her to bed me & (resident) got twisted up. Her ankle got wrapped around my leg. I didn't use a lift. I know I was supposed to use a lift, but sometimes she won't let me use it on her. No, I never told a nurse I just put her to bed. I wasn't thinking. ..."" When asked if he checked the assignment sheet to see that she required a lift, CNA #2 responded: ""I only look @ the names of the people I have. I never look @ that stuff. ..."" CNA #2 worked at the facility since 1/17/11. Review of the resident's care plan dated 9/8/10 showed the resident required assistance with transfer. On 5/26/11, a notation was added to the problem of Falls/Injuries that said ""sit to stand lift for transfers."" Review of the Assignments 200-223 sheets used by the CNAs at the time of the incident, revealed the resident required ""stand lift"" for transfers from bed to chair.",2014-10-01
9882,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,280,E,0,1,8DSB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review and interview, the facility failed to have evidence of participation of the resident and/or the resident's family in planning of care and treatment or changes in care and treatment for 3 of 6 sampled residents reviewed for Care Planning (Residents #1, #4, #5). In addition, the Care Plans were not reviewed and updated for 3 of 6 residents reviewed for care planning to reflect their current status. Resident #1's care plan was not updated to include contractures. The care plans for Residents #2, #3 were not updated related to falls. The findings included: The facility admitted Resident #1 on 04/23/08 with [DIAGNOSES REDACTED]. Record review of the 6/17/11 Quarterly Minimum Data Set (MDS) Assessment on 7/27/11 at 8:30am in Section B revealed that the resident ""rarely/never makes self understood"" and in Section C revealed short and long term memory problems. Record review on 7/26/11 at 11:30am, revealed that the resident had been in the hospital on [DATE]- 6/15/11 for Pneumonia, [DIAGNOSES REDACTED], and Sacral Decubitus Ulcer and 6/19/11- 6/25/11 for Pneumonia. Record review on 7/27/11 at 11:20am, revealed no evidence that the family was invited to participate in the 6/22/11 Care Plan though Resident #1 had significant changes in care needs. During an interview on 7/27/11 at 11:20am, the MDS Director stated that the last care plan reviewed with the family for Resident #1 was in December 2010. The MDS Director stated that Care Planning letters were routinely mailed out in advance and copies of the letter/envelopes were kept for documentation. However, the March and June, 2011 quarterly letters could not be provided. Review of the care plan with the MDS Director revealed no signature of family participation on the 6/22/11 care plan. The MDS Director confirmed that Resident #1 had been through significant health changes and stated that the last letter mailed out on file was 12/8/10. During a telephone interview on 7/27/11 at 2:20pm, Resident #1's family stated that the last care plan review notification and participation was ""about six months ago"". Continued record review revealed that Resident #1 had developed contractures and no care plan was available to reflect the current status. Review on 7/27/2011 of the 3/21/11 Pain Assessment revealed contractures as one cause and origin of pain. Review of the 6/17/11 Quarterly MDS Assessment on 7/27/11 at 8:30am in Section G, revealed ""Functional limitation in Range of Motion impairment on both sides"". Review of the 6/25/11 Admission Nursing Assessment indicated that the resident had contractures to the upper extremities. Review of the Occupational Therapy Initial Evaluation/Treatment Plan revealed Upper Extremity Function was very limited and very painful, expressed by illicit facial grimaces. Further summary notes stated ""Left hand 80% closed and Right hand 60% closed"". Upon review on 7/27/11 at 11:20am, Resident #1's 6/22/11 care plan did not include a plan of care with specific interventions for contractures to prevent further decline. The MDS Director was interviewed on 7/27/11 at 12:30pm regarding the care plan and stated ""There is one for comfort that includes contractures, but I don't have one for limited ROM"". The facility admitted Resident #5 on 8/13/2009 with [DIAGNOSES REDACTED]. The resident was listed as interviewable and fully participated in a resident interview conducted on 7/26/11 at 12:10PM. On 7/27/2011 at 11:40 AM, review of the Care Plan attendance sign in sheet for Resident #5 revealed that the resident's responsible party nor the resident had signed as attended/participated in careplan meetings. Evidence of the letters sent to the responsible party indicated that the last letter sent was dated January 13. 2011. In an interview with the Material Data Set Coordinator, she stated that the last documentation of a letter having been sent was January. 2011. She also stated that she could not locate any additional letters for 2011. The facility admitted Resident #3 on 1/3/11 with [DIAGNOSES REDACTED]. Review of the Nurses Notes on 7/26/11 at 5:00 PM revealed the resident had sustained falls on 1/4/11, 1/12/11, 1/19/11, 2/12/11, 2/27/11 and 7/5/11. Review of the resident's care plan on 7/27/11 at 12:15 PM revealed the falls care plan had not been updated for falls and no new interventions had been added to prevent further falls. The MDS (Minimal Data Set) Coordinator confirmed that the care plan had not been updated at approximately 12:30 PM. When the copy of the care plan was received, it had been updated to include all the falls and 2 new intervention were added to the care plan to include anti-tippers dated 1/12/11 and tab alarm dated 3/30/11 and discontinued on 5/19/11. During an interview with the MDS Coordinator on 7/27/11 at 2:45 PM, she verified that the care plan had been updated on 7/27/11 prior to the surveyor obtaining a copy. The facility admitted Resident #2 on 3/23/11 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 7/27/11 at approximately 11:05 AM revealed that Resident #3 had sustained a fall on 7/11/11 and 7/19/11. Further review revealed the Fall Risk Assessment completed on 3/23/11 and 7/12/11 both indicated the resident was at high risk for falls. At approximately 12:48 PM on 7/27/11, record review revealed the resident did not have a care plan for Fall Risk. During an interview on 7/27/11 at approximately 3:00 PM, the MDS Coordinator confirmed there was not Falls care plan and verified that based on the Fall Risk Assessment, a care plan for Fall Risk should have been initiated. The facility admitted Resident #4 on 2/24/10 with [DIAGNOSES REDACTED]. Review of the Resident Care Plan on 7/26/11 at approximately 11:55 AM, revealed there was no signature of Resident #4 or her family member on the care plan. Record review of the MDS (Minimum Data Set) with the ARD (Assessment Reference Date) of 5/11/11, reviewed on 7/26/11 at approximately 1 PM, revealed Resident #4 could "" make self understood "" and had the "" ability to understand others. "" Resident #4 was also noted on the facility's list of interviewable residents updated 7/5/11. On 7/27/11 at approximately 10 AM, Resident #4 stated that she had never been invited to a care plan meeting. Record review of the Social Progress Notes on 7/27/11 at approximately 10:35 AM revealed there was no documentation of participation in planning of care. An interview with Social Services on 7/27/11 at approximately 10:45 AM revealed that nursing staff informed residents when there was a care plan meeting and it was their choice if they would like to attend. During an interview with the MDS Director on 7/27/11 at approximately 11 AM, she stated that care planning letters were routinely mailed out in advance and copies of the letters were kept for documentation. The MDS Director could not provide copies of any care planning letter for Resident #4. During a review of the care plan with the MDS Director, she confirmed that Resident #4's or family member's signature of participation was not on the care plan.",2014-10-01
9883,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,318,D,0,1,8DSB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and record review, the facility failed to ensure that the resident with limited Range of Motion (ROM) received services to prevent further decline in ROM for 1 of 2 sampled residents reviewed with contractures. There was no evidence of ROM provided to prevent further decline for Resident #1. No splint/hand roll was applied per Occupational Therapy recommendation and as stated in the Certified Nurse Assistant (CNA) care plan for Resident #1. The finding included: The facility admitted Resident #1 on 04/23/08 with the [DIAGNOSES REDACTED]. On Initial Tour on 7/26/2011 at 11:05am, Resident #1 was observed laying on a firm normal pressure mattress in bed, propped on her right side by a wedge with bed cradle at the foot of the bed and both side rails up. Multiple observations of the resident during the survey on 7/26/11 and 7/27/11 revealed that the resident kept both hands fisted with no hand splints or hand roll present to prevent further decline of contractures. Record review on 7/27/2011 of the 3/21/11 Pain Assessment revealed contractures as one cause and origin of pain. Review of the 6/17/11 Quarterly Minimum Data Set (MDS) Assessment on 7/27/11 at 8:30am in Section G, revealed ""Functional limitation in Range of Motion impairment on both sides"". Review of the 6/25/11 Admission Nursing Assessment indicated that the resident had contractures to the upper extremities. Record review revealed Occupational Therapy (OT) services were provided beginning on 09/02/10 to 10/29/10. Review of the OT Initial Evaluation/Treatment Plan revealed Upper Extremity Function was very limited and very painful, expressed by illicit facial grimaces, and moderate/severe impairment was noted on initial evaluation. Further summary notes stated ""Left hand 80% closed and Right hand 60% closed"". Upon discharge from OT, Resident #1 was fitted with a left resting hand splint and a right hand roll with strap that therapy stated would provide ease of care with intentions to decrease the degree of pain and contracture of both hands. During an interview on 7/27/11 at 12:00pm, Certified Nursing Assistant (CNA) #1 provided a notebook that listed residents equipment log for needs, however she was unable to locate the equipment needed for Resident #1. The Equipment Log listed Resident #1 for a left hand splint and right hand roll. CNA #1 stated that at times she had only noticed a hand roll in the residents hand. CNA #3, who was caring for Resident #1, was interviewed and observed on 7/27/11 at 12:15pm to visualize if the left hand splint and right hand roll were in place. CNA#3 stated that she had only been employed with the facility for 3 months and had never seen a splint on the resident's hand but had seen hand rolls at times. She stated she had never seen or performed ROM for the resident. Upon search of the room, CNA #3 found the splint in resident's top drawer and placed it on the table. After leaving the room, the surveyor asked if equipment was needed for the resident's care, does it show on the charting kiosk. CNA #2 located on the kiosk under ""Safety Devices + Appliances"" that Resident #1 was to have a right hand roll. Upon review on 7/27/11 at 11:20am, Resident #1's 6/22/11 care plan did not include a plan of care with specific interventions for contractures to prevent further decline. The MDS Director was interviewed on 7/27/11 at 12:30pm regarding the care plan and stated ""There is one for comfort that includes contractures, but I don't have one for limited ROM"".",2014-10-01
9884,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,156,C,0,1,8DSB11,"On the days of the survey, based on interviews and review of Medicare Denial Letters and Liability Notices, the facility failed to provide the required advance Liability Notices ( Form and/or Form or 1 of the 5 approved forms) for 2 of 3 residents reviewed for Liability Notices and Denial Letters. The findings included: Review of the records in the Business office revealed Resident A ""met maxium (sic) level of therapy services"" and remained in the facility. The conversion date was 3/12/11 and a Form was completed and signed by the Resident on 3/7/11 however, the facility did not issue the required Form , Notice of Medicare Provider Non-Coverage. Resident #2, converted to Medicaid on 3/7/11, had Medicare days left and remained in the facility and the facility did not issue either Form or Form (or 1 of the 5 denial letters). These findings were confirmed by both the Admissions/ Social Services Director and the Nursing Home Administrator during an interview on 7/27/11 at approximately 10:30 AM.",2014-10-01
9885,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,159,B,0,1,8DSB11,"On the days of the Recertification Survey, based on record review and interviews, the facility failed to obtain authorization to manage personal funds for 1 of 3 residents reviewed for Trust Fund Accounts. The finding included: On 7/27/11 at approximately 10:55 AM, an expanded review of resident Trust Account Funds revealed Resident B did not provide written authorization to the facility to manage personal funds. The Resident Trust Fund Authorization form from the resident's financial record was blank and unsigned and was confirmed at that time with the Business Office Manager and the Regional Field Analyst.",2014-10-01
9886,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,274,D,0,1,8DSB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interviews, the facility failed to identify and complete a comprehensive assessment for significant changes in the resident's physical and mental condition for Resident #3, 1 of 1 sampled residents with a significant change in status not identified. The findings included: The facility admitted Resident #3 on 1/3/11 with [DIAGNOSES REDACTED]. On 7/27/11 at 8:33 AM, review of the quarterly Minimal Data Set (MDS) assessment and comparison to the admission MDS dated [DATE] revealed the resident had exhibited a significant improvement. One area of improvement included a decrease in the number of mood indicators and total depression score from 3 to 0 and a decrease in behaviors including delusions, verbal behaviors, rejection of care and wandering. The quarterly assessment indicated the resident also had improved performance in his Activities of Daily Living and required limited assistance in July with bed mobility, dressing and person hygiene that required extensive assistance on admission. In addition, the resident was coded as frequently incontinent of bowels on the January MDS and coded as always continent on the July assessment. During an interview at 8:54 AM on 7/27/11, the MDS Coordinator confirmed that she had not conducted a Significant Change in Status Assessment (SCSA). She further verified that the resident had experienced a significant improvement and stated that a ""SCSA should have been done.""",2014-10-01
9887,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,314,D,0,1,8DSB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews and record reviews and review of the facility's Nursing Procedures Manual: Dressings - Clean and Dressings - Sterile and the Dressing Competency, the facility failed to provide care and services to promote healing and prevent infection during wound care for 1 of 2 residents observed for wound care. During wound care for Resident #2, the Licensed Practical Nurse did not clean the wound bed. The findings included: The facility admitted Resident #2 on 3/23/11 with [DIAGNOSES REDACTED]. The Resident had a pressure ulcer on admission. On 7/27/11 at 11:29 AM, during observation of the pressure ulcer treatment for [REDACTED].#2, a concern was identified related to the cleaning of the wounds. The soiled dressing was removed from the resident's left foot covering a Stage III ulcer on her heel and an unstageable ulcer on her dorsal foot. LPN # 2 proceeded to clean the anterior peri-wound on the heel with one swipe using a 4x4 gauze presoaked with Normal Saline and then cleaned the posterior peri-wound with one swipe using a 4x4 gauze presoaked with Normal Saline. During an interview on 7/27/111 at 12:40 PM, the Director of Nursing confirmed that LPN #2 had made only 2 wipes with the normal saline soaked gauze, at the top and bottom of the wound. LPN #2 also verified at that time that she only made 2 wipes. At 12:48 PM, further record review of the most recent hospital discharge summary revealed that Resident #2 had been hospitalized from [DATE] to 6/20/11 [MEDICAL CONDITION] secondary to left infected heel ulcer. Review of the wound culture collected on 6/11/11 indicated the wound was infected with Proteus Mirabilis and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus. Review of the facility's Nursing Procedures Manual: Dressings - Clean revealed ""Process: #10. Cleanse the wound as ordered; pick up moistened sponges and wipe the area."" The Nursing Procedures Manual: Dressings - Sterile Process does not include cleaning the wound. On 7/27/11, the Nursing Home Administrator provided copies of the Dressing Competency for LPN #2 dated 5/3/11 and 7/26/11 where the Director of Nursing signed as the evaluator. The process includes the following: ""Clean the wound as ordered...Wound should be cleaned from center outwards...""",2014-10-01
9888,SUMTER VALLEY NURSING AND REHAB CENTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2011-06-01,314,G,1,0,4W8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review, interviews, observation, and review of the facility's policy for wounds entitled Pressure Ulcer Treatment, the facility failed to initiate interventions to prevent pressure ulcers from developing, and failed to timely assess and treat a pressure ulcer for 1 of 7 residents reviewed for pressure ulcers. (Resident #2) The findings included: The facility admitted Resident #2 on 03/16/2011 with [DIAGNOSES REDACTED]. Review of the hospital discharge summary indicated that Resident #2 had a fall at home 4 to 5 days before coming to the hospital. On arrival at the hospital she was diagnosed with [REDACTED]. Following the surgery her appetite was poor but she did start to eat more and was discharged to the nursing home on 03/16/2011 for a 2 to 3 month course of rehabilitation therapy before returning home. The Nursing Admission assessment dated [DATE] indicated Resident #2 weighed 113.5 pounds and was 5 feet 5 inches tall; her nutrition included a mechanical soft diet with Med Pass three times a day. Her skin assessment included a Stage II pressure ulcer on the right buttocks that measured 1 centimeter (cm) x .5 centimeters... Review of the medical record documented in the Nurse's Notes and the Social Work Notes that the resident's appetite was poor, she spit out her food and meds and she was not eating adequately. The notes stated that on 4/11/2011 a conference with the family was held to discuss the resident's poor intake and increased skin breakdown. The option of a feeding tube was discussed with the family and they declined at the time. The family was encouraged to speak with the physician regarding the feeding tube. The resident continued to decline and a feeding tube was placed on 05/09/2011. Review of the Dietary Notes documented that on 03/28/2011 Resident #2's weight was 104 pounds after she was weighed on new scales purchased by the facility. Dietary recommendations included, Decubivite twice a day, Prosource twice a day times 30 days, increase the Med Pass to twice a day and House shakes twice a day. On 05/12/2011, three days after the feeding tube was placed Resident #2 weighed 91.4 pounds. Dietary Notes stated that the resident's estimated dietary needs was provided by the tube feeding of Fibersource HN 50 cc with 100 cc of water. At the family's request Resident #2 continued to receive a mechanical diet. Dietary update dated 05/25/2011 recorded the resident's weight at 98.8 pounds, an increase of 7.4 pounds. Review of the resident Care Plan dated 03/25/2011 identified alterations in skin integrity as a concern. Interventions included Pressure reduction mattress and cushion to W/C, Reposition frequently, Keep clean and dry, and Weekly body audits. In reviewing the Weekly Skin Audits the 05/13/2011 audit included an addendum that stated, ""Air mattress placed 05/15/2011"". The intervention, ""pressure reduction mattress"" was not placed on Resident #2's bed until 05/15/2011. Review of the medical record on 6/01/2011 revealed weekly skin audit sheets that showed the following pressure ulcer measurements and treatments: 04/04/2011 Base of the spine (coccyx) L 1 cm (centimeter) x W 1 cm; [MEDICATION NAME] Cream 04/07/2011 Base of the spine (coccyx) L 1 cm x W l cm; [MEDICATION NAME] Cream 05/05/2011 Coccyx L 1cm x W 2 cm; [MEDICATION NAME] Cream 05/13/2011 Coccyx L 5 cm x W 3 cm Area on coccyx has 40% of necrosis noted with skin black. Surrounding and erthemotous centrally coccyx appears to be worsening. Skin easily sloughed; [MEDICATION NAME] Cream: Addendum Air Mat (mattress) placed 5/15/2011. 05/23/2011 Sacrum/Buttocks (previously identified as coccyx) L 6 cm x W 2.5 cm with tunneling 0.5 superior edge and 0.3 medially; Duoderm 05/27/2011 Sacrum L 5 cm x W 2.2 cm with tunneling 0.3 superior edge and 0.2 cm medially; Wound bed improved, regranulation noted; Duoderm. Review of the Nurse's Notes dated 04/04/2011 documented that at the weekly body audit an area measuring 2 cm x 1 cm stage I noted on Lt (left inner buttocks) Blistered area noted on Rt. (right) buttocks. Blistered area noted on Lt buttocks measuring 2 cm x 1 cm small stage I area noted above the coccyx. 04/10/2011 at body audit area to (L), (R) buttocks have increased in size since last weekend. (L) inner buttocks measures with 3.25 cm x 1.75 cm Stage I decubitus. (R) inner buttocks measures with 5 cm x 1.75 cm stage I decubitus. Area at base of spine is closed measures 2.25 cm x 1.25 cm. 04/25/2011 at the time of the weekly body audit documented ...Open areas on buttocks are beginning to show signs of healing - areas are pink and dry. 05/02/2011 stated that the areas on the buttocks show slight improvement. 05/08/2011 Body Audit done. Areas at (L) and (R) inner buttocks are healing. Areas are dry and light scabs noted. Area at coccyx remains open with no drainage noted... 05/22/2011 Open area to coccyx is larger in size and measures 4 cm x 8 cm. Area has yellow tissue covering the area with healing noted around the edges. Duoderm applied as ordered... 05/29/2011 Body audit done. ...Wound at sacral area noted with yellowish/white tissue in various places with small strand measuring approximately .2 cm x .25 cm that is white/yellow in color, hanging from edge of wound... Dr. was informed of the sacral wound measuring 1.75 cm in depth... New orders recd (received) to d/c present tx to wound at coccyx area and to initiate new tx of wet to dry drsg (dressing). Review of the physician's orders [REDACTED]. D/C (discontinue) Calazyme tx to coccyx 2. Cleanse Coccyx with wound cleanser, pat dry and apply duoderm q (every) 3 days; 05/29/2011 stated, ""T.O. (telephone order) clean wound at sacral area with wound cleanser, pat dry, pack with wet to dry dressing, cover with ABD dressing bid until healed."" Review of the Weekly Skin Audits, the Nurse's Notes and the physician's orders [REDACTED].#2's wound worsened and the treatment was not changed until 05/20/2011, one week after the facility was aware of a decline in the resident's wound. Review of the facility Pressure Ulcer Treatment policy stated in the General Guidelines, ""...The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s) b. Managing tissue load..."" In an interview with the Director of Nurses and the Administrator on 06/01/2011 they confirmed the findings related to Resident #2. They stated they had a QA (Quality Assurance) for pressure ulcers and their projected day of completion for the QA was 06/15/2011. The Director of Nurses stated that on 05/01/2011 it was determined that the QA was not working as they had planned and that an audit of all resident's with pressure ulcers was conducted, new work sheets were implemented and inservices for all licensed staff conducted. The facility staff stated that new mattresses, wheelchair cushions and wheelchairs were order as a result of the QA. The decline in Resident #2 wound occurred after the 05/01/2011 audit, this was confirmed by the facility.",2014-10-01
9889,SUMTER VALLEY NURSING AND REHAB CENTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2011-06-01,520,D,1,0,4W8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. The findings included: On 06/01/2011 a Census and Condition documented the facility had 13 resident's in the facility with pressure ulcers, 7 of which were present on admission. Interview with the facility staff on 06/01/2011 revealed that on 03/01/2011, the facility had begun a plan to improve pressure ulcer care with a 06/15/2011 date for resolution. The plan included the 100% completion of body audits, weekly assessments, monitoring treatments, care plans, completing Braden scales, weekly documentation, compliance rounds and inservice's on pressure ulcer care. The Director of Nurses stated that on 04/01/2011 new wound tracking forms were started and the staff was inserviced about the forms, that in April the unit managers on both units resigned and it was identified that staff education was a problem. On 05/01/2011 body audits were again conducted on all residents, two new unit managers were hired and the new unit managers were responsible for assessing and documenting the pressure ulcers weekly; the unit nurses were to continue to provide wound treatments. The facility staff added that new air mattresses, wheelchair cushions and wheelchairs were ordered as a result of the QA (quality assurance); a new consulting Registered Dietician was hired. Despite on-going plan(s) to improve pressure ulcer care, continued concerns were identified with one of seven sampled residents reviewed with pressure ulcers related to assessment/tracking and treatment related to the care of resident's with pressure ulcers. Cross refers to F-272 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. Cross refers to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds and adequately monitor residents with wounds that placed residents at risk for serious harm.",2014-10-01
9890,SUMTER VALLEY NURSING AND REHAB CENTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2011-06-01,272,G,1,0,4W8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews the facility failed to assure that each resident was adequately and accurately assessed for pressure ulcers for one of seven resident records reviewed for pressure ulcers. Resident #2 had either no assessments or inaccurate assessments for pressure ulcers. The findings included: The facility admitted Resident #2 on 03/16/2011 with [DIAGNOSES REDACTED]. Review of Resident #2's medical record on 6/01/2011 revealed Weekly Skin Audit (assessments) sheets from 04/04/2011 through 05/25/2011 did not correspond to the Weekly Body Audits (assessments) documented in the Nurse's Notes for the same time period. On 05/13/2011 documentation on the Weekly Skin Audits sheets showed the resident's pressure ulcer worsened and the treatment was not changed until 05/20/2011. Cross Refers to F-314 related to the facility failed to initiate interventions to prevent pressure ulcers from developing and failed to timely assess and treat a pressure ulcer for 1 of 7 residents reviewed for pressure ulcers.",2014-10-01
9891,SUMTER VALLEY NURSING AND REHAB CENTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2011-06-01,309,D,1,0,4W8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to provide necessary care and services for one of one resident reviewed for urinary tract infections. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 06/01/2011 revealed a note written 05/23/2011 that stated the resident's daughter called the facility to ask where her mother was that she was waiting at the urologist office for her mother to arrive for her 3:15 PM appointment. The note stated that the transportation company was not called to arrange transport for Resident #1 to the urologist. Review of the appointment log revealed that the facility was aware Resident #1 had an appointment with the urologist on 05/23/2011 at 3:00 PM. In an interview with the Administrator on 06/01/2011 she confirmed that Resident #1 had missed her appointment and that a new system was put in place to solve the problem they had with missed appointments.",2014-10-01
9892,LIFE CARE CENTER OF CHARLESTON,425332,2600 ELMS PLANTATION BLVD,N CHARLESTON,SC,29406,2011-03-30,281,E,0,1,4FN211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the South Carolina Board of Nursing Advisory Option #9, the facility failed to provide care and services that met professional standards of practice for one of one sampled resident with a Peripheral Inserted Central Catheter(PICC) Line. Resident #10 was administered PICC Line flushes without a written physician's order and antibiotics were administered per Licensed Practical Nurses(LPN) with no documentation of advanced training and there were numerous occasions when a Registered Nurse(RN) was not on site when the LPN's administered the medications and flushes via the PICC Line. The findings included: The facility admitted Resident #10 on 1/14/11 with [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated 3/25/11 for the following: 1) Please send for PICC Line placement 2) [MEDICATION NAME] 500 milligrams(mgs) IV(intravenous) q(every) 8 hrs(hours) x(times) 10 days once PICC Line placed 3) [MEDICATION NAME] 70 mgs IV q 8 hrs x to days 4) [MEDICATION NAME] 20 mgs po(by mouth) qd(every day). Review of the March 2011 Medication Administration Record(MAR) revealed the resident received [MEDICATION NAME] as ordered via the PICC Line by a RN. Further review of the March MAR indicated [REDACTED]. Review of the March MAR for 3/27, 3/28, and 3/29 revealed the LPN administered the antibiotics each day at 12 AM and 2 AM. Further review of the physician's orders revealed an order written [REDACTED]. No physician's order was noted prior to 3/28/11 regarding flushing the PICC Line. An interview with the Director of Nursing(DON) on 3/30/11 revealed that prior to the order, the nurses were using the facility policy for flushing the PICC Line. Review of the facility staffing sheets for the time of 3/26-3/30/11 revealed that there were four shifts when a RN was not in the building as required while the medication and flushes were being done via a PICC Line per documentation on the medication administration record. Review of the March 2011 MAR for the time period of 3/26 - 3/30/11 revealed that the PICC Line medications were administered by three LPN's who had no proof of having been trained to work with PICC Lines per state regulations as confirmed by the Director of Nursing on 3/30/11. Per the South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion # 9B) states: ""The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/lines that includes didactic and supervised clinical competency training with return demonstration.... The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter site (port A cath). The Agency must have specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN."" Section 40-33-20 defines supervision as meaning "" the process of critically observing, directing, and evaluating another's performance.""",2014-10-01
9893,LIFE CARE CENTER OF CHARLESTON,425332,2600 ELMS PLANTATION BLVD,N CHARLESTON,SC,29406,2011-03-30,272,D,0,1,4FN211,"**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 assess 1 of 1 resident performing self care of a Foley Catheter to determine if the resident had the ability to perform self catheter care. (Resident #8). The findings included: Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the record on 3/29/11 revealed no documentation that the resident performed his own catheter care. During a conversation with Certified Nursing Assistant #1 on 3/30/11 indicated the resident did not wish to be observed for catheter care as the resident did his own care and barely allowed a staff member to observe once a day. Further review of the record on 3/30/11 again revealed no documentation that the resident performed self catheter care. Nor was there an assessment of the resident's ability to perform self catheter care appropriately. The Care Plan dated 1/27/11 stated under Approaches for ""complications r/t (related to) recent indwelling catheter"", ""Cath Care per protocol."" Interview with the Director of Nursing on 3/30/11 at approximately 2:30pm indicated that the resident had not been assessed upon admission to the facility for self catheter care as the resident had informed them that he had been trained elsewhere. The DON indicated that the facility should have assessed the resident on admission and developed a care plan accordingly.",2014-10-01
9894,LIFE CARE CENTER OF CHARLESTON,425332,2600 ELMS PLANTATION BLVD,N CHARLESTON,SC,29406,2011-03-30,363,D,0,1,4FN211,"On the days of the survey, based on observation and interview, the facility failed to serve the regular diets the correct amount of scalloped potatoes with ham. The staff served one #8 scoop (4 ounces) of scalloped potatoes with ham instead of 8 ounces as listed on the menu. The findings included: Observation on 3/29/11 at approximately 12:00 noon revealed cook #1 plating regular diets. Cook #1 was putting one #8 scoop (4 ounces) of scalloped potatoes with ham on the plate. During the plating of food the Dietary Manager asked the cook how many scoops of scalloped potatoes with ham was to be given, the cook stated one and continued to plate in this manner. Review of the menu indicated that for the regular diets 8 ounces of scalloped potatoes with ham should be given. Interview at 12:10pm with the Dietary Manager indicated the serving size for the regular diet should be 8 ounces. When asked how much was the cook giving, the Dietary Manager stated one scoop. The Dietary Manager then asked Cook #1 how many scoops of scalloped potatoes with ham was the cook giving, the cook stated 1. When asked what size was the scoop the cook stated #8. When asked what quantity was a #8 scoop the cook stated 4 ounces.",2014-10-01
9895,LIFE CARE CENTER OF CHARLESTON,425332,2600 ELMS PLANTATION BLVD,N CHARLESTON,SC,29406,2011-03-30,502,E,0,1,4FN211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to follow a procedure to ensure that expired laboratory supplies were not stored with other laboratory supplies in 2 of 5 medication rooms. The findings included: On [DATE] at approximately 11:40am inspection of the Day Spring Medication Room revealed the following: 1 box of [MEDICATION NAME] Glucose Control Solution, Lot [MEDICATION NAME], expired [DATE] was found in a supply tote. This date was imprinted on the box by the manufacturer and had been written on the box by the facility. This finding was verified as being expired on [DATE] at approximately 11:45am by Registered Nurse (RN) #1. On [DATE] at approximately 10:40am RN #2 stated that the control solution is used daily on the evening shift to calibrate the glucometers. On [DATE] at approximately 11:05am inspection of the Morning Star Medication Room revealed the following: 1 box of [MEDICATION NAME] Glucose Control Solution, Lot [MEDICATION NAME], expired [DATE] was found in a supply tote. This date was imprinted on the box by the manufacturer and had been written on the box by the facility. This finding was verified as being expired on [DATE] at approximately 11:10am by RN #3 who stated that the control solution is used daily on the evening shift to calibrate the glucometers. On [DATE] at approximately 1:10pm the Director of Nursing stated that it is the facility's policy to use the control solution daily at night to calibrate the glucometers. The manufacturer's package insert (ART Rev. A,[DATE]) for [MEDICATION NAME] Glucose Control Solution stated ""Do not use control solution 90 days after opening or if they are expired.""",2014-10-01
9896,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-01-26,241,D,0,1,7VM811,"On the days of the survey, based on observations and staff interview, the facility failed to provide care in an environment that maintained dignity for residents that were being fed in the hallway on 1 of 5 units. The findings included: On 1/24/2011 at 11:50 AM, two (2) residents were observed being fed in hallway outside of the dining area on unit 132. On 1/24/2011 at 5:30 PM, two (2) residents were again observed eating their supper meal in the hallway outside of the dining area on Unit 132. On 1/25/2011 at 12:15 PM, three (3) residents were observed being fed in the hallway left of the nurses station on unit 132. The residents were being fed in the hallway in full view of passers by. On 1/25/2011 at 12:25 PM, during an interview with Registered Nurse (RN) #1, she stated that the residents were fed in the hallway because there were residents in the day area (dining area) who would take other residents food. When RN # 1 was questioned if there was some other place the residents could eat instead of the hallway, the RN agreed the residents could eat in their rooms.",2014-10-01
9897,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-01-26,323,E,0,1,7VM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and staff interviews, the facility failed to provide an environment free of accident hazards for 19 of 38 rooms on Unit 132. Peeling paint was observed on multiple doorways. The findings included: During facility observations on 1/25/2011 at 8:45 AM, 19 doorways were observed to have chipped peeling paint. The paint chips were able to be peeled off the doors in pieces. Unit 132 was a locked unit with residents with various Psychiatric [DIAGNOSES REDACTED]. The rooms with the peeling paint of the doorways included, the Tub and Shower room, Soiled Utility room, the Storage room left of the nurses station, the Linen room, Activity/Day room and resident rooms #103, 105, 108, 109, 110, 111, 112, 113, 117, 118, 121, 122, 124, and resident room number 125. The Maintenance Supervisor was interviewed on 1/25/2011 at 3:30 PM. He stated that the units were on a rotating schedule for being painted. ""Unit 132 was painted in October"". He stated that he didn't know when unit 132 was scheduled to be painted again. The concern was expressed to the Maintenance Supervisor that the paint peeled and clumped and was easily pulled off in pieces and could be eaten by the residents. He stated that the problem with the painted door frames was that they had been painted with oil base paint. When painted in October, the door frames were painted over with Acrylic paint making the paint chip and peel. The MSDS (Material Safety Data Sheet) for the paint used on the door frames was reviewed. Under the section of the MSDS titled: Effects of Excessive Overexposure, it states, ""Based on the presence of components (12) ingestion of this product will cause irritation of the gastrointestinal tract and may cause effects resembling those from inhalation of vapor. Based on the presence of components (12) vapors of this product may cause irritation of the eyes, nose, throat, upper respiratory tract, mucus membranes and skin."" Under the section of the MSDS titled: First Aid, Ingestion: Rinse mouth immediately. Give exposed individual 6-8 ounces of liquid. ... Do NOT induce vomiting unless advised by a physician. Contact a physician immediately."" The DON (Director of Nursing) was interviewed on 1/26/2010 at approximately 1:00 pm. The DON denied that any resident had eaten paint chips, but agreed that it could be a concern.",2014-10-01
9898,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-01-26,332,D,0,1,7VM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to ensure that it was free of medication error rates of 5 % or greater. The medication error rate was 7.5 %. There were 3 errors out of 40 opportunities for error. The findings included: Error #1 and Error #2: On 1/25/11 at 8:08 AM, during observation of medication pass on Unit 140, Registered Nurse (RN) #4 was observed to administer one drop of [MEDICATION NAME] 0.5 % Ophthalmic Solution into both eyes of Resident #31 (Error #1) and one drop of [MEDICATION NAME] Ophthalmic Solution into both eyes of Resident #31 (Error #2). Review of the current physician's orders [REDACTED].#31 revealed that the order was for 1 drop of [MEDICATION NAME] 0.5% Ophthalmic Solution into the LEFT eye only and one drop of [MEDICATION NAME] Ophthalmic Solution into the LEFT eye only. During an interview on 1/25/11 at 8:25 AM, RN #4 stated that she had misread the physician's orders [REDACTED]. Error #3: On 1/25/11 at 9 AM, during observation of medication pass on Unit 138, Licensed Practical Nurse (LPN) #3 was observed to pour generic [MEDICATION NAME] powder up to the 15 milliliter (ml) mark in a plastic dose cup, dissolve the powder in 8 ounces of orange juice and administer the solution to Resident #32, along with his other morning medications. Reconciliation of medication pass for Resident #32 revealed that the physician's orders [REDACTED]. LPN #3 was asked to measure 1 capful (cap from bottle supplied by the manufacturer) of [MEDICATION NAME] powder and pour the measured [MEDICATION NAME] powder into a plastic dose cup. The capful of [MEDICATION NAME] powder was observed to fill the plastic dose cup up to the 25 ml mark. LPN #3 then confirmed that Resident #32 had been given the wrong dose of [MEDICATION NAME].",2014-10-01
9899,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2011-01-26,514,E,0,1,7VM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interview, the facility failed to document nutritional supplements were provided as ordered for Resident #5. (One of three sampled residents reviewed with dietary supplements ordered and not documented) The findings included: The facility admitted resident # 5 on 10/02/1996 with [DIAGNOSES REDACTED]. Review of the resident's medical record was conducted on 1/24/2011. The resident's most current care plan dated 12/22/2010, had a nutritional problem that included.....""underweight with a BMI (Basal Metabolic Rate) of 17.2. The goal for the problem included...""She will not lose any weight."" (Current weight 86.6 lbs 11/2010). An approach for the problem of the weight loss stated, ""Observe and record meal, snack and supplement intake daily. Report any refusals to RN (Registered Nurse)/RD (Registered Dietician). The Approach Start Date was 03/02/2005. Review of the Nutritional assessment dated [DATE] had desired weight as 99-121 lbs (pounds),....""She has lost 12 lbs or 12.2% Body weight/180 days-Significant Wt. (weight) loss..."" 6/14/2010 Nutritional Progress Note stated, ""...Recommend Changing supplement to a more calorically dense one..... ordering 2K cal HN tid (three times a day). 6/21/2010 Nutritional Progress Notes stated....""weight loss of 14 lbs or 13.7% in 180 days. On 11/5/10 the RD documented weight at 85.8. ""...She receives 2 K cal HN tid (three times a day) ...She has lost 13 lbs or 13% of Body Wt (weight) in 180 days."" The Nutritional assessment dated [DATE] had documented, ""Resident is a S/C (Significant Change) d/t (due to) unstageable pressure area on anterior of Left foot....2 Kcal HN tid per nursing notes she consumes 2-3 cans/day. Review of the weights since 6/15/2010 included documented weights of 88.2 lbs (6/15/2010), 90.6 lbs(7/16/2010), 90.2 (8/17/10), 98.4 (9/14/10), 87.8 (9/15/10), 85.8 (10/20/10), 86.6 (11/17/2010), 89.0 (12/16/2010), 85 lbs (1/19/11). The CNA (Certified Nursing Assistant) Supplemental Record documented 2kcal HN Tid for 60 days. The times listed for administration were ""0900 (9 AM), 1400 (2:00 PM), 2000 (8 PM). The September Supplemental Record was documented on September 2, September 6, September 7 for the 0900 and the 1400 times of day as the resident having received the supplement. The time of 2000 was blank on September 4, September 5, 10 th, 14, 18, 19, 24, 28, and the 30 th. Out of 90 cans of supplement to have been given, only 27 cans were documented as being given as ordered. The CNA October Supplement Sheet had 58 cans documented as given out of 93 cans. November Supplement record did not have any supplement documented for the 1400 time frame. 31 supplements were documented out of 90. The December Supplement Sheet had 65 cans of supplement documented out of 93 that were ordered to be given. RN #1 was interviewed on 1/24/2011 at 5:40 PM. When she was asked about the blanks on the nourishment sheet, she stated, ""They (CNA's) should sign for it if given. If they (residents) refuse it should be marked or documented in the nurses notes."" The December CNA nourishment sheet was compared to the nurses notes. There was no documentation in the nurses notes referring to the supplements or supplements not being given.",2014-10-01
9900,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2011-06-14,157,D,1,0,9MW811,"**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 ensure 1 of 14 resident's responsible party and/or physician was notified with a change in condition. Resident #20 sustained 5 small bruises on her upper arm; neither the responsible party nor the physician was notified. The findings included: The facility admitted Resident #20 on 5/2/2007 with [DIAGNOSES REDACTED]. Review of the Skin Sheets revealed on 5/19/2011 ""5 small fading discolorations to upper left arm."" Further review revealed no other documentation related to the injury. No corresponding nurse's note or incident report was located. During an interview on 6/13/2011 at 2:45 PM, the Responsible Party stated that she was not notified of the bruising to Resident #20's left upper arm. During an interview on 6/13/2011 at 3:20 PM, the Director of Nurses (DON) confirmed the 5 small discolorations to the left upper arm. She also confirmed there was no other documentation regarding the injury. The DON verified the physician and the family should have been notified.",2014-10-01
9901,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2011-06-14,225,D,1,0,9MW811,"**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 ensure 2 of 2 resident's with injuries of unknown origin were thoroughly investigated and reported to the State Certification Agency. The findings included: The facility admitted Resident #20 on 5/2/2007 with [DIAGNOSES REDACTED]. Review of the Skin Sheets revealed on 5/19/2011 ""5 small fading discolorations to upper left arm."" Further review revealed no other documentation related to the injury. No corresponding nurse's note or incident report was located. The facility admitted Resident #21 on 8/12/2010 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 6/13/2011 revealed an entry dated 3/24/2011 at 9 AM that documented: ""resident noted to have a fading discolored area to left shoulder. Dtr (daughter) notified and stated that she saw it on Saturday. (NP) (nurse practitioner) notified."" On 3/25/2011 at 8 AM, ""CNA (Certified Nursing Assistant) reported to this nurse resident had blue area across toes. Resident guarding left foot. FNP (family nurse practitioner) notified, notified family... New order for x-ray of left foot."" Review of the X-Ray report revealed it was negative for an acute fracture. Review of the Incident Report revealed on 3/24/2011 the resident was noted to have a discolored area to the left shoulder. The steps taken to prevent reoccurrence were ""encourage staff to be aware of resident easily getting discolored areas"". The Administrator and the Medical Director had not signed the incident report. An incident report dated 3/25/2011 revealed a ""CNA reported discolored area across top of left toes, resident guarding foot."" The intervention put in place was ""resident started on [MEDICATION NAME] r/t (related to) resident being jumpy with sudden jerky movements. Resident #21 was noted to transfer with the aid of a sit to stand lift. Review of the reportable incidents revealed the incidents for Residents #20 and #21 were not investigated nor reported to the State Certification Agency. During an interview on 6/13/2011 at 3:20 PM, the Director of Nurses (DON) confirmed the 5 small discolorations to Resident #20's left upper arm. She also confirmed the injury was ""suspicious in nature."" The DON also confirmed the injuries to Resident #21. The DON confirmed the incidents were not investigated or reported to the State Certification Agency.",2014-10-01
9902,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2011-06-14,226,D,1,0,9MW811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility's policy on Abuse Prohibition, the facility failed to implement written policies and procedures that prohibit abuse for 2 of 2 sampled residents. Injuries of unknown origin for Resident #20 and #21's were not investigated or reported to the State Certification Agency. The findings included: The facility admitted Resident #20 on 5/2/2007 with [DIAGNOSES REDACTED]. Record review revealed Resident #20 sustained an injury of unknown origin that was not reported nor investigated. The facility admitted Resident #21 on 8/12/2010 with [DIAGNOSES REDACTED]. Record review revealed Resident #21 sustained two injuries of unknown origin that were not reported or investigated. Review of the facility's policy on Abuse Prohibition revealed ""Component V: Reporting/Response. 1. All alleged violations concerning abuse, neglect or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the state Survey and Certification Agency."" ""Component VI. 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property etc are thoroughly investigated and appropriate action taken. 2. The facility conducts an internal investigation and reports the results to enforcement agencies within 5 working days. 3. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions."" During an interview on 6/13/2011 at 4:00 PM, the Director of Nurses and the Administrator confirmed the facility's policy on investigating and reporting injuries of unknown origin. The DON confirmed the incidents were not investigated or reported to the State Certification Agency",2014-10-01
9903,HARVEST HEALTH & REHAB OF JOHNS ISLAND,425368,3647 MAYBANK HIGHWAY,JOHNS ISLAND,SC,29455,2011-06-22,159,D,0,1,O0ZK11,"On the days of the survey, based on interview and review of Resident Trust Fund records revealed that the facility had no authorization to manage the residents' funds. (2 of 4 records reviewed for authorization funds) The findings included: On 6/22/11 at 2:30 PM, a review of 4 randomly selected Resident Trust Fund records and an interview with the Business Manager was completed. The review revealed that for 2 records there was no written authorization for the facility to manage the residents' funds. During an interview on 6/22/11 at 3:00 PM, the Business Manager and Administrator confirmed that they could not locate written authorizations to handle the 2 residents' funds.",2014-10-01
9904,HARVEST HEALTH & REHAB OF JOHNS ISLAND,425368,3647 MAYBANK HIGHWAY,JOHNS ISLAND,SC,29455,2011-06-22,160,D,0,1,O0ZK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of Resident Trust Fund records, 1 of 2 records reviewed for conveyance of funds revealed that the facility failed to convey the residents ' funds within 30 days of the residents' death. The findings included: On [DATE] at 2:30 PM, a review of 2 randomly selected Resident Trust Fund records and an interview with the Business Manager and the Administrator was completed. The review and interview revealed that for one resident record, the resident died on [DATE] and the funds ($1061) were not conveyed to the resident's estate until [DATE]. The Business Manager and the Administrator were unaware of any reason that caused this delay in the conveyance of funds.",2014-10-01
9905,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,152,D,0,1,TY5Z11,"**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 ensure that for 2 of 6 sampled Residents (Residents #2 and #6) reviewed for Advanced Directive status, that the rights of the Residents were exercised by the person appointed under State law to act on the resident's behalf. Neither resident had been deemed to lack capacity to make health care decisions which could enable others to make decisions on their behalf. The findings included: Resident #2, was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 10:05am revealed a ""Do Not Resuscitate Order"" (DNR) dated 4/23/10 was signed by the resident's daughter (Power of Attorney). Further review of the record did not reveal evidence that two physician's declared the resident lacked the capacity to make health care decisions. Interview on 4/5/11 at approximately 2:15pm with Registered Nurse #1, after review of the record, confirmed that there was no documentation by two physicians declaring the resident incapable of making health care decisions. Resident #6 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/6/11 at approximately 10:30am revealed a ""Do Not Resuscitate Order"" dated 5/24/10 was signed by the resident's daughter. Further review of the record did not reveal documentation by two physicians' declaring the resident lacked the capacity to make health care decisions. Interview on 4/6/11 at approximately 3:10pm with the Director of Nursing confirmed that there was no documentation declaring the resident incapable of making health care decisions.",2014-10-01
9906,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,280,E,0,1,TY5Z11,"**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 revise resident care plans for 3 of 9 residents reviewed. The care plans did not address infectious disease(s) the residents had acquired. (Residents # 2, #3, and #5) Resident #2's Care plan was not updated for recurrent Urinary Tract Infections. Resident #3's Care Plan did not reflect [MEDICAL CONDITION] (MRSA) and Resident #5's Care Plan did not include multiple antibiotic therapies for [MEDICAL CONDITION] for a surgical site of the knee. The findings included: Resident #2, was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 10:05am revealed Physician's cumulative orders dated 4/1/11 stating [MEDICATION NAME] 50mg (milligrams) Monday, Wednesday, Fridays was to to be administered [MEDICATION NAME] for a recurrent UTI. Further review revealed a previous physician's orders [REDACTED]. Review of the Care Plan dated 5/1/10 revealed no plan had been developed to address the [DIAGNOSES REDACTED]. An interview was conducted on 4/5/11 at approximately 2:15pm with Registered Nurse (RN) #1, who reviewed the medical orders and care plan and confirmed that the [DIAGNOSES REDACTED]. Resident #3, was admitted on [DATE], with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 11:05am revealed physician's orders [REDACTED]. Review of the care plan dated 2/4/11 revealed no plan had been developed to address the [DIAGNOSES REDACTED].#1 who reviewed the medical orders and care plan confirmed that the [DIAGNOSES REDACTED]. The facility admitted Resident #5 on 3/24/2011 with [DIAGNOSES REDACTED]. Review of Resident #5's Nurses' Notes indicated that on 3/24/2011 at 4:00 PM, that five blisters were noted beneath the surgical incision and that a dressing was applied due to yellowish drainage. At 9:50 PM, the dressing contained a large amount of drainage from the blisters. Further documentation revealed on 3/25/2011 there was redness and swelling to the inner knee and the resident was receiving Cipro. On 3/26/11 from 11 PM to 7 AM, it was noted that the resident stated it ""feels like fire"". The area was hot to touch, red and swollen and the dressing was changed due to drainage. On 3/26/11 at 1430, the documentation stated that the area around the incision was pink and the knee was warm to touch. Also on 3/26/11 the notes indicated [MEDICATION NAME] discontinued and [MEDICATION NAME] was started. On 3/27/ and 3/28/11 documentation continued to state that the incision was red, swollen and warm with moderate drainage. On 3/29/11 the medical record indicated that the resident had [MEDICAL CONDITION]. Review of Resident #5's Care Plan revealed that careplan failed to address the [DIAGNOSES REDACTED].",2014-10-01
9907,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,281,D,0,1,TY5Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations and interviews, the facility failed to ensure that services provided or arranged by the facility met professional standards of quality. The facility failed to obtain an order to transfer Resident #3, (1 of 9 residents reviewed for physician orders), to the hospital. The facility failed to ensure that the physician orders for Resident #4 were transcribed correctly on the resident's Monthly Orders, Medication Administration Record [REDACTED] The findings included: The facility admitted Resident #4 on 3/17/2011 with [DIAGNOSES REDACTED]. On 4/5/2011 at 10:30 AM, review of the3/17/11 physician orders written by hand on admission indicated that the resident was to receive [MEDICATION NAME] 2 gm. IV every 24 hours. The printed orders for April 2011 contained an order for [REDACTED]. instead of grams every 24 hours. In an interview with Licensed Practical Nurse (LPN) #1, she verified that the incorrect dose had been printed on the Monthly Orders, the MARs and the medication label. On 4/6/11 at 3:00 PM, the Interim Director of Nursing agreed that the transcription error should have been identified at ""change over"" which is the change from each month to new MARs. Resident #3, admitted on [DATE], with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 11:05am revealed nursing notes dated 3/22/11 ""Resident was admitted to xx Medical Center."" Review of the Physician's order revealed there were no orders to tranfer the resident from the nursing home to the Medical Center. Interview with Licensed Practical Nurse #1 on 4/5/11 at approximately 1:25pm confirmed that the was no Physician's order to transfer the resident to the Medical Center. Record review on 4/5/11 at approximately 11:05am revealed a Physician's order dated 3/24/11 ""[MEDICATION NAME] 2.5mg (milligrams) qd (everyday)"". Further review of the record revealed no orders for a PT/INR ([MEDICATION NAME] Time/International Ratio) to monitor the effectiveness of the [MEDICATION NAME]. Interview with the resident's Physician/Facility Medical Director, on 4/6/11 at approximately 10:15am, indicated that an order should have been written for the monitoring of the [MEDICATION NAME] and that the nursing staff should have contacted the Physician for clarification.",2014-10-01
9908,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,371,F,0,1,TY5Z11,"On the days of the survey, based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions as evidenced by an improperly stored open container of thickener, a storage bin with a build up of debris, observation of soiled hood filters,and an ice machine with a torn gasket. The findings included: Observations on 4/5/11 at approximately 7:10am and 4/6/11 at approximately 1:30pm revealed in the main kitchen a storage bin containing parts to a Robo Coup on the shelf under a prep table to have a heavy build up of dried food particles and debris. The filters to the hood had an accumulation of grease and particles on them. In the Country Kitchen, the ice machine had a torn gasket - part of which was missing. On the counter by the microwave was a 64 ounce bottle of Simply Thick Instant Food Thickener. The bottle was open to the environment and the spout coming out of the bottle had a dried brown substance on it. Observations on 4/5/11 at approximately 12:05pm revealed four, 16 ounce covered containers used to mix the thickener with a liquid to be wet on the inside. An interview and tour of the kitchens was conducted on 4/6/11 at approximately 1:30pm with the Dietary Manager. The Dietary Manager confirmed the above findings. In addition, it was learned that the 16 ounce containers were probably rinsed out between uses and not sent to be cleaned in the dishwasher were the containers would be cleaned and sanitized.",2014-10-01
9909,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,514,F,0,1,TY5Z11,"**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 maintain clinical records that were complete as evidenced by missing laboratory (lab) results for 2 of 9 sampled resident records reviewed (Resident #2 and 3). The findings included: Resident #2, admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 10:05am revealed physician's orders [REDACTED]. Further review of the record revealed results of the labs were not available on the record. Resident #3, admitted on [DATE], with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 11:05am revealed physician's orders [REDACTED]. Further review of the record revealed the PT/INR results were not available on the record. An interview was conducted on 4/5/11 at approximately 2:30pm with Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. Both nurses reviewed the aforementioned records and confirmed that the lab results were not available on the records. The interviews indicated that the lab results were sent to the ordering physician and after the physician reviewed the results, the results were to be forwarded to the facility with any new orders. At the present time the facility was unable to access the laboratory provider's computer system to be able to review and/or print off copies of the results themselves. The facility was dependent on the physician sending forward the lab results. This system has been in place for several months and the facility has had only sporadic access to the results from the lab company's computer system. Interview on 4/6/11 at approximately 9:45am with the facility's Medical Director confirmed that the above system was the process for handling lab results. If nursing informed the MD that the facility did not have lab results, the MD was able to access the results for nursing when the MD was in the facility. The MD was aware that there was difficulty in obtaining lab results but thought that the problem had been resolved some time ago.",2014-10-01
9910,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,279,D,0,1,TY5Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical/ nursing needs related to the care of a Peripherally Inserted Central Catheter (PICC) Line. Resident #4 was admitted to the facility with a PICC Line. The resident's Care Plan did not reflect the presence nor care related to the PICC Line. (1 of 1 sampled resident's reviewed for careplans related to the use of a PICC line.) The findings included: The facility admitted Resident #4 on 3/17/2011 with [DIAGNOSES REDACTED]. On 4/5/2011 at 9:50 AM, review of Resident #4's medical chart, revealed that the resident had been admitted with a PICC Line. Further review revealed physician orders [REDACTED]. Review of the Care Plan indicated that the resident had an IV (Intravenous). The Care plan did not reflect the correct line nor the treatment and care of the line. In an interview with Licensed Practical Nurse (LPN) #1, she verified that the resident's Care Plan did not address a PICC Line nor the associated treatments.",2014-10-01
9911,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,431,E,0,1,TY5Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy failed to ensure that drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. The Intravenous (IV) medication for Resident $4,(1 of 1 reviewed for IV medications) was recieved by the facility with the incorrect dosage on the label and the Monthly Orders and Medication Recoreds for Resident #4 also was printed with the incorrect dose. The findings included: The facility admitted Resident #4 on 3/17/2011 with [DIAGNOSES REDACTED]. On 4/5/2011 at 10:30 AM, review of Resident #4's physician orders [REDACTED]. IV every 24 hours. The printed orders for April 2011 contained an order for [REDACTED]. not 2 grams every 24 hours. In an interview with Licensed Practical Nurse (LPN) #1, she verified that the incorrect dose had been printed on the Monthly Orders, the MARs and the medication label.",2014-10-01
9912,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,441,F,0,1,TY5Z11,"On the days of the survey, based on observations, interviews and review of the facility's Laundry Water Temperature Log and Laundry Service Reports, the facility failed to handle, store, process and transport linens so as to prevent the spread of infection. The facility failed to maintain the required water temperature and sanitization levels for laundry. The Maintenance Director was unsure of the sanitization level and quoted an incorrect water temperature requirement. The findings included: On 4/5/2011, during tour of the laundry area , a temperature log was observed hanging on a bulletin board in the area. The highest temperature recorded was 126 degrees with the lowest at 99 degrees. On 4/6/2011 at 10:00 AM, in an interview with the Maintenance Director, he stated the required temperature for laundry was 99 degrees. When asked by the surveyor what the sanitization level should be for laundry, he was unable to provide the information. The Maintenance Director then called the chemical supply company representative who stated it was 125 parts per million. Both the chemical supply representative and the Maintenance Director stated there was no documentation available which documented the sanitization level being used by the facility. The Maintenance Director also verified that the temperature log was not completed on a daily basis and contained many missing temperatures. Review of the Laundry Service Reports for January, February and March 2011 revealed no information related to the sanitization levels.",2014-10-01
9913,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2011-04-06,456,E,0,1,TY5Z11,"On the days of the survey, based on observations, interviews and review of the facility's Clean Dryer Vents Log, the facility failed to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. 2 of 2 dryer vents were observed with an extremely heavy build up of lint. These dryers were used for residents clothing and linens. The findings included. During initial tour of the facility at 8:10 AM, the laundry room door was found unlocked. The room contained 2 industrial clothes dryers. The lint filters for each dryer had an extremely heavy build up of lint. The dryer closest to the wall had rolls of lint on the floor of the vent chamber and a heavy build up on the lint screen. The next dryer had a heavy build up on the screen with a moderate amount on the lint on the chamber floor. During an interview with Registered Nurse #1, she verified the condition of the lint collection areas of both dryers. She stated that the Certified Nursing Assistants do laundry on the 11:00 PM to 7:00 AM shift. On 4/6/2011 at 10:00 AM, during an interview with the Maintainable Director, he stated there was no policy related to a schedule for cleaning lint filters and that he had instructed staff to clean them on a daily basis and sign the sign off sheet. Upon review of the sign off sheet, he verified that it had not been signed as done on a daily basis. The log was not signed on March 1-8 ,11-13,19, 20, 25,26, 27 and April 2nd and 3rd.",2014-10-01
9791,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,441,F,1,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review, observations, interview, and review of facility surveillance documentation, the facility failed to maintain an Infection Control Program that provided a safe and sanitary environment to help prevent the development and transmission of infections. Linens were not protected from contamination, hand washing did not follow acceptable standards of practice, trash in soiled utility rooms was not covered, housekeeping was unaware of how to take care of an isolation room, a urinary tract infection was not documented on the log, and a tube feeding syringe was not cleaned after use. (Residents #1, #2, #6, #17 and random observations) The findings included: The facility admitted Resident #6 on 2/12/10 with a [DIAGNOSES REDACTED]. During the initial tour of the facility on 7/25/11 at approximately 10:00 AM, Resident #6 was identified as being on contact isolation. Record review revealed the resident returned from the hospital on [DATE] with a left anterior chest wall abscess containing MRSA. The resident was placed on contact isolation until 7/25/11 when a culture showed only a light growth of normal flora. In an interview on 7/26/11 with Certified Nursing Assistant #2 (CNA#2), she could not relate how she would clean an isolation room and didn't think she had been inserviced on the procedure. In an interview with the Housekeeping Supervisor on 7/27/11 at 11:30 AM, he stated that the housekeepers were supposed to don a gown and gloves, do isolation rooms last, and wipe everything off with a sanitizer. He stated he did not present the inservice but the Infection Control Nurse had done so. Observations on 7-27-2011 at 11:05 AM in the laundry room, revealed a fan blowing from the soiled work area towards the washers. At approximately 11:10 AM observation revealed 2 large laundry carts used to transfer clean, dry resident clothing were dirty at the bottom of each cart. Interview with Laundry Personnel #1 confirmed that the fan was on in the soiled laundry area because it was so hot in the lower floor of the facility and there was no air conditioning. She also confirmed that the carts were used to transfer clean laundry to another area for folding and soiling was present in the bottom of the carts. The facility admitted Resident #2 on 8/28/09 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. During an observation of a tube flush on 7/26/11 at 4:00 PM, Licensed Practical Nurse(LPN)#6 was observed after washing his hands three times during the procedure , to not use a barrier to turn off the faucet. During an interview with LPN #6 on 7/26/11 at 4:25 PM, he stated that he could not remember if a barrier had been used to turn off the faucet. The facility admitted resident #1 on 12/31/09 with the following Diagnosis: [REDACTED]. During the observation of the tube flush and feeding on 7/25/11 at 4:30 PM Licensed Practical Nurse #3 washed his hands before and after the treatment and turned the faucet off both times without using a barrier. After pouring [MEDICATION NAME] and Med Pass in the syringe used for administration, the nurse did not wash or rinse the syringe. He was observed to wrap it in paper towels and place it in a plastic bag. When ask about this on 7/26/11 at 3:30 PM he stated "" Yeah, I thought about rinsing the syringe afterward, but I didn't. I should use a towel to turn the faucet off."" Review of the facility performance standard titled ""Hand Washing"", item #7 states to ""turn off faucet with a clean paper towel."" During initial tour on 7/25/11 at approximately 9:45 AM, observation of the soiled utility room on Hall 1 and Hall 2 revealed a trash barrel in each room without a lid. Observation of the soiled utility room on Hall 1 on 7/27/11 at 9:00 AM revealed a trash barrel without a lid. Bags of trash were noted in the barrels. On 7/27/11 at approximately 9:40 AM, RN #1 confirmed a lid was not covering the barrel on Hall 1. After observing treatments on the 300 Unit on 7/26/11, a trash barrel without a lid in the soiled utility room was observed. Bags of trash were noted in the barrel. The facility admitted Resident #17 on 1/31/11 with [DIAGNOSES REDACTED]. Review of the closed medical record on 7/26/11 revealed a physician's telephone order dated 5/10/11 for [MEDICATION NAME] DS one tablet twice daily for 10 days for a Urinary Tract Infection. During an interview on 7/27/11 at approximately 10:15 AM, the facility's Infection Preventionist was asked for information related to the tracking/trending of data concerning infections within the facility. The Infection Preventionist stated that nursing staff documents information related to residents on antibiotics with [DIAGNOSES REDACTED]. When asked how this information is documented and tracked, the Infection Preventionist produced the Infection Control Surveillance Logs. Review of the log for May 2011 indicated that Resident #17's UTI and causative organism was not documented on the log. The Infection Preventionist stated that this information should be documented on the log and did not have an explanation as to why this was omitted from the surveillance data.",2014-11-01
9792,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,156,C,1,1,7GFL11,"On all days of the survey, based on observations and interview, the facility failed to prominently display in the facility the telephone number of the Protection and Advocacy Network and information on how to file a complaint with the State Survey and Certification agency. The findings included: On all days of the survey, the telephone number to the Protection and Advocacy Network and information on how to file a complaint with the State survey and certification agency were not observed to be prominently displayed in the facility. On 7/27/11 at 11:40 AM, the Director of Nursing confirmed the postings were not displayed.",2014-11-01
9793,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,164,D,1,1,7GFL11,"**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 provide full visual privacy during medical treatment during 1 of 10 treatments observed.(Resident #2) The findings included: The facility admitted Resident #2 on 8/28/09 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. During observation of the gastrostomy tube flush on 7/26/11 at 4:00 PM, LPN #6(Licensed Practical Nurse) did not utilize the privacy curtain during the treatment. During the procedure, LPN #7 knocked and entered the room without waiting for a response. The resident's bed was located near the door and staff were observed walking past the open door while the treatment was in progress. During an interview with LPN #6 on 7/26/11 at 4:25 PM, LPN #6 confirmed that the privacy curtain had not been pulled around the resident while providing the procedure. During an interview with LPN #7 on 7/26/11, she confirmed that she had not waited for an answer before entering the resident's room.",2014-11-01
9794,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,315,D,1,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the facility policy titled ""Catheters: Care and Anchoring, Changing of, and review of catheter care from the ""South Carolina Nurse Aide Candidate Handbook"", the facility failed to provide proper care for 1 of 2 sampled residents reviewed for catheter care. At the time of the catheter care for Resident #9, the facility staff member did not use correct technique in cleansing or securing the catheter to prevent tension on the bladder wall. The findings included: The facility admitted Resident #9 on 8/14/07 with [DIAGNOSES REDACTED]. During observation of catheter care on 7/26/11 at 9:11 AM, CNA #1(Certified Nursing Assistant) attempted to retract the foreskin around the penis. During the procedure, CNA #1 pushed the penis between the resident's legs and did not fully retract the foreskin. Each time CNA #1 attempted to obtain a wipe, the foreskin partially returned and had to be retracted. During the cleansing of the catheter tubing, CNA#1 did not anchor/secure the tubing to prevent tugging on the catheter. Review of the facility policy revealed that retracting the foreskin of an uncircumcised male or securing/anchoring the tubing was not addressed. Review of the ""South Carolina Nurse Aide Candidate Handbook"", page 35, item #8 , states while holding catheter near meatus without tugging, cleans at least four inches of catheter nearest meatus, moving in only one direction, away from meatus using a clean area of the cloth for each stroke. During an interview with CNA #1 on 7/27/11 at 12:40 PM, CNA #1 confirmed that she did not keep the foreskin retracted during the care, but did not recognize that she did not secure/anchor the catheter tubing.",2014-11-01
9795,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,333,D,1,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observation, record review and interview the facility failed to ensure that a Resident #21 was free of a significant medication error during the observation of a medication pass. The findings include: During the Medication Pass Observation on 7/26/11 at 8:45 AM, Licensed Practical Nurse #1 pulled the punch cards out of the cart and starting pushing them out into a cup. She did this very fast, so the surveyor had to ask to see the cards and the pills in the cup. It was noted at that time by the surveyor that there was two [MEDICATION NAME] 0.2 mg (milligrams) in the cup. There were two medication punch cards of the same drug in the stack of medication cards used. The nurse was stopped ask to identify the pills in the cup. She then stated ""Oh, there are two [MEDICATION NAME]'s. There must be two cards in that stack. The night shift must have opened another card."" At that time LPN #1 stated "" that's an error"". The Consultant Pharmacist stated on 7/27/11 at 9:00 AM "" They should check each medication given with the MAR and punch card always. [MEDICATION NAME] 0.4 mg instead of 0.2 mg could drop the blood pressure pretty quick.""",2014-11-01
9796,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,314,D,1,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and recertification survey, based on record review, interviews, observation, and review of the facility Dressing Changes Related to Wound Treatments policy, the facility failed to initiate interventions to prevent pressure ulcers from developing, and failed to reassess and treat a pressure ulcer for 1 of 6 residents reviewed for pressure ulcers. Resident #16 admitted with bilateral leg ulcers was found to have an area on her buttocks on 1/12/2011, there was no evidence the physician was notified of the area or that it was assessed and treated after the initial care provided on 1/12/2011. The findings included: The facility admitted Resident #16 on 12/30/2010 with [DIAGNOSES REDACTED]. Review of the 12/20/2010 hospital discharge summary indicated that Resident #16 was admitted to the hospital on [DATE] with stage 2-3 ulcerations involving both ankles circumferentially and extending proximally to the distal part of both legs. The condition of Resident #16's legs had been present for about 3 months. On 12/30/2010 the resident was discharged to the facility from the hospital for continued care. A review on 7/27/2011 of the Skin Integrity Documentation Form, Documentation of Skin and Wound Care dated 12/31/2010 stated, ""... admitted to LTC (long term care) facility following hospitalization and tx (treatment) for chronic venous stasis wounds to lower legs/feet, [MEDICAL CONDITION]. Skin assessment completed with dark, thick eschar, to bilateral heels, black in color, mild redness---surrounding each wound. Thick parchment like skin to both feet, peeling, cracking and sloughing. Red, thick crustations to lower distal portion of each leg r/t (related to) [MEDICAL CONDITION]. Several open areas to (L) (left) leg---medial aspect measures 9 x 5 x 0.1 cm (centimeters), lateral aspect of (L) leg measures 11 x 7 x 0.2 cm. Each wound overall size, with small areas of closed skin between some of wounds. Right lateral leg/ankle wound measures 9 x 5 x 0.2 cm, posterior portion of distal leg near upper wound with milder redness and sloughing skin, pink/red base that---measures 1.8 x 2 x < 0.1 cm. Right heel eschar measures 6 x 6 cm with surrounding redness, overall size 6 x 7 cm, left heel eschar 6.5 x .7 cm with redness. Braden scale score of (14) at moderate risk for further skin compromise with adjusted risk level to high r/t presence of ulcers comorbidities and resistance to care recently as notes in hospital medical record."" 12/31/10 Right heel - unstageable - 6 x 6 centimeters 1/5/11 - unstageable 5.2 x 6.6 centimeters 1/12/11 - unstageable 5.2 x 6 centimeters 1/17/11 - Hospital 12/31/10 Left heel - unstageable - 6.5 x 7 centimeters 1/5/11 - unstageable - 6.5 x 7 centimeters 1/12/11 - unstageable - 5 x 6.4 centimeters 12/31/10 Right lateral leg - stage IV 9 x 5 x 0.2 centimeters 1/5/11 - stage IV 7.5 x 2.8 x 0.2 centimeters 1/12/11 - stage IV 8 x 2 x 0.2 centimeters The Skin Notes dated 1/12/2011 at 12:30 PM documented that Resident #16 ""c/o (complained of) pain to buttock during wound care, skin assessment of area reveals 3.2 x 4 dark purple wound with small areas of peeling skin... Encouraged to reposition self call for assistance as needed with mobility and incontinence care."" A later note at 2:00 PM on 1/12/2011 indicated ""[MEDICATION NAME] applied to buttocks daughter visiting and informed."" There was no documentation that the physician was notified, that an order was received related to the treatment or that the 3.2 x 4 area was added to the treatment sheet. Review of the physician's orders [REDACTED].#16's buttocks. Review of the Daily Skilled Nurses Notes from 1/12/2011 through 1/17/2011 revealed no documentation related to the wound on Resident #16 buttocks. The documentation did indicate under the ""skin"" section the presence of the leg ulcers. Review of the Treatment Record for January 2011 documented the treatment to the leg ulcers as; ""cleanse bilateral lower leg ulcers with wound cleaser (sic) pat dry apply [MEDICATION NAME] cream cover with dry dressing and secure with tape"" ""apply skin prep (non sting) to bilateral heels qd (daily)"". There was no documentation showing that the area on Resident #16's buttocks was assessed or treated after the initial assessment on 1/12/2011. Review of the facility Dressing Changes Related to Wound Treatments policy stated on page 2 of 3, ""... Apply topical wound therapy/treatment as directed per physician orders...""",2014-11-01
9797,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,157,D,1,1,7GFL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint and recertification survey, based on record review and review of the facility Dressing Changes Related to Wound Treatments policy, the facility failed to consult with the Resident 16's physician regarding a wound on her buttocks that was assessed and initially treated on 1/12/2011, there was no evidence the physician was notified of the area (1 of 6 residents sampled with wounds). The findings included: The facility admitted Resident #16 on 12/30/2010 with [DIAGNOSES REDACTED]. Review of the 12/20/2010 hospital discharge summary indicated that Resident #16 was admitted to the hospital on [DATE] with stage 2-3 ulcerations involving both ankles circumferentially and extending proximally to the distal part of both legs. The condition of Resident #16's legs had been present for about 3 months. On 12/30/2010 the resident was discharged to the facility from the hospital for continued care. The Skin Notes dated 1/12/2011 at 12:30 PM documented that Resident #16 ""c/o (complained of) pain to buttock during wound care, skin assessment of area reveals 3.2 x 4 dark purple wound with small areas of peeling skin... Encouraged to reposition self call for assistance as needed with mobility and incontinence care."" A later note at 2:00 PM on 1/12/2011 indicated ""[MEDICATION NAME] applied to buttocks daughter visiting and informed."" There was no documentation that the physician was notified, that an order was received related to the treatment or that the 3.2 x 4 area was added to the treatment sheet. Review of the physician's orders [REDACTED].#16's buttocks. Review of the Daily Skilled Nurses Notes from 1/12/2011 through 1/17/2011 revealed no documentation related to the wound on Resident #16 buttocks. The documentation did indicate under the ""skin"" section the presence of the leg ulcers. Review of the facility Dressing Changes Related to Wound Treatments policy stated on page 2 of 3, ""... Apply topical wound therapy/treatment as directed per physician orders...""",2014-11-01
9798,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,157,J,1,0,Z1DH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility's failure to notify the proper authorities of an alleged assault in a timely fashion and the facility's failure to notify the physician timely and to notify the resident's attending physician. Resident #1 was allegedly sexually abused on 7/2/2011 by another resident's spouse. The facility failed to call 911 until three and half hours after the incident. The facility failed to notify the on call physician until six and a half hours after the incident. The facility failed to notify the attending physician of the incident at all. (One of one allegation of sexual abuse reviewed.) The findings included: The facility admitted Resident #1 on 3/30/2011 with [DIAGNOSES REDACTED]. Record review on 7/11/2011 of the Unusual Occurrence Incident Report dated 7/2/2011 at 9:25 AM revealed the following description documented by Registered Nurse #1: ""As I was coming out of room [ROOM NUMBER], I saw (Resident #2's family member) have his right hand down resident blouse stating, ""your titties feel warm"" and using his left hand to try to get resident's hand to touch his penis which was sticking out of his zipper."" The incident was reported to RN #2 (weekend supervisor). The on call physician was notified at 3:55 PM. The family was notified at 9:30 AM. Review of the Physician and NP Tracking Form revealed Resident #1 was not placed on the problem list for the Attending Physician to see on 7/5/2011 (the next available day the physician would be in the building). Review of the 24 Hour report revealed no entries were documented related to the incident that occurred on 7/2/2011 involving Resident #1. During an interview on 7/11/2011 at 10 AM the Social Services Assistant (SSA) confirmed 911 was not called until 12:54 PM, three and a half hours after the incident. During an interview on 7/12/2011 at 9:25 AM, the Attending Physician stated that she was not notified of the incident that occurred on 7/2/2011. The Physician stated that Resident #2's family had mentioned the incident to her in passing but stated again that the facility staff had not notified her of the incident. During an interview on 7/12/2011 at 10:30 AM, the On Call Physician confirmed that he was not notified of the incident until approximately 4 PM on 7/2/2011, six and a half hours after the incident occurred. During an interview on 7/12/2011 at 12:20 PM, the Director of Nursing (DON) confirmed Resident #1's physician was not notified of the incident and confirmed that the On Call Physician was not notified until 6 1/2 hours after the incident. The DON confirmed there should not have been a delay in notifying the physicians or 911. Cross Refers to F-223 as it related to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it related to the facility failure to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident.. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of ""J"". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of ""D"" as of 7/12/2011 at 2:00 PM.",2014-11-01
9799,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,223,J,1,0,Z1DH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility's failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. (One of one allegation of sexual abuse reviewed.) The findings included: The facility admitted Resident #1 on 3/30/2011 with [DIAGNOSES REDACTED]. Record review on 7/11/2011 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that coded Resident #1 as having short and long term memory and severely impaired abilities for daily decision making. Resident #1 was also coded as requiring one-person extensive assistance for transfers, mobility, locomotion, dressing, hygiene, toilet needs and bathing. Resident #1 was also coded as wandering at least 3-6 times during the assessment period. Review of the Nurse's Notes revealed an entry dated 7/2/2011 at 9:25 AM, ""Res (resident) was in hallway at room [ROOM NUMBER]. A family member had his hand down res shirt and his penis out stating, ""your titties are warm."" I was coming out of room [ROOM NUMBER] when I heard and observed this. I approached family member and stated ""No! we do not do this, you need to put it up and go on down the hallway. Put it away and go down the hallway."" I proceeded to notify nurse on dogwood unit."" At 2 PM, ""Body audit performed, no redness, discharge, no outward signs of trauma noted to vagina or breasts. No s/sx (signs and symptoms) of distress noted at this time."" At 3:55 PM, ""Dr (physician on call) was notified by myself of the situation that occurred this morning. No orders received. Dr informed that body audit was performed, social services contacted and police were notified."" Review of the Unusual Occurrence Incident Report dated 7/2/2011 revealed the following description documented by Registered Nurse #1: ""As I was coming out of room [ROOM NUMBER], I saw (Resident #2's family member) have his right hand down resident blouse stating, ""your titties feel warm"" and using his left hand to try to get resident's hand to touch his penis which was sticking out of his zipper."" The incident was reported to RN #2 (weekend supervisor). The physician was notified at 3:55 PM. The family was notified at 9:30 AM. Further record review revealed no physician's orders were written related to the incident. No physician progress notes [REDACTED]. Review of the Physician and NP Tracking Form revealed Resident #1 was not placed on the problem list for the Attending Physician to see on 7/5/2011 (7/5/2011 was the next available day the physician would be in the building). Review of the 24 Hour report revealed no entries were documented related to the incident that occurred on 7/2/2011 involving Resident #1. Review of the Care Plan revealed it had been updated on 7/2 to ""continue to observe for (increased) depression, social withdrawal, increased agitation, anxiety- related to recent incident, room change."" Review of the Police Department Incident Report revealed the police were called and dispatched at 12:54 PM on 7/2/2011 to respond to an incident of ""assault and battery 3rd degree"" at Brookview Healthcare Center. ""R/O (responding officer) responding to Brookview Nursing Home and spoke with (Social Worker, SW). SW stated that an incident had occurred between suspect, who was a visitor at the home, and victim, who is a resident. A nurse (RN #1) observed suspect with his hand down victim's shirt fondling her breasts and that suspect also had his penis out in his hand trying to get victim to touch it. R/O spoke with both victim and suspect's families and determined that a charge of assault and battery 3rd degree would be appropriate. Suspect was booked into CCDC (Cherokee County Department of Corrections) and charged with assault and battery 3rd degree. Suspect placed on trespass notice at Brookview."" Review of the facility's 5 Day Follow Up report sent to the State Certification Agency on 7/6/2011 revealed the interventions in place were ""police were called and (Resident #1's family) will be pressing charges- (Suspect) was escorted off premises."" The Immediate Corrective actions were ""supervised visitations from Monday-Friday, hours 9-5."" The interventions taken to prevent future occurrences were ""monitoring visitors and observing and reporting behaviors."" Review of the facility obtained witness statement from RN #1 revealed ""I was coming out of a resident's room from washing my hands and noted (Resident #2's family member) with his hand down (Resident #1's) shirt stating ""your titties feel warm."" (Resident #2's family member) also had his penis out of his pants trying to get (Resident #1) to touch it. I approached (family member) and told him ""No sir! We do not do this. You need to put it away and go on up the hallway."" I then went to the dogwood unit and notified (Licensed Practical Nurse #1) of what I had heard and seen. This incident happened outside of room [ROOM NUMBER] on the Peach Unit. I was coming out of room [ROOM NUMBER] on Peach Unit."" During a telephone interview on 7/11/2011 at 10:25 AM, RN #1 stated that she was coming out of room [ROOM NUMBER] when she observed Resident #2's family member with his hand down Resident #1's blouse fondling her breasts and also had his penis out. She stated that she approached him and told him to ""put it away and go on down hallway."" RN #1 stated that she then left the unit and reported the incident to the nurse on Dogwood (LPN #1). RN #1 stated that she saw the family member walking down the hallway but ""didn't see what room he went into."" RN #1 stated that LPN #1 then notified the supervisor. RN #1 then walked back to the Peach Unit. RN #1 stated that Resident #1 remained on the Peach Unit and was under supervision after the incident."" Review of the facility obtained statement from RN #2 (weekend supervisor) revealed she was on the Magnolia Unit when LPN #1 approached her. RN #2 entered (Resident #2's room), an activity assistant was present in the room. RN #2 asked the AA to leave. RN #2 documented that she asked (Resident #2's family member) ""what was going on, it was reported to me that some inappropriate behavior had taken place. The visitor said she used to be in the room with my wife. I told the visitor to sit right there and I would be right back...After talking with Peach Nurse that witnessed this behavior of this visitor and getting all the information including that this visitor was questioning why (Resident #1 changed rooms), I immediately went back to (Resident #2's) room with 2 witnesses and asked visitor to leave immediately and not to come back..."" RN #1 stated that after she escorted the family member out of the building, she notified Social Services of the incident. During an interview on 7/11/2011 at 10:30 AM, RN #2 stated that LPN #1 reported the incident to her on 7/2/2011. RN #2 stated that once she was aware of the entire situation she immediately escorted the family member out of the building. She stated that it was reported to her by a family member that the police ordered that Resident #2's family member could not visit and the facility was to post a picture of him in the facility. RN #2 stated that no pictures were posted because the facility was allowing the family member to visit. RN #2 stated that the family member had not been back in the facility since 7/2/2011. During a telephone interview on 7/11/2011 at 10:55 AM, LPN #1 stated that RN #1 reported the incident that occurred on 7/2/2011. LPN #1 stated that she saw Resident #2's family member walk down the hallway past the desk and into Resident #2's room. LPN #1 stated that she asked the Activities Assistant to go into Resident #2's room and ""make conversation."" LPN #1 stated that she reported the incident to RN #2 and RN #2 escorted the family member out of the facility. During an interview on 7/11/2011 at 10 AM, the Social Services Assistant (SSA) stated that she was called at home and notified of the incident on 7/2/2011. She stated that she arrived at the facility 20 minutes later at approximately 10 AM. The SSA stated that she notified both Resident #1 and #2's family members. She stated that she called 911 at 10:45 AM. The SSA stated that the police officer spoke with both Resident #1 and #2's family members. She further stated that the officer offered a rape kit to Resident #1's family members and they declined. The SSA stated that Resident #1's family was pressing charges. The SSA stated that Resident #2's family member could visit the facility but would have to have supervised visits. She also stated that the police officer provided a picture of the family member to post. The SSA confirmed that no pictures were posted in the facility. The SSA stated she did not notify staff of the incident that occurred on 7/2/2011 and did not provide inservicing to all staff members. The SSA confirmed that no counseling had been provided to Resident #1 and no other psychosocial interventions had been provided to Resident #1 and no interventions were put in place for Resident #2. During a follow up interview on 7/11/2011, the SSA confirmed 911 was not called until 12:54 PM, three and a half hours after the incident. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that he was notified of the incident on 7/2/2011 via the SSA. He stated that Resident #2's family member was allowed supervised visits during normal working hours (Monday - Friday, 9-5). He also stated that he had not received any court documents and the restricted visits were still in place. The Administrator confirmed that the family member had not been back to the facility. The Administrator stated that the SSA was provided a picture of the family member to post, however he confirmed no pictures were posted. The Administrator stated that a picture would be posted at the nursing stations if the family member returned to the facility. During an interview on 7/12/2011 at 9:25 AM, the Attending Physician stated that she was not notified of the incident that occurred on 7/2/2011. The Physician stated that Resident #2's family had mentioned the incident to her in passing but stated again that the facility staff had not notified her of the incident. The Physician stated that the on call physician was notified on 7/2/2011. She stated that doctors did not come to the facility on the weekends and that if there were a concern then the resident would have been sent to the emergency room . The Physician also stated that the physicians relied on the nursing assessments and since the family refused the rape kit and the nurses reported that the resident was ""ok"" there would have been no need to send the resident to the emergency room . The Attending Physician stated that a healthcare provider had not assessed Resident #1. During an interview on 7/12/2011 at 10:30 AM, the On Call Physician confirmed that he was not notified of the incident until approximately 4 PM on 7/2/2011, six and a half hours after the incident occurred. He stated that it was reported to him that the entire incident was witnessed and the resident appeared to be ""ok"". He stated that a physical assessment had not been reported to him. He also stated again that he was not informed that the nurse observed the incident already in progress and had not witnessed the entire incident. The On Call Physician stated that if he was told the incident was not witnessed entirely then he would have ordered the resident to be sent to the emergency room . He also stated that he expected the nursing staff and the social service staff to provide counseling and for the healthcare provider to be involved. He further stated that he expected the staff to have notified 911 and the physician within the hour the incident occurred. The On Call Physician stated that the nursing staff should have placed the resident on the provider list to be seen by the physician on the next visit. During an interview on 7/12/2011 at 11:30 AM, the Medical Director stated that he was not notified of the incident until the Attending Physician briefly reported the incident on the evening of 7/11/2011. He stated that he should have been notified. The Medical Director stated that he expected the facility to have followed the no trespass ordered by the police to protect all of the residents. He stated that he also expected the facility to address the residents' psychosocial needs and provide counseling. The Medical Director stated that he also expected the healthcare provider(s) to have seen and assessed the resident or to have sent to the emergency room for evaluation. He also stated that the resident should have been placed on the provider list and the Attending Physician should have been notified of the incident. Cross Refers to F-157 as it related to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-226 as it related to the facility failure to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refer to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of ""J"". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of ""D"" as of 7/12/2011 at 2:00 PM.",2014-11-01
9800,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,226,J,1,0,Z1DH11,"On the days of the Complaint and Extended Inspection based on record review, interview and review of the facility's policy on Abuse and Neglect, the facility failed to implement their Abuse Policy to protect Resident #1 who was allegedly sexually abused and to protect all residents at risk for sexual abuse. (One of one allegation of sexual abuse reviewed.) The findings included: On 7/2/2011 Resident #1 was allegedly sexually assaulted by another resident's spouse (Resident #2). The facility failed to put interventions in place to protect Resident #1 and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that Resident #2's family member was allowed supervised visits during normal working hours (Monday - Friday, 9-5). The Administrator stated that the police provided a picture of the alleged perpetrator to post. He confirmed no picture was posted that a picture would be posted at the nursing stations only if the family member returned to the facility. During a follow up interview at 3:45 PM with the Social Services Assistant and the Administrator the SSA stated that she did not speak with all staff on all units regarding the incident on 7/2/2011. She stated that she had only spoken with the first shift nurses on the Dogwood unit. Both the Administrator and the SSA confirmed that staff were not aware of the incident and were not aware that the suspect was not allowed in the facility. Review of the facility's Abuse and Neglect Policy and Procedure revealed the following: ""It is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse, corporal punishment and involuntary seclusion by a facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends or other individuals... Sexual Abuse includes but is not limited to sexual assault, sexual coercion, and sexual harassment... Protect the alleged victim from further abuse by identifying and removing the cause of the danger... When the abuse is detected GET THE FACTS, Physically assess the involved resident for injuries... Document the incident in the clinical record...All alleged violations... are reported immediately to The Director of Nursing, The Administrator, The resident's Attending Physician..."" Cross Refers to F-157 as it related to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it related to the facility's failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-250 as it related to the facility failure to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it related to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it related to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it related to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of ""J"". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of ""D"" as of 7/12/2011 at 2:00 PM.",2014-11-01
9801,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,250,J,1,0,Z1DH12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NOT CORRECTED On the day of the follow up Complaint survey based on record review and interview the facility failed to implement their plan of correction related to medically related social services for 1 of 4 sampled residents. Resident #13 displayed suicidal ideation, and no interventions were put in place. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurse's note dated 8/1/2011 at 5 PM that documented ""Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)"" Review of the Physicians orders revealed the resident's Effexor was increased to 75 mg (milligrams) on 8/1/2011. Further record review revealed no other documentation related to the resident's suicidal ideation. Review of the Social Service Notes revealed an entry dated 8/9/2011 that did not include any reference to the suicidal ideation. No interventions were put in place related to Resident #13's behaviors. During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors. The SW confirmed no notes were written in the resident's record related to the behaviors. All confirmed that no interventions were put in place related to Resident #13's behaviors/comments. The Nurse Consultant verified that all suicidal ideation should be taken seriously and the resident should be monitored and interventions should be implemented and documented. The Social Worker stated that she did see the resident on 8/1/2011 and speak with the family, however, she confirmed that she failed to document the encounter. The Social Worker also confirmed that no further monitoring or documentation was put in place for Resident #13's behaviors. A Plan of Correction (POC) related to F250 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;...""The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis.""",2014-11-01
9802,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,251,J,1,0,Z1DH11,"On the days of the Complaint and Extended Inspection based on interviews and review of the employee files, the facility failed to employ a qualified social worker. The facility did not have a licensed social worker on staff. The findings included: Review of the employee file for the Social Services Assistant revealed she did not have a current and/or active license. Review of the employee file for the newly hired Social Services Director revealed she was not a licensed Social Worker. During an interview on 7/11/2011 at 3:45 PM, the Administrator confirmed neither the Social Services Assistant nor the Social Service Director had a current license for Social Work. The Administrator confirmed the facility was greater that 120 beds and did not have a licensed social worker on staff nor have the oversight of a social services consultant. Cross Refers to F-157 as it relates to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it relates to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it relates to the facility failed to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it relates to the facility failed to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it relates to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. Cross Refers to F-490 as it relates to the failure of the facility Administration to protect residents from further abuse and failed to assure all staff had knowledge of the incident. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of ""J"". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of ""D"" as of 7/12/2011 at 2:00 PM.",2014-11-01
9803,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,280,J,1,0,Z1DH12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NOT CORRECTED On the day of the Follow Up Complaint survey based on record review and interview the facility failed to follow their plan of correction related to care plan revisions for 1 of 4 sampled residents. Resident #13's care plan was not updated related to the suicidal ideation. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurse's note dated 8/1/2011 at 5 PM that documented ""Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)"" Review of the Care Plan revealed the care plan was updated on 8/1/2011 with an increase of [MEDICATION NAME], however, the suicidal ideation was not added to the care plan nor were any interventions. A Plan of Correction (POC) related to F280 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;...""The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis."" During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors and confirmed that the care plans were not updated with the resident's behaviors and new interventions.",2014-11-01
9804,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,319,J,1,0,Z1DH12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NOT CORRECTED On the day of the survey based on record review and interview the facility failed to implement their plan of correction related to behavior monitoring and interventions for 1 of 4 sampled residents. Resident #13 had suicidal ideation. There was no monitoring or interventions put in place related to the suicidal ideation. The findings included: The facility admitted Resident #13 on 2/25/2008 with [DIAGNOSES REDACTED]. Record review on 8/10/2011 revealed a nurses note dated 8/1/2011 at 5 PM that documented ""Pt crying and yelling out making comments that she is going to kill herself. She just wants to die. (Attending Physician, Social Worker and family called.)"" Review of the Physicians orders revealed the resident's [MEDICATION NAME] was increased to 75 mg (milligrams) on 8/1/2011. Further record review revealed no other documentation related to the resident's suicidal ideation. Review of the Social Service Notes revealed an entry dated 8/9/2011 that did not include any reference to the suicidal ideation. No interventions were put in place related to Resident #13's behaviors. Review of the Behavior Monitoring Sheets for 8/2011 revealed increased agitation, restlessness and anxiety were monitored behaviors. No suicidal type behaviors/comments were added to the monitoring sheets. During an interview on 8/10/2011 at 4 PM, the Social Worker Director, the Social Worker Consultant, the Administrator and a Nurse Consultant all confirmed Resident #13's behaviors. All confirmed that no interventions were put in place related to Resident #13's behaviors/comments. The Nurse Consultant verified that all suicidal ideation should be taken seriously and the resident should be monitored and interventions should be implemented and documented. The Social Worker stated that she did see the resident on 8/1/2011 and speak with the family, however, she confirmed that she failed to document the encounter. The Social Worker also confirmed that no further monitoring or documentation was put in place for Resident #13's behaviors. A Plan of Correction (POC) related to F319 was submitted to the State Agency with a compliance date of 8/3/2011. Included in that POC was the following;...""The MDS (Minimum Data Set) Coordinators will review psychosocial needs of all residents that are requiring initial assessments, quarterly assessments, significant changes and scheduled care plan meetings. Daily review of unusual occurrences, grievances and 24 hour report sheets will be conducted by the IDT ( Interdisciplinary Team) and monitored for appropriate psychosocial follow-up. Inservices were provided for all staff of the expectations in providing psychosocial support for any resident exhibiting behaviors that would suggest the need for assessment. This inservice was provided by the Social Service Director and Administrator on 7-11-11. The Social Service Director will be responsible for providing scheduled educational inservices for all staff on a quarterly basis.""",2014-11-01
9805,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2011-07-12,490,J,1,0,Z1DH11,"On the days of the Complaint and Extended Inspection, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the failure of the facility's Administration to put interventions in place to protect Resident #1, allegedly sexually abused on 7/2/2011; to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. The findings included: On 7/2/2011 the husband of Resident #2 allegedly sexually abused Resident #1. The facility's Administration violated the no trespass police order and notified the suspect's family that supervised visits would be arranged. The Administration failed to put interventions in place to protect Resident #1. Inservices for staff related to the incident and interventions to protect all residents at risk for sexual abuse were not addressed by the Administration. During an interview on 7/11/2011 at 11:15 AM, the Administrator stated that he was notified of the incident on 7/2/2011 by Social Services. He stated that Resident #2's husband would be allowed supervised visit during normal working hours (Monday - Friday, 9-5). He also stated that he had not received any court documents and the restricted visits were in place. The Administrator stated that the police provided the facility a picture of the family member to post, however he confirmed no pictures were posted. The Administrator stated that a picture would be posted at the nursing stations only if the family member returned to the facility. During a follow up interview at 3:45 PM with the Social Services Assistant and the Administrator the SSA stated that she did not speak with all staff on all units regarding the incident on 7/2/2011. She stated that she had only spoken with the first shift nurses on the Dogwood unit. Both the Administrator and the SSA confirmed that staff were not aware of the incident and were not aware that the suspect was not allowed in the facility. Cross Refers to F-157 as it relates to the facility failure to timely notify the emergency services of alleged assault of a facility resident. Failed to timely notify the on call physician of the incident and failed to provide a thorough accounting of the incident. The facility failed to notify the resident's attending physician of the incident. Cross Refers to F-223 as it relates to the facility failure to put interventions in place to protect Resident #1 and to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Cross Refers to F-226 as it relates to the facility failed to implement the policy on sexual abuse related to the protection of residents. Cross Refers to F-250 as it relates to the facility failed to ensure that Resident's received the necessary social services following an allegation of sexual abuse. Cross Refers to F-251 as it relates to the facility failure to employ a licensed social worker to provide the medically related social services to residents. Cross Refers to F-280 as it related to the facility failure to care plan interventions following an allegation of sexual abuse. Cross Refers to F-319 as it relates to the facility's failure to provide necessary interventions to address the psychosocial needs of Resident #1 allegedly sexually abused on 7/2/2011 by Resident #2's husband. The psychosocial needs of Resident #2 related to the loss of the daily visits from her husband were not addressed. On 7/11/2011 at 4:35 PM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F-251, F280, F-319, and F-490 at a scope and severity of ""J"". The findings related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse. On 7/2/2011 Resident #2's husband allegedly sexually abused Resident #1. The facility failed to put interventions in place to protect Resident #1 after the allegation and failed to educate the staff regarding the allegation and the interventions necessary to protect all residents at risk for sexual abuse. Following a review of the Allegation of Compliance documentation, inservice content, staff inservice completion sign off sheets, and staff interviews, the Immediate Jeopardy was removed and citations F-157, F-223, F-226, F-250, F-251 F-280, F-319, and F-490 were lowed to a scope and severity of ""D"" as of 7/12/2011 at 2:00 PM.",2014-11-01
9806,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,225,D,0,1,XM2111,"On the days of the survey, based on record review, interviews, and review of the facility policy entitled ""Abuse Policy and Procedure"" (copied 3/22/11 at 3:30 PM), the facility failed to report 1 of 3 incidents to the State Agency within twenty-four hours as required. An allegation of abuse related to a Certified Nursing Assistant (CNA) accused of being ""rough"" with a resident during care was not reported timely to the State Agency. The findings included: On 3/21/11 at 6:00 PM, review of facility reports revealed that an allegation of abuse was made on 12/18/10. A CNA reported that another CNA was providing care to a resident and was rough and raised her voice to the resident. The CNA reported the abuse to her Charge Nurse on 12/18/10. The 24 hour report was sent on 12/22/10. On 3/22/11 at 3:00 PM, an interview with the Social Service Director was conducted. She stated that the incident happened on 12/18/10. Per the Social Service Director a CNA went to her Charge Nurse to report an allegation of abuse. She stated that the Charge Nurse did not report the allegation and that the CNA who initially reported the allegation went to the Director of Nursing (DON) on 12/22/10 as to why nothing had been done. The Social Service Director stated that the nurse did not follow protocol in reporting the abuse allegation. She stated they were not aware of the allegation until 12/22/10. Review of the nursing schedule for 12/19/10 through 12/22/10 revealled the CNA accused of being abusive to a resident on 12/18/10 continued to work on 12/19/10 and on 12/21/10. Review of the abuse policy entitled""Abuse Policy and Procedure"" copied on 3/22/11 at 3:30 PM, revealed that ""Alleged violations involving mistreatment, neglect or abuse....are reported accordingly. Any person observing abuse of a resident should immediately report it to the Administrator, Social Services Director, Director of Nursing or other department head. The department head immediately writes the allegation on a grievance form and forwards it to the Administrator. The Administrator or designee immediately begins investigating the allegation. The Department of health and Environmental Control and the ombudsman are also notified, as appropriate. The initial report must be phoned or faxed in within 24 hours.""",2014-11-01
9807,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,371,F,0,1,XM2111,"On the days of the survey, based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions. Sanitizer was stored near the placement of food and the trayline. Desserts were transported uncovered. Food items were uncovered, not labeled nor dated. Sanitary concerns were observed during observations of the tray line. The findings included: On 3/21/11 at 9:15 AM, during initial tour of the kitchen, it was observed that a sanitizer bucket was on a prep table while danishes were being placed on a platter. On 3/22/11 at 11:00 AM, during lunch trayline observation, 2 buckets of sanitizer were observed on A prep tables near clean dishes and clean silverware. On 3/22/11 at 11:40 AM, during lunch tray cart set up it was noted that all desserts placed on the trays were uncovered. The Certified Dietary Manager (CDM) acknowledged that they do not cover the desserts on the trays. The cook was observed using the same dish cloth to wipe food off the rims of plates throughout the trayline. The cooked placed the dish cloth on a cart with soiled pan lids after each time she wiped a plate with it. On 3/22/11 at 12:20 PM, during tour of the kitchen with the CDM, it was observed that a pan with 4 desserts in the walk in freezer was uncovered, not labeled, and not dated. During the Initial Tour of the Cana Unit beginning at 9:15 AM on 3-21-11, the Nourishment Room refrigerator contained six plastic bowls of what appeared to be pudding dated 3-25-11. When questioned, Registered Nurse (RN) #3 stated that this was the expiration date. At approximately 9:40 AM, RN #3 approached the Certified Dietary Manager (CDM) about the repackaged pudding dating. The CDM stated that the pudding ""was good for 12 days in cups in the refrigerator"". On 3/22/11 at 2:45 PM, an interview with the CDM was conducted. The CDM stated that foods that are not in their original packaging should not be held for longer than 3 days. She did not know why the pudding in the nourishment room was dated to expire on 3/25/10.",2014-11-01
9808,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,456,E,0,1,XM2111,"On the days of the survey, based on observation and interview, the facility failed to maintain essential equipment in safe operating condition based on 1 of 3 dryer lint collectors observed in the laundry area. The findings included: On 3/22/11 at 9:50 AM, during a tour of the laundry room, it was observed that one dryer lint collector was split on the sides and holes were noted on the lint collector. The lint collector was unable to adequately collect lint due to the amount of rips and holes on it. The Laundry Supervisor acknowledge that the dryer should not be used but that it had been used that morning.",2014-11-01
9809,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,329,D,0,1,XM2111,"**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 correctly administer insulin as ordered by the physician for 1 of 2 residents with sliding scale insulin. (Resident # 20) The findings included: The facility admitted Resident # 20 on 1-31-11 with [DIAGNOSES REDACTED]. Review of the Medical Record on 3-22-11 revealed an order for [REDACTED].= 2 u(nits), 201-250 =4 u, 251-300 = 6 u, >(greater than) 300 = 8 u"". Review of the Sliding Scale Flow Sheet for 2-25-11 at 12 PM revealed a reading of 221 and a note written ""gave his regular 8 u dose"" There was no indication that the sliding scale dose of 4 units was given. Review of the Sliding Scale Flow Sheet for 3-2-11 at 8 AM revealed a reading of 195, with a note of ""2 u held""; the 12 PM reading was 165 with no indication that the sliding scale dose of 2 unit was given. The Nurses Notes for both 2-25-11 and 3-2-11 revealed no notations related to the sliding scale insulin being held. During a subsequent interview with Registered Nurse (RN) # 2 on 3-22-11 at approximately 2:00 PM, she confirmed that she checked the finger sticks as noted above, but had not signed off the sliding scale insulin as being given on 2-25-11 or on 3-2-11. She further stated that since the regular dose of insulin was given so close to the sliding scale, she didn't think the sliding scale was necessary. She confirmed that she should have notified the physician if in doubt about giving the sliding scale.",2014-11-01
9810,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,431,F,0,1,XM2111,"On the days of the survey, based on observation and interview the facility failed to provide storage for medications under proper temperature controls for 1 of 3 medication rooms. The findings included: During the review of medication rooms on 3-21-11 at approximately 2:20 PM, the temperature in the medication room on Damascus Hall appeared to be above normal. The Maintenance Director confirmed that the temperature was at 83 degrees, and he further stated that a new air conditioner had been ordered and should have been delivered already. This information was shared with the Director of Nursing at that time. On 3-22-11 at 12:00 Noon, the Maintenance Director and this surveyor did a recheck of the temperature of the medication room which revealed the temperature on the counter level as 87.7 degrees, and the temperature near the shelves at 90.2 degrees. During a subsequent conversation with the Pharmacy consultant at 12:15 PM, she stated that most medication should not be stored in temperatures above 86 degrees. She further stated that she was aware that an air conditioner had been ordered. Medications stored in the room included emergency supplies for the entire building, supplies on a treatment cart and various back up stock items.",2014-11-01
9811,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,221,D,0,1,XM2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, interviews, and review of the facility policy entitled ""Implementation of Restraints and/or Enablers..."" (undated), the facility failed to ensure that one of two residents reviewed for restraints (Resident #19) had an assessment, physician's order, and plan of care for the restraint's use related to treatment of [REDACTED]. The findings included: The facility admitted Resident #19 on 1-17-05 with [DIAGNOSES REDACTED]. Observations on the two days of the survey revealed the resident in a wheelchair at the nursing station with a seatbelt in place. Record review on 3-22-11 at 1:15 PM revealed no Physician's Order for the seatbelt or assessment for its use. The 1-10-11 Fall Risk Evaluation scored the resident as a high risk for falls. A low bed and mat were ordered to minimize injury in the event of falls. There was no evidence on the Medication/Treatment Administration Records (MAR/TAR) that the seatbelt was in use. There was no evidence that other measures (i.e., positioning devices, alarms, etc.) had been attempted prior to use of the seatbelt in the wheelchair. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 1-5-11, Section P noted no restraints coded as being used. Section C of the MDS noted the resident with both short- and long-term memory deficits and requiring extensive assistance with decision-making. Section G of the MDS noted that the resident required extensive assistance of two persons for transfer and ambulation and had no functional limitations in range of motion. Review of the Care Area Assessment Documentation Notes for the Annual MDS (Assessment Reference Date 10-6-10) revealed that the resident ""needs partial physical support of one to stand for transfer and ambulation. At times she makes a rocking motion with staff right before she stands up...In the hallway she walks with staff (gait belt use) standing beside or directly behind her with limited assistance...does not initiate independent standing or ambulation..."" Review of the Interdisciplinary Care Plan most recently updated on 1-25-11 revealed no reference to use of the seatbelt. (This care plan was noted as being reviewed and updated quarterly from 11-07 through 1-11.) The only documented evidence of the seatbelt being used was noted on the Patient Plan of Care for CNA's (Certified Nursing Assistants) which stated ""W/C (wheelchair) has attached seat belt."" During an interview on 3-22-11 at 1:30 PM, Registered Nurse (RN) #3 stated that she didn't really know whether the seatbelt was a restraint or not and had ""struggled with what to do with it"". It had been applied because it was attached to the wheelchair and could not be removed. The RN and Licensed Practical Nurse #1 thought that the belt had been implemented when the family brought in a new chair (due to the resident's weight gain) with the belt attached. Neither could determine specifically when the chair had been brought to the facility. Both nurses reviewed the Physician's Orders and Interdisciplinary Care Plan and confirmed that there was no reference to the use of the seatbelt. The RN verified that no restraint assessment had been done, and stated that there should be a Physician's Order and Care Plan for the use of the belt. During an interview on 3-22-11 at 2 PM, CNA #1 verified the use of the seatbelt and that the resident was able to access various parts of her body and ""would find some way"" to do so as needed. During an interview on 3-22-11, the Director of Nurses (DON) stated that the belt was an enabler, even though the resident could not remove it. She stated it was being used so that when the resident jerked, leaned forward, or rocked, she would not fall/slide out of the chair. She stated that no physician order was required for enablers, that it ""was put on using nursing judgement"". Review of the facility policy entitled ""Implementation of Restraints and/or Enablers..."" provided by the DON on 3-22-11 at 2:40 PM revealed the following: ""The nurse, therapy, and/or MD may evaluate for the use of a restraint and/or enabler. The use of an enabler may be a nursing judgement. Obtain MD order if necessary (not necessary for assist siderails)...Enter the restraint or enabler on the TAR which is to be signed off every shift by the nurse indicating that the device is in place as ordered...Ensure that the intervention is entered on the Care Plan and the CNA Care Plan.""",2014-11-01
9812,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2011-03-22,333,D,0,1,XM2111,"**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 ensure that one of fourteen residents reviewed for medication assessment was free of significant medication errors. Nursing staff failed to follow specific physician's orders [REDACTED].#5. The findings included: The facility readmitted Resident #5 on 1-21-11 following hospitalization for ""elevated BP (blood pressure) (197/113), c/o (complaints of) chest pain along with tremors"". Review of the hospital Transfer Summary on 3-21-11 at 3 PM revealed that, during her hospitalization , ""...because of moderate hypertension, she was started on [MEDICATION NAME] 0.2mg at (milligrams) h.s. (hour of sleep) daily for both its antihypertensive as well as sedative effects."" Resident #5 was readmitted /transferred with orders for ""[MEDICATION NAME] 0.2mg at h.s. daily, hold if systolic blood pressure less than 120."" Review of the 1-11 and 2-11 Medication Administration Records (MARs) revealed no BPs recorded prior to administration of the medication. Review of the 3-11 MAR indicated [REDACTED]= 114/74; on 3-14-11 BP = 112/82; on 3-15-11 BP = 111/71), equivalent to a 15% error rate for this medication for the month of 3-11. During interviews on 3-21-11 at 3:45 PM and 4 PM, Registered Nurses #4 and #5 reviewed the MARs and confirmed that the BP was not monitored prior to medication during 1-11 and 2-11 and was initialed as given when the systolic BP was recorded as less than 120. During an interview on 3-22-11 at 2:45 PM, the Director and Registered Nurses and Registered Nurse #5 presented information related to a record audit that had identified that BPs were not being monitored prior to medication administration. The staff had audited all records to assure to ensure compliance as of 3-1-11. However, they verified that the physician's orders [REDACTED].",2014-11-01
9813,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2011-03-09,241,E,0,1,PV2A11,"During the days of the survey, based on observation, interview and review of facility meal times, the facility failed to treat residents in a manner that maintains or enhances each resident's dignity based on dining room meal delivery. Residents in 3 out of 3 dining rooms observed, did not receive meals around the same time and some residents had to wait for long periods of time while other residents were served trays immediately. Findings included: On 3/8/11 at 12:15 PM in the North wing dining room, it was observed that 3 resident were sitting at a table together when the first tray cart was delivered. Two residents at the table were served their meals. The third resident was told that her meal was on the second tray cart. The resident proceeded to wheel herself out of the dining room at that time and sat in her wheel chair right outside the dining room. The second tray cart arrived at 1:00 PM. After receiving her tray, the resident picked up the plate and began quickly shoving food into her mouth. On 3/8/11 at 12:50 PM an interview was conducted with Certified Nursing Assistant (CNA) #2. She revealed that the kitchen decides which resident's food goes on which cart. She stated that usually the same people eat in the dining room. The CNA stated that she does not know why the tray carts are set up the way they are. On 3/8/11 at 6:10 PM during the dinner meal observation in the North Wing Dining room, the same resident was observed sitting in the dining room at a table by herself. Trays were passed in the dining room starting at 6:15 PM. All residents were provided with trays except for the one resident. (The same resident that did not receive a tray at lunch.) The resident stayed in the dining room throughout the meal while everyone else ate. Three staff members were in the dining room assisting other residents. The resident received her tray at 6:55 PM. At this time, all other residents in the dining room had completed their meals. On 3/9/11 at 12:56 PM during the lunch meal in the East Wing dining room, it was observed that at 3 tables two residents had meals while one resident still waited for his/her tray. Per review of the facilities ""Meal Service Serving Times"" for lunch in the North Wing the 1st cart was at 11:45 AM and the second cart was at 12:35 PM; in the East Wing the 1st cart was at 11:55 AM and the 2nd cart was at 12:45 PM; in the West Wing the first cart was at 12:05 PM and the 2nd cart was at 12:55 PM. The Dinner carts in the North Wing revealed that the 1st cart should be sent at 6:20 PM and the 2nd cart at 6:25 PM; in the East Wing the 1st cart should be at 5:50 PM and the 2nd cart at 6:00 PM; in the West Wing the 1st cart should be at 5:30 PM and the 2nd cart at 5:40 PM. Per interview with the former Food Service Director on 3/9/11 at 12:30 PM, he stated that he does not know why the staff does not call the kitchen if they need a tray for a resident. On 3/8/2010 at 6:00 PM, the East Dining Room was observed to have one half of the tables with residents eating their PM meal. There were 8 residents sitting on the other side of the dining room with no trays. The second cart did not arrive on the unit until 7:00 PM. The waiting residents were served at that time. General observation of the West Wing Dining Room on 3/8/11 at 8:43 AM revealed a resident calling out, wanting breakfast. She complained of other residents ""stuffing their faces"" while she was hungry. Another resident sitting at a table stated she hadn't had her breakfast yet, and asked the surveyor if she was going to get something to eat. There were a total of 6 residents in the dining room waiting for their breakfast, while a total of 9 residents had either finished eating their breakfast or were just finishing being fed by staff. At 8:46 AM a staff member stated ""The other cart is here"". A resident wearing a lime green shirt was pushed to a table and served her tray from the 2nd cart. One resident in a pink shirt and glasses was pulled up to the same table along with one resident wearing an orange sweater sitting in a high backed wheelchair. They were all served their breakfast trays from the 2nd cart. Further observation revealed a resident who had been sitting next to the door in the dining room wheeled to a table at 8:50 AM. By 8:55 AM the last two residents who had been sitting in the dining room without a breakfast tray had been served. During an interview on 3/8/11 at 9:00 AM, Certified Nursing Assistant (CNA) #2 stated that she didn't know what time the first cart had come out that morning, but thought the first cart came out around 8:00 AM while the second cart usually came out around 8:30 AM. She stated she didn't know how long the other residents had been sitting in the dining room waiting for the second cart with their breakfast trays on them.",2014-11-01
9814,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2011-03-09,371,F,0,1,PV2A11,"On the days of the survey, based on observation, interview, and the facility's posted meal times, the facility failed to use sanitary equipment and failed to distribute food in a timely manner to 3 of 3 units observed. Findings included: On 3/8/11 at 3:25 PM during tour of the kitchen with the District Manager, it was revealed that the microwave contained rust on the door and on the inside bottom. The District Manager confirmed that there was rust in the microwave. On 3/8/11 at 12:15 PM during lunch on the North Wing, it was observed that the first tray cart arrived on the unit at 12:15 PM. Residents were then served sporadically throughout the unit. The next tray cart arrived on the floor at 1:00 PM. On 3/8/11 at 12:50 PM an interview was conducted with Certified Nursing Assistant (CNA) #2, she revealed that the kitchen decides which resident's food goes on which cart. On 3/8/11 at 6:10 PM during dinner observation on the North Wing, it was observed that the first tray cart arrived on the unit at 6:10 PM. Residents were again served sporadically throughout the unit. The next tray cart arrived on the unit at 6:55 PM. Residents who's trays were not on the first cart were told they would have to wait until the second cart arrived. Per review of the facilities ""Meal Service Serving Times"" for lunch in the North Wing the 1st cart is at 11:45 AM and the second cart is at 12:35 PM; in the East Wing the 1st cart is at 11:55 AM and the 2nd cart is at 12:45 PM; in the West Wing the first cart is at 12:05 PM and the 2nd cart is at 12:55 PM. The Dinner carts in the North Wing revealed that the 1st cart should be sent at 6:20 PM and the 2nd cart at 6:25 PM; in the East Wing the 1st cart should be at 5:50 PM and the 2nd cart at 6:00 PM; in the West Wing the 1st cart should be at 5:30 PM and the 2nd cart at 5:40 PM. On 3/8/2010 at 6:00 PM, the East Dining Room was observed to have 1/2 the tables with residents eating their PM meal. There were 8 residents sitting on the right side of the dining room with no trays. The second cart did not arrive on the unit until 7:00 PM. The residents sitting on the right side of the dining room were served at that time. Resulting in a 1 hour delay between the time the first and second cart was delivered to the East Unit. Observation of the West Wing Dining Room on 3/8/11 at 8:43 AM revealed the 2nd cart containing breakfast trays delivered to the dining room at 8:46 AM. An interview with Certified Nursing Assistant (CNA) #2 who had served trays in the dining room that morning revealed the first breakfast cart usually came out at 8:00 AM and the 2nd cart usually arrived around 8:30 AM. Review of meal service times provided by the facility revealed the 1st cart was to come out at 7:50 AM and the 2nd cart was to be delivered at 8:20 AM.",2014-11-01
9815,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2011-03-09,372,D,0,1,PV2A11,"On the days of the survey, based on observation and interview, the facility failed to dispose of garbage properly based on trash observed behind dumpsters and one plug missing from a dumpster. Findings included: On 3/7/11 at 6:00 PM, during initial tour of the kitchen, it was observed that one of the dumpsters was missing a plug. It was also observed that behind the dumpsters was a broken wooden fence with trash covering the bushes and ground behind the dumpsters. It was noted that there was at least five single use gloves on the ground as well as used medicine cups. On 3/8/11 at 3:25 PM, during a second tour of the kitchen with the District Manager, it was noted that a plug was missing from one of the dumpster. There was trash covering the bushes behind the dumpsters. Per interview with the District Manager on 3/8/11 at 3:25 PM, it was revealed that a plug was missing from one of the dumpsters. He also stated that he thinks the trash was from the last big storm. Although when asked if the dumpsters were open during the last storm, he stated they were not.",2014-11-01
9816,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2011-03-09,322,D,0,1,PV2A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observation, record review, the facility policy, and interviews, the facility failed to ensure that a resident with a gastrostomy tube (G tube) received an appropriate tube flush with administration of a medication. Resident #2 was observed to have medication and water pushed through the gastrostomy tube instead of allowing the flush to flow by gravity. The findings included: The facility admitted Resident #2 on 1/8/07 and readmitted him on 4/30/10 with diagnoses, including, but not limited to, Pneumonia. On 3/8/11 at 2:18 PM, during observation of a tube flush, Licensed Practical Nurse (LPN) #1 crushed an [MEDICATION NAME] 325mg (milligram) tablet, measured 200 milliliters (mls) of water and dissolved the crushed [MEDICATION NAME] tablet in approximately 10 mls of the water. LPN #1 gloved and checked for placement and residual. She then poured 30 mls of water into the barrel of the syringe, attached to the G tube, and pushed the the water through the syringe using the plunger. The [MEDICATION NAME] solution (approximately 10 mls) was placed in the syringe and pushed through the tube and all remaining water flushes, 60 mls at a time, were placed into the barrel of the syringe and pushed through the tube. At no time was there an attempt to allow any of the solution or flushes to flow through the barrel of the syringe by gravity. The facility's ""Competency Gastrostomy Tube Flush Procedure"" states (in part): ""Pour in ordered amount of flush. Allow flush to flow by gravity."". During an interview on 3/8/11 at 3:13 PM, the facility's pharmacist stated that she had observed tube flushes with medications with LPN #1 (last time 2/2/11) and that the nurse had not pushed any of the liquids, but had let them flow by gravity. During an interview on 3/9/11 at 8:19 AM, LPN #1 stated that she knew that she should have let the flushes and medication solution flow by gravity and that she usually did it that way, but she was nervous while being observed.",2014-11-01
9817,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2011-03-09,333,D,0,1,PV2A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interview, the facility failed to ensure that a resident observed during medication pass (Resident #20) was free of a significant medication error. The findings included: On 3/8/11 at 7:52 AM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer 1/2 tablet of [MEDICATION NAME] 25 milligram (mg) and 5 other medications to Resident #20. After administering the medications LPN #1 confirmed, during an interview, that she had not taken the resident's pulse before giving the [MEDICATION NAME]. Review of the current ""physician's orders [REDACTED].#20 revealed an order for [REDACTED].",2014-11-01
9818,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,152,D,0,1,LEF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review of a closed chart and interviews, the facility failed to obtain 2 physician signature to deem Resident #15 incompetent to sign her advance directive for Do Not Resuscitate (DNR). (1 of 15 sampled residents reviewed) The findings included: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 7/13/11 revealed Resident #15 was deemed competent to make her own health care decisions related to DNR (Do Not Resuscitate) by the facility's physician. Further record review revealed the Advanced Directive for DNR was not signed by the resident and there was no evidence the resident lacked the capacity to make health care decisions. Interview on 7/13/11 at approximately 9:20 AM with the Social Service Director, Medical Records Staff and Director of Nursing confirmed the findings.",2014-11-01
9819,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,160,C,0,1,LEF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based of record review and interviews, the facility failed to convey resident's funds and final accounting of those funds within 30 days of the individual or probate jurisdiction administering the resident's estate for 4 of 4 sampled residents reviewed. The findings included: An interview on [DATE] at approximately 10:15 AM with the Business Office Manager revealed concerns with 4 of 4 conveyance of funds records reviewed. Resident A expired on [DATE] and a check was written to a funeral home on [DATE]( prior to the resident expiring) in the amount of $900.00 which left the resident's trust fund account with a zero balance per the Business Office Manager. Review of the Resident Trust Fund Statement for Resident A printed out on [DATE] indicated the resident account will not have a zero balance entered on the account until [DATE]. Resident B expired on [DATE] and a check was written in the amount of $190.00 in the name of the expired resident on [DATE](after the resident expired). A review of the Resident Trust Fund Statement revealed the resident's account will not have a zero balance until [DATE]. Resident C expired on [DATE] and a check was written to a funeral home on [DATE]. Review of Resident C Trust Fund Statement reviewed for period ""[DATE] thru [DATE]"" revealed resident account did not have a zero balance. Resident D expired on [DATE] and a check was written to a funeral home on [DATE]. Review of Resident D Trust Fund Statement printed on [DATE] revealed no documentation of a check written on [DATE] to the funeral home. Further review of the Resident Trust Fund Statement revealed the account did not have a zero balance until [DATE]. The Business Office Manager stated the funds were submitted to the funeral homes per written request of the family/responsible party. The Business Office Manager further stated it was a facility practice to close out the account by paying for burial expenses in advance when questioned about Resident A account. An interview on [DATE] at approximately 3:35 PM with the Administrator, Director of Nursing and facility Consultant revealed the Administrator was aware of the check written to the expired resident and the funds being paid to the funeral homes. An interview on [DATE] at approximately 10:18 AM with the facility Administrator and the Business Officer Manager confirmed the findings of the Resident Trust Fund Statements and the Administrator stated there were some system problem with the account statements.",2014-11-01
9820,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,285,D,0,1,LEF611,"**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 coordinate assessments with the pre-admission screening and resident review program (PASARR) under Medicaid in part 483, subpart C prior to admitting Resident #8 ( 1 of 15 records reviewed for PASARR.) The findings included: The facility admitted Resident # 8 on 6/27/11 with [DIAGNOSES REDACTED]. Record review on 7/11/11 revealed no documentation of a PASARR having been done for this resident. The DON (Director of Nursing) could not locate the PASARR in the medical record and contacted the Director of Social Services. During an interview with the Social Service Director, it was confirmed that the hospital did not send a PASARR with the resident when he was transferred to the facility on [DATE].",2014-11-01
9821,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,310,D,0,1,LEF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to ensure that 1 of 9 sampled resident's ability related to eating/chewing was assessed. Resident #1 with documented dental problems and an inability to eat a regular diet was not asssessed for an alternate diet. The findings included: The facility admitted Resident #1 on 5/3/10 with [DIAGNOSES REDACTED]. Record review on 7/11/11 revealed a Minimum Data Set ((MDS) dated [DATE] and 6/12/11 that indicated the resident had memory problems with severely cognitive impaired in daily decision making skills. An observation on 7/11/11 at 12:15 PM revealed resident being fed a regular diet by staff. An observation at 12:30 PM revealed the resident's food tray back on the food cart uneaten. Record review revealed a ""Dental Assessment"" dated 4/07/11 that indicated Resident #1 had problems chewing food because of the number of missing teeth. The assessment further indicated the resident did not like pureed food and preferred regular food but had problems chewing it. The resident's weight was documented as: 4/04/11 - 115 pounds, 5/04/11 -119 pounds, 6/06/11-121 pounds, 7/04/11-114 pounds and 7/11/11-111 pounds. Further record review revealed there was no documentation of any speech therapy provided related to an alternate diet. An interview on 7/12/11 at approximately 9:55 AM with the Speech Therapist revealed she had not assessed the resident related to alternate diet. The Speech Therapist stated she was aware of the chewing concerns because it was discussed in care plan meeting. The Speech Therapist stated a trial of the pureed diet should be documented in the dietary notes. The Speech Therapist looked through the chart and confirmed there was no documentation that the resident was evaluated related to an alternate diet due to chewing problems. During an interview on 7/12/11 at approximately 10:05 AM . the Dietary Manager reviewed the resident's medical record and confirmed there was no documentation to indicate an alternate diet was provided for the resident.",2014-11-01
9822,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,312,D,0,1,LEF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview the facility failed to provide grooming and personal hygiene care of 1 of 9 sampled residents reviewed for finger nail care. Resident #1 was observed on 2 days of the survey with contracture fingers and finger nails which were observed to be long, jagged with a black substance under the finger nails. The findings included: The facility admitted Resident #1 on 5/3/10 with [DIAGNOSES REDACTED]. Record review on 7/11/11 revealed a Minimum Data Set ((MDS) dated [DATE] and 6/12/11 that indicated the resident had memory problems with severely cognitive impaired in daily decision making skills. An observation on 7/11/11 at 12:15 PM revealed resident being fed by staff. The resident fingers were observed to be contracted with long, soiled and jagged finger nails. An observation on 7/11/11 at 5:50 PM revealed staff seated at the table while the resident was eating a sandwich with the black substance under the finger nails. An observation on 7/12/11 at 11:55 AM with surveyor and Licensed Practical Nurse (LPN) #1 who confirmed the findings and further stated nail care was to be done each morning during activities of daily living care. LPN #1 stated Diabetic residents finger nails are cut by the nurse on an as needed basis. The LPN verified Resident #1 finger nails needed to be cut.",2014-11-01
9823,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,366,F,0,1,LEF611,"On the days of the survey, based on observations, interviews, and review of the daily menus, the facility failed to inform residents of substitutes available of similar nutritive value at meals. The findings included: On 7/11/11 at 1:00 PM, observation of the lunch meal was conducted with staff offering soup, sandwiches and cereal as alternate choices. During two additional random meal observations, the CNA's ( Certified Nursing Assistant) offered residents a sandwich or soup when the resident stated they did not want the meal offered. Multiple residents were observed in the dining room not eating the meal and no staff was observed or heard offering alternates of similar nutritive value to these residents. On 7/12/11 at 11:25 AM, an interview with the CDM (Certified Dietary Manager) was conducted. She stated that they do have an alternate vegetable and an alternate meat available but did not know how the residents were made aware of the alternate meal. She stated that they do not post an alternate meal and she thinks that the CNAs know it is available. She said they have always offered a soup or sandwich if a resident did not like the meal offered. She stated that she knows what the residents like and dislike so she makes the alternate for a resident if they have a known dislike of a certain food. Per review of the menus for 7/11/11 and 7/12/11 for lunch and dinner, no alternate meal was posted on the menu. During meal observation on 7/11/11 at 12:15 PM to 1 PM multiple residents served in the Activity Room and the Main Dining Room were observed not eating the meal provided. Staff was heard offering residents sandwiches as a meal substitute. During meal observation on 7/11/11 at 5:50 PM to 6:30 PM multiple residents served in the Activity Room and the Main Dining Room that did not eat the food provided were offered soup, sandwiches and cereal as a substitute meal. During group interview on 7/12/11 at approximately 11:20 AM 6 of 6 group members were not aware of a substitute menu which provided items of similar nutritional value for items they did not like. Four of 6 group members stated they were aware soup, sandwiches and cereal were the alternate meal.",2014-11-01
9824,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,371,F,0,1,LEF611,"On the days of the survey, based on observations and interview, the facility failed to store and serve food under sanitary conditions. The findings included: On 7/11/11 at 10:15 AM, the initial tour of the kitchen was conducted with the CDM (Certified Dietary Manager). A tray of glasses of nectar thick liquids was not dated in the Reach in Cooler. An ice scoop was observed uncovered above the ice machine. On 7/11/11 at 1:00 PM, observation of the lunch meal was conducted. A bottle of hand sanitizer was observed on the counter next to drinks and desserts for the residents throughout the meal service. On 7/11/11 at 3:15 PM, a tour of the nourishment room was conducted with the CDM. It was observed that an ice scoop was uncovered above the ice machine. On 7/11/11 at 6:34 PM, observation of the supper meal was conducted. It was observed that a bottle of hand sanitizer was on the counter next to resident drinks throughout the meal service. On 7/12/11 at 12:05 PM, a tour of the kitchen was conducted with the CDM. In the Walk in Cooler it was observed that two cases of cucumbers were moldy, 2 cantaloupe had mold on them, and one black banana was observed next to the fans on the top shelf. On 7/12/11 at 2:30 PM, an interview with the CDM was conducted who verified the findings.",2014-11-01
9825,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,157,D,0,1,DO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility staff failed to notify the physician when medications were not available, nor obtain an order to give the medications when available for Resident # 3. ( 1 of 6 residents reviewed for physician notification) The findings included: The facility admitted Resident # 3 on 6/24/11 at 2100 hours (9PM) with [DIAGNOSES REDACTED]. Record review on 8/2/11 revealed MARS (Medication Administration Sheets) documentation (Initials Circled) that all 9 AM medications for 6/25/11 had not been given. The back of the MARS showed ""[MEDICATION NAME] 81mg(milligram) -did not give-not available"", 6/25/11 9 AM n/a (not available) from Pharmacy-*** to deliver today, 6/25/11 2 PM meds still not delivered from ***. The resident did not receive physician ordered medications of [MEDICATION NAME], [MEDICATION NAME], or Aspirin on 6/25/11. There was no documentation in the record that the physician had been notified that the medications were not available. The medications arrived at the facility at 3 PM. The Physician was not notified to see if the medications could be given at that time since the resident only received these meds once a day. Interviews with the DON(Director of Nursing) and the Pharmacy Consultant confirmed that orders must be sent to the Pharmacy by 4:30 PM for next day delivery. However, someone is on call 24 Hours and prescriptions may be called in later than that time. The Pharmacy will contact their emergency back-up pharmacy to deliver the meds immediately. The Pharmacy Consultant also stated that the staff should have obtained an order to give the medications when delivered. The DON also confirmed the Physician had not been notified nor any orders obtained.",2014-11-01
9826,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,425,D,0,1,DO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to obtain medications for Resident #3 and Resident # 7, resulting in the resident's not receiving physician ordered medications. Resident # 3 did not receive Heparin and 6 other medications on 6/25/11. Resident #7 did not receive Iron on 7/8/11 and Coreg on 7/26/11. Ferrous was not available from 6/24 - 6/28/11. ( 2 of 9 sampled residents reviewed for pharmacy services.) The findings included: The facility admitted Resident # 3 on 6/24/11 at 2100 hours with [DIAGNOSES REDACTED]. Record review on 8/2/11 revealed documentation that all 9 AM meds for 6/25/11 had not been administered. The back of the MARS documented ""Synthroid 81mg(milligram) -did not give-not available"", 6/25/11 9 AM n/a (not available) from Pharmacy-*** to deliver today, 6/25/11 2 PM meds still not delivered from (pharmacy. The resident did not receive Heparin, Norvasc, Aricept, Pepcid, Prednisone, Synthroid, or Aspirin on 6/25/11. Interviews with the DON(Director of Nursing) and the Pharmacy Consultant confirmed that orders must be sent to the Pharmacy by 4:30 PM for next day delivery. However, the pharmacy is on call 24 Hours and the pharmacy will contact their emergency back-up pharmacy to deliver the medications immediately. The DON also stated there was a back-up pharmacy in town which the facility frequently used to obtain medications. There was no explanation provided as to why the facility did not obtain the physician ordered medications in a timely manner. The facility admitted Resident #7 on 6/23/11 with [DIAGNOSES REDACTED]. According to Medication Record documentation and interview, ""Ferrous"" had not been available for administration from 6/24/11 through 6/29/11, Coreg had not been available for administration for the morning dose on 7/26/11, and Ferrous Fumarate had not been available for the morning dose on 7/8/110. Record review on 8/3/11 at 9:22 AM revealed a Medication Record dated 6/23/11 through 6/30/11 which documented an entry for ""Ferrous 100 mg (milligrams) PO (By Mouth) two times a day chewable ferrous fumarate"" which had been lined through. Next to the entry had been written ""DC'd (discontinued) 6/29/11"". Initials had been circled indicating the medication had not been given twice daily as ordered from 6/24/11 through the morning dose on 6/29/11. There was no documentation on the back of the Medication Record to indicate why the medication had been held. Review of cumulative physician's orders [REDACTED]. Review of Nurse's Notes dated 6/27/11 at 11:15 AM stated ""Order clarified for iron. Ferrous fumarate 100 mg chewable tabs PO BID (Twice Daily). Order posted"". A second note dated 6/27/11 stated ""Per pharmacy ferrous fumarate is no longer available in chewable tabs (tablets). Order (changed) to Ferrous Fumarate 106 mg PO BID"". A Nurse's Note dated 6/29/11 stated ""Order clarification per pharmacy-Ferrous Fumarate 324 mg 1 PO BID"". Review of Physician's Telephone Orders revealed orders for iron had been written as the Nurse's Notes documented. Review of communication notes to the Physician revealed an entry dated 6/26/11 to ""Please clarify ferrous 100 chewable"". Next to the entry was written ""may use fumarate"". Another entry dated 6/27/11 stated ""Ferrous Fumarate unavailable in chewable form. Order (changed) to Ferrous Fumarate 106 mg PO BID per pharmacy rec(ommendation)"". A third entry dated 6/28/11 stated ""Please clarify Ferrous order"". The Consultant Pharmacist provided documentation that the pharmacy had sent the facility a request to clarify the 6/23/11 order since they had been unable to find the 100 mg chewable tablet. She stated that the 106 mg was the elemental iron in the medication. She also stated that the Pharmacy had delivered Ferrous Fumarate on 6/27/11, but since the order that clarified the medication dosage had not been written until 6/29/11, the resident had not received the iron until 6/29/11. Record review of the Medication Record dated 7/1/11 through 7/31/11 revealed an entry for ""Coreg 25 mg Tablet, Take 1 Tablet By Mouth Twice Daily"", scheduled for 8:00 AM and 8:00 PM. The medication had been initialed as having been given for both doses on 7/25/11, however, the 8:00 AM dose on 7/26/11 has been circled and on the back of the record in the ""Nurse's Medication Notes"" was written ""7/26/11 Coreg unavailable- awaiting arrival from pharmacy"". There was no indication that the medication had been given for the morning dose on 7/26/11. Continued review of the Medication Record dated 7/1/11 through 7/31/11 revealed an entry for ""Ferrous Fumarate 324 mg PO BID"" (Twice Daily). The record indicated the resident had received Ferrous Fumarate as ordered on [DATE]. The dose scheduled for 7/8/11 at 8:00 AM had been circled with a notation on the back of the record which indicated the iron was not available for administration. There was no indication that the medication had been given for the morning dose on 7/8/11. During an interview on 8/3/11 at 10:08 AM, the Consultant Pharmacist verified the above Medication Record entries and notations that the medications had not been available. During an interview on 8/3/11 at 12:02 PM, the Pharmacist stated she would bring documentation form the Pharmacy which showed the 7/26/11 dose of Coreg and the 7/8/11 dose of iron had been delivered by the Pharmacy and should have been available at the time of Med Pass. Review of Delivery Manifests provided by the Consultant Pharmacist documented Coreg 25 mg #30 tablets had been delivered to the facility on [DATE] and again on 7/26/11 (in the evening). However, the medication had been ordered twice daily and only 30 tablets had been documented as having being delivered on the manifests for those dates. The manifest also documented that Ferrocite #30 tablets had been delivered to the facility on [DATE]. Review of the policy provided by the facility entitled ""Medication Ordering and Receiving From Pharmacy"" revealed that for repeat medications or refills that staff are to ""...Reorder medication three to four days in advance of need to assure an adequate supply is on hand...""",2014-11-01
9827,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,156,E,0,1,DO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of Medicare Notices and interview, the facility failed to provide the mandated Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) for three of three residents reviewed. Residents A, B, and C who had remained in the facility after having been taken off Medicare A with days remaining did not receive the required notice. The findings included: Review of the Notice of Medicare Provider Non-Coverage on 8/2/11 revealed Resident A's current skilled services had ended on 1/14/11. During an interview on 8/3/11 at 11:15 AM, Social Services (SS) stated Resident A had not used up her 100 days but had reached as much of her goal for therapy as possible and had moved back to her Long Term Care (LTC) bed. Review of ""Social Progress Notes"" revealed Resident A was transferred to a LTC bed on 1/17/11. According to SS, a SNF ABN had not been done for Resident A. Review of Resident B's Notice of Medicare Provider Non-Coverage on 8/2/11 revealed skilled services would end on 7/8/11. According to the Resident Status Report provided by the Business Office, Resident B had been admitted on [DATE] had used 44 of her 100 days. During an interview on 8/3/11 at 11:15 AM, SS stated Resident B had undergone short term rehabilitation and was discharged home after she had met all of her goals. The facility had not completed a SNF ABN for her. SS stated that Resident B's last covered day under Medicare A had been 7/20/11 and that she had been discharged home on[DATE]. She stated the family had paid privately for the resident to stay a couple extra days. According to ""Social Progress Notes"", Resident B had been discharged home on[DATE]. Review of the ""Billing and Census Changes"" for Resident B revealed Resident B had been changed from Medicare A to Private Pay on 7/21/11. Review of Resident C's Notice of Medicare Provider Non-Coverage on 8/2/11 revealed Resident C's current skilled services had ended on 5/19/11. A handwritten note in the ""Additional Information"" section documented that the resident's Power of Attorney and family waived the 48 hour notice and was anxious to stop therapy and return to a LTC bed. According to the Resident Status Report provided by the Business Office, Resident C had used 92 of her 100 days. During an interview on 8/3/11 at 11:15 AM, SS stated that the resident had been making progress in therapy and had been been moved to a bed upstairs on 5/20/11. A SNF ABN had not been completed for her. Review of ""Billing and Census Changes"" revealed Resident C had been changed from Medicare A to Private Pay on 5/20/11. Review of Social Progress Notes dated 5/22/11 revealed ""Res(ident) transferred to Unit 2 for LTC on 5/20/11..."".",2014-11-01
9828,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,315,D,0,1,DO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the policy provided by the facility entitled ""Foley Catheter Care"", the facility failed to ensure appropriate care and services for Resident #5, one of one residents reviewed with a catheter. The findings included: The facility admitted Resident #5 on 7/25/11 with [DIAGNOSES REDACTED]. Observation on 8/3/11 at 10:32 AM revealed Certified Nursing Assistant (CNA) #1 performing Catheter Care for Resident #5 with Licensed Practical Nurse (LPN) #1 assisting. CNA #1 washed her hands, applied gloves, and pulled the resident's sheet down and draped her with a towel. She assisted the resident to turn and placed a pad underneath the resident. With the same gloved hands CNA #1 dipped a 4 X 4 gauze into a basin partially filled with body wash/water and wiped down the catheter tubing. She then turned the 4 X 4 gauze to another area and wiped down the catheter tubing again. She did not hold the labia open and took another 4 X 4 gauze, dipped it in the basin, and wiped down the right side of the labia from front to back. She used another part of the 4 X 4 to wipe down the left side of the labia. With a dry 4 X 4, the CNA wiped down the right side of the labia and with another area of the 4 X 4 dried the left side. With a new dry 4 X 4 gauze, the CNA wiped down the catheter tubing. She picked up the basin and with the same gloves used for catheter care pulled the privacy curtain open and went into the bathroom to discard the water from the basin into the toilet. During an interview on 8/3/11 at 10:55 AM, LPN #1 verified the above. She stated she would have cleansed the labia first (not the catheter tubing), and would have disposed of each 4 X 4 after 1 wipe. She stated she would have cleaned and rinsed the labia first making sure to hold it open and then would have cleaned the catheter. Review of the policy entitled ""Foley Catheter Care"" on 8/3/11 at 11:00 AM revealed under ""Procedure ...4. Wash hands and put on gloves. Place towel/protective pad under buttocks. 5. Put soap on gauze sponges, or use catheter care kit. *For female- separate labia and cleanse perineal area from front to back (top to bottom) using one sponge for each stroke. (Do not allow labia to close until finished with rinsing.) Place soiled sponge in plastic bag. Then cleanse down the catheter tubing itself from the side nearest the resident, down the tubing toward the connector to the bag..."".",2014-11-01
9829,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,371,F,0,1,DO6P11,"On the days of the survey, based on observation and interview the facility failed to store, prepare, and serve food under sanitary conditions. The findings included: On 8/2/11 at 10:05 AM, the initial tour of the kitchen was conducted with the CDM (Certified Dietary Manager). It was observed in the walk in cooler that a bowl of pre-made tartar sauce was dated 7/29/11. The manager confirmed that the tartar sauce was made by the staff and was out of date. On 8/2/11 at 12:50 PM, a tour of the Unit 1 Pantry was conducted with the CDM. A black mold-like substance was observed on a pipe inside the ice machine. On 8/3/11 at 8:20 AM, a tour of the kitchen was conducted with the CDM. In the walk in freezer an open pie was not dated and a bag of french fries was opened and not labeled or dated. The slicer blade had 4 chips in the blade. The CDM confirmed all findings.",2014-11-01
9830,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,372,F,0,1,DO6P11,"On the days of the survey, based on observation and interview, the facility failed to contain garbage properly. The findings included: On 8/2/11 at 10:05 AM, the initial tour of the kitchen was conducted with the CDM (Certified Dietary Manager). It was observed that the dumpster and cardboard dumpster did not have plugs. Ants were observed going in and out of the plug hole. The CDM confirmed that the plugs were missing.",2014-11-01
9831,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2011-08-03,441,F,0,1,DO6P11,"On the days of the survey, based on observation, interview, and review of the facility policies entitled "" Policies and Procedures for Handling Soiled Linen"", "" Standard Precautions Infection Control"" dated 11/01/10 and "" Handwashing/Hand Hygiene Infection Control"" dated 11/01/10, the facility failed to provide an environment that protects residents from the transfer of communicable diseased based on the handling of soiled linen during laundry. The findings included: On 8/2/11 at 10:20 AM, observation of the laundry procedure was conducted with Housekeeper #1. A bag of soiled laundry was observed on top of a bin. Clean napkins were placed next to it uncovered and not in a container. Housekeeper #1 was observed placing gloves on her hands and then open a bag of laundry. She was not observed to wear an apron at any time. The housekeeper picked up each piece of soiled linen, shaking it over the plastic bags of soiled linen. The soiled linen came into contact with her shirt and arms. The laundry that she touched was linens, towels, wash clothes, sheets, and bed pads. After filling the washer, Housekeeper #1 started the washer and then removed her gloves and placed them in the trash. Without washing her hands, she then picked up a bin of clean napkins and brought the bin to the dryers. On 8/2/11 at 10:30 AM, an interview was conducted with Housekeeper #1. She stated that gloves and apron were kept on a shelf in the soiled laundry area. On 8/3/11 at 9:10 AM, an interview was conducted with the Housekeeping Supervisor. She stated that staff is expected to wear a gown and gloves whenever touching soiled laundry. She stated that staff is not suppose to sort laundry - they are suppose to just place the laundry straight from the plastic bags into the washer. All staff is expected to wash hands before entering the clean laundry area per the Housekeeping Supervisor. Per review of the policy entitled ""Policies and Procedures for Handling Soiled Linen"" copied on 8/3/11 at 9:30AM, it stated that ""... all personnel shall wear gloves and aprons when collecting, transporting, and handling soiled linen, when putting linen into washer's employees should hold away from clothing. All personnel to wash hands thoroughly after handling soiled linen."" Per review of the policy entitled ""Standard Precautions"" from Infection Control dated 11/1/10, which stated "" Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces...and wash hands immediately to avoid transfer of microorganisms to other residents or environments."" The policy also stated ""Handle, transport, and process linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contaminating of clothing, and avoids transfer of microorganisms to other residents and environments "" . Per review of the policy entitled ""Handwashing/Hand Hygiene"" from Infection Control dated 11/1/10, which stated "" Employees must wash hands....after handling soiled or used linens"" and ""after removing gloves or aprons; and after completing duty.""",2014-11-01
9832,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,241,E,0,1,3N8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the days of the survey, based on observation, interview, and record review, the facility failed to promote care for residents in a manner that enhances each resident's dignity during care of resident, personal body exposure, and in dining. Resident's # 1, #5, #6, and #18 were observed being treated in a manner which did not promote their dignity by staff based on 4 of 27 residents reviewed for dignity. Additional random observations were made throughout the days of the survey of residents being treated in a manner that did not enhance each resident's dignity in 3 of 5 units observed and in the main dining room. The findings included: On 4/11/11 at 10:20 AM, during initial tour of the 601 Ward, Resident #18 was observed in a low bed with a white t-shirt pulled up exposing his stomach and wearing an adult brief. The Licensed Practical Nurse (LPN) stood in the doorway looking at the resident while discussing him and did not enter room to cover the resident. Resident #18 was again observed on 4/11/11 at 6:07 PM, 4/12/11 at 9:15 AM, 4/12/11 at 10:00 AM in white t-shirt with adult brief showing from doorway. Review of the residents care plan on 4/11/11 at 1:30 PM, revealed that the resident required assistance with ADL (activities of daily living) care related to cognitive impairment and debility. The approaches included staff was to assist with dressing daily. On 4/11/11 at 10:30 AM, during initial tour of the 601 Ward, Resident #6 was observed seated in a Broda chair, with a catheter bag on the floor under the resident's chair. A CNA (Certified Nursing Assistant) entered the room, and without speaking to the resident reclined the residents chair causing the resident to jump and moan. On 4/11/11 at 4:00 PM, Resident #5 was observed in his Broda chair outside of the shower room. Certified Nursing Assistant (CNA) #7 was observed pulling an empty wheel chair out of the bathroom with one arm. The wheel chair crashed into the side of Resident #5's wheelchair causing the resident to jump. The CNA did not say anything to the resident and continued to pull the empty wheelchair. A random resident was observed on 4/11/11 at 1:20 PM in bed with gown on and adult brief visible from doorway. The same random resident was again observed on 4/11/11/at 3:20 PM in bed with gown on and adult brief visible while the family of the resident's roommate was in the room. On 4/11/11 at 3:35 PM, a random resident was observed being wheeled down the hall with his side and the side of his buttocks exposed while being transported to his room from the shower room. On 4/12/11 at 12:00 PM, CNA #6 was observed pushing a resident sideways down the hall in his Broda chair to the day room. On 4/11/11 at 5:50 PM, in the 601 Ward Day Room four staff members were observed sitting by the door talking to each other while residents were in the day room were eating their meals. During observation of the main dining room on 4/12/11 at 11:00 AM, two dietary staff members were observed eating lunch in the dining room while residents seated at tables next to the staff were waiting for their meals to be brought to them. Four tables were observed with all residents eating their meals except for one resident still waiting to be served. Eight staff members in the dining room were observed eating lunch while residents were in the dining room eating their meals. Only one staff member was available to assist residents at this time. Two tables closest to the staff table had one resident at each table eating alone. A random observation of the evening meal on 4/11/11 at 5:10 PM revealed 19 or more residents seated at different tables in the main dining room with one CNA (Certified Nursing Assistant) serving trays. The Dietary Manager was also present during the meal observation. The dining tables had 2 to 4 residents seated at a table. The CNA was observed randomly delivering trays to the designated resident as the trays were taken off the food cart. There were no observations of the CNA serving all of the residents at the same table before serving another table. One resident was heard speaking to a fell ow resident at a different table and stated ""You finally got your food?"" and the other resident responded ""About time, I didn't think I would get served."" A random observation on 4/12/11 at 10:10 AM revealed CNA #4 in the hallway on Ward 603 with a resident in wheelchair near the nurses station and shower room. CNA #4 stated the resident was transported from room [ROOM NUMBER]. The resident was seated in a wheelchair with the back of a hospital gown open, exposing the residents back and brief. The surveyor asked the CNA to look at the resident from behind and asked if the CNA was aware that the resident was exposed? The CNA responded that he/she was aware the resident was exposed and stated ""I was in a hurry to get her to the shower"". There were male residents seated around the nursing station. CNA #5 was also present and witnessed the resident being exposed to other residents around the nursing station. CNA #5 stated he/she was aware it was a dignity issue and instructed CNA #4 to take the resident back to room and cover the resident. The facility admitted Resident #1 on 11/27/07 with [DIAGNOSES REDACTED]. Record review on 4/11/11 revealed a Quarterly MDS (Minimum Data Set) dated 3/01/11 and Annual MDS dated [DATE] that indicated the resident had memory problems and severely impaired cognitive skills for daily decision making. During lunch meal observation on 4/12/11 at 12:25 PM, Resident #1 was noted in his/her room (Ward 602) in a Broda chair not served or eating while his roommate was served and eating with the bed curtains opened. CNA (Certified Nursing Aide) #8 was asked when the food arrived on the unit? CNA #8 stated ""The cart arrived on the unit at 11:50 AM."" At 12:30 PM a second food cart was observed being transported to the unit. During an interview on 4/12/11 at 12:33 PM CNA #9 stated Resident #1 food tray was on the first cart when questioned as to where was the resident's food tray. CNA #8 quickly responded and stated the resident's food tray was not on the first cart. The staff transferred Resident #1 to the day room at 12:40 PM after requesting another food tray from the kitchen. CNA #8 was observed standing while feeding Resident #1 until another CNA instructed the CNA to get a chair and sit while feeding the resident. On 4/12/11 at 12:42 PM a staff member delivered a tray from another unit and stated Resident #1's food tray was delivered to the wrong unit. A random observation on 4/12/11 at 9:30 AM with LPN #1 (Licensed Practical Nurse) revealed a female resident in the shower room on Unit 603. The female resident was on the right side of the shower room away from the shower stall with a CNA (Certified Nursing Assistant). The resident was standing by the wall completely unclothed. The privacy curtain was not pulled while the CNA was proceeding to dress the resident. There were 2 other CNA's next to the resident emptying soiled linens from a barrel into a cart. No privacy was provided for the resident; and when the door was opened the resident could be seen from the hall. The LPN confirmed the incident in the shower room and stated. ""That was unfortunate. I did do an inservice with those staff on providing privacy and dignity for the residents. The current privacy curtains will also be replaced with longer curtains."" Multiple random observations on Unit 605 on two days of the survey revealed residents in both Day Rooms and the hall watching other residents eating while they were waiting for their food trays or waiting to be fed. Observation of the second Day Room on 4/11/11 at 5:30 PM revealed 4 residents (3 in geri-chairs) seated against the wall in the Day Room watching while other residents were being served their dinner trays at the tables. Observation of the first Day Room at 5:33 PM revealed one resident sitting in a wheelchair against a wall while other residents sat at the tables and ate. Observation of the first Day Room at 5:46 PM revealed the one resident still sitting in his wheelchair against the wall. Another resident (who had not eaten yet) had come in from the hall and was sitting on a couch, and another resident in a wheelchair was sitting in the corner of the room watching others eat. Observations of the corridors of Unit 605 at 5:50 PM revealed 12 plus residents sitting in chairs/wheelchairs watching other residents eat their dinner in the hall. Observations of the second Day Room at 5:52 PM revealed the three residents in geri-chairs still waiting to be fed while other residents finished eating. Observations at 6:05 PM of the second Day Room revealed the 3 residents in geri-chairs still waiting to eat after the first dining service was finished. At 6:09 PM the second tray cart arrived on the unit for the 2nd dining service. At 6:25 PM, two residents in geri-chairs were still against the wall waiting to eat, the one other resident in a geri-chair was seated next to the table, all were still waiting to be fed. At 6:32 PM observations of the second Day Room revealed the last resident to eat (resident sitting in geri-chair against the wall) being fed by staff. Observation of the second Day Room on 4/12/11 at 12:20 PM revealed 1 resident in a wheelchair and 1 resident in a geri-chair watching other residents eat while waiting to be fed. During an interview on 4/13/11 at 10:00 AM, Licensed Practical Nurse (LPN) #1 verified there had been residents in the Day Rooms and corridors of the unit watching others eat on 4/11/11 and 4/12/11. She stated that residents were taken out of the Day Rooms that morning and placed in the hall way so they weren't sitting watching other residents eat. She stated that the first tray cart contained the meal trays for those residents who could feed themselves, and the meal trays for the residents needing to be fed were on the second tray cart. The nurse indicated that some of those residents observed were the ones waiting to be fed and in the geri-chairs against the wall.",2014-11-01
9833,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,248,E,0,1,3N8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews, and review of the facility's activity calendars, the facility failed to provide an ongoing structured program of activities to meet the mental, physical, and psychosocial needs for residents in 4 of 5 units observed (Unit 601, 602, 603, and 605) and for 6 of 27 sampled residents reviewed for activities (Residents #4, #5, #6, #8, #10, and #18). The findings included: The facility admitted Resident #10 on 12/29/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Observations on two days of the survey on Unit 605 revealed music playing in one Day Room, and a television playing in the second Day Room and the hallway; but no structured program of activities or group activities (large or small) provided for Resident #10. Observations on Unit 605 on 4/11/11 at 1:30 PM revealed Resident #10 sitting in the Day Room in his wheelchair with country music playing. Continued observation from 2:52 PM to 3:40 PM revealed the resident sitting in the same Day Room with his head tilted forward and eyes closed. At 4:20 PM, the resident remained seated in the Day Room with music playing. Observation at 5:20 PM revealed the resident eating his dinner in the same Day Room. Observations on 4/12/11 from 9:33 AM to 10:33 AM revealed Resident #10 sitting in his wheelchair in the Day Room. Country music was playing and his head was down and eyes closed. At 10:33 AM a staff member came with a brief in her hand to take him to his room. The resident returned to the Day Room at 10:45 AM. No structured activities were noted going on during these times on the unit or offered to the resident. At noon, the Resident was observed leaving the Legion dining room after having eaten. Review of the Annual Minimum Data Set assessment dated [DATE] revealed a staff assessment of activity preferences for Resident #10. According to this assessment, Resident #10 preferred reading books, newspapers, or magazines; listening to music, being around animals such as pets, doing things with groups of people, participating in favorite activities, spending time outdoors, and participating in religious activities. His annual note dated 3/10/11 stated ""(Resident) continues to be assessed as needs activities for social interaction...He attends on/off unit activities like music therapy, snack time, w/c (wheelchair) rides, singing, religious services. (Resident) sits at the nurses station and watches TV and at times he sits in the day (with) other peers listen to music..."". Review of the comprehensive Care Plan for Resident #10 revealed ""Resident needs activities for social interaction"". The goal listed was that the ""Resident will be receptive to 1-2 group invitations per week thru next review date"" and included approaches to ""Visit routinely to maintain rapport, Assure resident of our help and concerns, Play gospel/calming music for resident, Activities as tolerated, Encourage resident to attend group activities of interest, Attending group music therapy, preaching services, and looking at magazines"". During a phone interview on 4/13/11 at 11:45 AM, the resident's family member stated she visits once a week and stated that when she is there she doesn't see any type of activities going on in the unit. Review of activity documentation for resident participation for March 1st through April 11th 2011 revealed the resident had attended a ""Spiritual/Religious"" and an ""Off Unit Music"" activity 6 times each for the time period, approximately once weekly. He was marked as attending an ""Outing Visit"" for 8 days throughout the time period. He attended a ""Party"" on 2 days, had a ""Special Event"" on 2 days, and had ""Music Therapy"" and ""Pet Therapy"" for one day each. The resident had been marked for daily ""Resident Visits"", ""On Ward Music"", ""Snack Time"", and ""TV"". The facility admitted Resident #4 on 3/21/11 with [DIAGNOSES REDACTED]. Review of the Admission MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #4 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Observation on 4/11/11 at 1:34 PM revealed a staff member pushing the resident down the hall in his wheelchair. Observation at 2:32 PM revealed the resident sitting in the hallway in front of the nurse's station attempting to get up out of his wheelchair. Observation on 4/12/11 at 9:20 AM revealed Resident #4 in bed. Observation at 11:06 AM revealed the resident sitting in the second Day Room. The TV was playing but the resident was not watching or involved in any type of socialization or activity. Observations during two days of the survey revealed no structured program of activities or group activities provided on unit 605 for Resident #4. Review of Activity documentation on 4/13/11 revealed an ""Initial Note"" dated 4/7/11 which stated that the resident had made furniture and walked after retirement. It stated ""Resident likes coffee, tea, use(d) to bowl and golf. He enjoys different types of music. Activity staff will observe resident and talk (with) caregivers to meet residents needs. After assessing resident his care plan will be as follow(s): Resident needs space and time to adjust to facility. Plan of care will continue thru next review"". According to his ""Background Information"" dated 3/21/11, the resident's current activity interests included walks, sports (bowl/golf), music, spiritual/religious, walking outdoors, watching movies, gardening, talking, parties/social events, and radio. Review of the comprehensive Care Plan for Resident #4 revealed ""Resident needs time and space to adjust to facility. Staff to offer consistency, balance, and assistance"". The goal was ""Resident will accept recreational group invitations or staff visits 2-3 times per week thru next review date"". Approaches included ""Invite/encourage and assist resident to programs of potential interest. Observe positive interactions to repeat success, Explain staff goals to promote social and recreational programs, Activities as tolerated, Look for signs that would indicate that resident is ready for higher level of involvement, Compliments for participation and efforts"". Under approaches to be used to keep the resident free from complications related to Depression, the Care Plan listed ""...Engage resident in dayroom activities, music therapy, snacks, reminiscing about sports"", and to ""Discuss preferences with daughter"". An approach listed for the resident to have no decline in mood, behavior, or ADL status due to long term placement was ""Provide activities of resident's choice/liking to provide them with contentment, Visits 1:1 PRN (As needed)"". Review of documentation of ""Individual Resident Daily Activities"" dated March 22, 2011 through April 12, 2011 revealed daily documentation of ""Resident Visits, On Ward Music, TV, and Snack Time"". Two days each were marked for ""Off Unit Music"", Spiritual/Religious, and ""Choir Practice""; 5 days were marked for ""Outing Visits"", and one day each marked for ""Socializing"", ""Party"", ""Music Therapy"", and ""Special Events"". During an interview on 4/12/11 at 9:25 AM, Nursing Assistant (NA) #1 stated her job was sit with residents in the Day Room and to monitor them to prevent them from falling. During an interview on 4/12/11 at approximately 9:50 AM, Licensed Practical Nurse (LPN) #2 stated that the residents watch TV in the Day Room and hall or listen to music in the other Day Room. She stated that NA #1 did activities (Ball Toss and Puzzles) with the residents in one of the Day Rooms. She stated that there are two Activity Assistants that take care of activities on the unit. Observation at 9:55 AM revealed NA #1 sitting on the couch in the second Day Room. The TV was on but no activities were taking place. She stated she had just finished playing ball and was waiting for someone to unlock the cupboard so she could get coloring items out. Multiple residents were observed sitting around tables, some had their heads down and eyes closed. When asked about other activities, NA #1 and LPN #2 stated there was a TV in the hall along with the one in the Day Room on which residents watched TV and movies. Observation on 4/12/11 at 11:15 AM of the second Day Room revealed 7 residents, 2 with eyes open and 5 with eyes closed resting. No activities were observed in progress. Random observations on Unit 605 from 1:46 PM to 2:38 PM revealed no structured individual or group activities provided for the residents. Observation at 2:38 PM revealed 7 residents in the first Day Room and 12 residents in the hall sleeping, sitting, and/or looking out the window. During an interview on 4/12/11 at 11:14 AM, Activity Assistant #1 explained that room visits were a brief visit by the activity assistant to let each resident know what the activities are for that day. When asked about any activities on the unit she stated sometimes they have Bingo in the middle of the ward, residents watch movies or TV, play musical instruments that residents shake and play, and sometimes they go out in the yard. She stated they liked to take the residents off the unit. During an interview on 4/13/11 at 10:15 AM, LPN #2 stated that the residents on the unit wander, and that staff try to do one on one with them, but that you ""can't get them to do a whole lot"". She stated the residents liked to go outside, and that at times an activity assistant or a CNA (if they got done with their work early) would take several residents outside. She stated that she rotated only 5 or 6 residents at a time because someone had to be with them. She stated it was a little chilly yesterday for them to go out, but verified that on 4/11/11 the weather was nice but no residents were observed going outside. She stated the Activity Calendar posted in the hall was for the whole facility and was not unit specific, and that it had been provided for families to participate if they desired. She stated that the activity assistants take residents off the unit approximately 3-4 times a week. She stated the unit did not have it's own activity calendar for any activities provided on the unit. Review of the facility Activity Calendar for April 11, 2011 revealed the following: 8:30- Activity Room Opens with Coffee & News, 9:00 - Resident Visits, 10:00- Choir Practice, 2:00 - Rev. xxx, 6:30 - Movie & Popcorn. The Activity Calendar for April 12, 2011 revealed 8:30- Activity Room Opens with Coffee & News, 9:00- Resident Visits, 2:00 - Bessie Baptist, 6:30- Pastimers. During an interview on 4/13/11 at 12:15 PM, the Activities Director stated that the ""Resident Visits"" included on the ""Individual Resident Daily Activities"" log were the activity assistant visits in the morning to all residents to just touch base with them and let them know what activities would be provided that day. She stated that ""Outing Visits"" would include going out into the yard, and that ""Snack Time"" was a snack for the residents. When asked about activities on Unit 605, she stated that there was a NA in one of the Day Rooms and her job was to provide activities for the residents. She stated that each resident should get approximately 15-30 minutes of activities. When told that observations on Unit 605 on April 11th and 12th revealed no structured activities taking place, she stated that she knows the activity assistants give the NA activities for the residents to do. She stated there was no calendar or log of structured activities taking place for the lower functioning residents on that unit. The facility admitted Resident #8 on 6/10/10 with [DIAGNOSES REDACTED]. Record review on 4/11/11 revealed a Admission MDS (Minimum Data Set) dated 6/25/10 and a Quarterly MDS dated [DATE] that indicated the resident had memory problems with impaired cognitive skills for daily decision making. Random observations on 4/11/11 from 10:40 AM to 6:15 PM revealed Resident #8 in room in bed wearing bed gown with no structured activities in progress. Random observation on 4/12/11 from 8:45 AM to 3 PM revealed resident in room in bed wearing gown with no structured activities in progress. The television was not playing and there was no music provided. An interview on 4/13/11 at approximately 11:45 AM with the Activity Director (AD) revealed Resident #8 did not receive one to one activities because the resident sits at the nurses's station with other residents and watches people as they pass by. The AD further stated Resident #8 had been in bed all day on 4/11/11 and 4/12/11 because he had not been feeling well. The AD stated Resident #8 did participate in bible study today (4/13/11). Review of the resident's care plan with the AD revealed the resident enjoyed ""singings, outside when weather permits, bible study."" No of the activities listed on the care plan was provided on 2 days of the survey as confirmed by the AD. Random observations on 4/11/11 at 1 PM to 2:30 PM of Ward 603 revealed 5 to 6 residents seated in front of the nurses' station with no structured activities in progress. The residents were noted with the heads down, eyes closed and/or mouth opened. There was a television playing above the nurse station positioned/facing the middle of the hallway. None of the residents were watching the television and there was not staff interaction other the placing more residents in front the nurses station and taking residents to receive activities of daily living care. Random observations on 4/12/11 at 8:40 AM to 11 AM of Ward 602 and 601 revealed the television was used as a program of activities for resident placed in the day/activity rooms. On Ward 602 on 4/12/11 at 9:05 AM AA (Activity Assistant) #3 asked a group of 9 resident placed in the day area what the wanted to watch on television. One resident requested the sports channel and the AA stated - "" Let's watch some country music video"". The country music video activity continued from 9:05 AM until 11 AM. There was no staff interaction observation other than removing residents for ADL (activities of daily living). The observed activity on ward 601 was residents watching a black and white television show ""Daniel Boone"" or a video created by the facility in which some of the staff and residents were on the video. Resident #5 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was not observed participating in any activities on 4/11/11 and 4/12/11. On 4/11/11 at 1:45 PM, review the resident's care plan for activities stated that the resident requires 1:1 activities for social interaction. Approaches included: music in residents room, hand massage, pet therapy, praise resident for all efforts, visit resident daily. Review of the activity 1:1 logs for 2/2011, 3/2011, and 4/2011. which revealed that 1:1 visits were documented on an activity calendar with the activity but no there was no documentation about the visit. The last documentation from activities was a quarterly review on 2/14/11. Resident #6 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was not observed in any structured activities on 4/11/11 and 4/12/11. Review of the resident's care plan on 4/11/11 at 2:20 PM, revealed that the resident would be involved in activities as tolerated, invited/encouraged and to assist resident to programs of potential interest, promote social and recreational programs. Resident #18 original admission was on 4/1/09 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Resident was not observed in any structured activities on 4/11/11 and 4/12/11. On 4/11/11 at 1:30 PM, review of the care plan dated 3/7/11 documented the resident needs activities for social interaction. The approaches included: activities as tolerated, inform resident of all activities as scheduled, visit routinely to maintain rapport, assist resident to activities, invite and encourage resident to off unit activities. An interview with the Activities Assistant #2 was conducted on 4/12/11 at 9:18 AM. She stated that her 1:1 activities consisted of music in the room, watching movies, and hand massages. She stated that Resident #18 was able to do activities before but that he was currently in the hospital. She stated she was unaware that he had returned to the facility. She stated that when residents come back from the hospital they are reassessed whenever their next care plan review is scheduled. Resident #18 last care plan review was in March 2011 and was not due for 3 months from that date. An interview with the Activity Director was conducted on 4/13/11 at 11:45 AM. She stated that residents that go to the hospital are only reassessed if they come back to the facility with a significant change. Otherwise, they will be seen at their next care plan review. She stated that the Department Heads go to meetings every other day to discuss residents and then she told her activity assistants when a resident returned. She stated that her activity assistants visit each resident every morning to let them know what activities are available. She stated that she will checks on Activity Assistants to see if they are doing visits but does not make any documentation. The Activity Director stated that documentation of visits is only quarterly and the Activity Assistant does not document 1:1 visits.",2014-11-01
9834,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,249,E,0,1,3N8Y11,"On the days of the Recertification survey, based observations and interview, the facility failed to ensure that the Activity Director implemented and monitored the provisions of the activity program for residents that could not or would not participate in structured program of activities. The findings included: An interview on 4/13/11 at approximately 11:45 AM with the Activity Director (AD) revealed there were no formal instructions given to the AA (Activity Assistants) of each Ward (601-605) regarding how one to one activities should be documented. The AD stated verbal instruction were given and the AA were to follow the individual care plans. The AD stated he/she relies on the AA to keep him/her informed of what was happening on each unit. The AD further stated they are doing things with the residents each day like talking and conversation. Review of the activity calendars for February, March and April of 2011 revealed at 9 AM every day the AA provide short one to one activities called ""resident visits"" which entails (per the AD): The AA will greet residents, see if they need anything and inform them of the activities for the day. When asked how the lower functioning resident would know about daily activities, the AD stated a large activity calendar was located on each unit. The AD stated the outing were provided to residents. In reviewing the activity calendars with the AD it was revealed that outings were unplanned at times there was no structured system in place to ensure that all residents that were physically/mentally able had the opportunity to participate in outings. The AD then stated some outings were provided based on requests by the residents. The AD stated that all the activities on each unit should work the same. Based on observations on 4/11-12/11 there was no evidence observed that structured activities were in place.",2014-11-01
9835,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,325,D,0,1,3N8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, the facility failed to ensure that a 1 of 13 sampled residents on a therapeutic diet received the diet as ordered. Resident #8 was on a mechanical soft diet and was to receive fortified foods on all meals with gravy on all meats that was not followed. The findings included: The facility admitted Resident #8 on 6/10/10 with [DIAGNOSES REDACTED]. Record review on 4/11/11 revealed a Admission MDS (Minimum Data Set) dated 6/25/10 and a Quarterly MDS dated [DATE] that indicated the resident had memory problems with impaired cognitive skills for daily decision making. Further record review revealed a physician order [REDACTED]."" Observation of dinner meal on 4/11/11 at 6:10 PM revealed Resident #1 received chopped chicken, yellow and green vegetable mix, noodles, tea, milk, jello and roll. There was no gravy noted on the meat and no fortified food provided as ordered. CNA (Certified Nursing Aide) #11 confirmed the observation and stated the vegetable mix was squash. Observation of the lunch meal on 4/12/11 at 11:35 revealed the resident received tea, pie, chopped meat loaf, scalloped potatoes, green beans, bread, pudding butter and no gravy on the meat. CNA #5 confirmed the observation. On 4/13/11 at 10 AM, an interview with the Certified Dietary Manager was conducted. He stated that fortified foods consist of oatmeal at breakfast and pudding with lunch/supper. He stated that if a resident did not like or want pudding then the resident would get a fortified cookie instead.",2014-11-01
9836,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,371,F,0,1,3N8Y11,"During the days of the survey, based on observation and interview, the facility failed to store, prepare and serve food under sanitary conditions. Staff personal items were observed on the tray line, the vent of the ice machine was dusty, items on the salad bar were held at improper temperatures, kitchen equipment was in disrepair, and food items were unlabelled and undated. The findings included: On 4/12/11 at 11:00 AM during observation of tray line, it was observed that under the tray line was a purse with staff shirt draped over it touching tray pans. The tray pan was then used to place food items on it. The vent on the ice machine was observed to be dusty. Temperatures were taken on the salad bar. The pistachio salad was 43 degrees, sour cream was 44 degrees, and chicken salad was 42 degrees. Other cold items were pulled from the salad bar before a temperature was taken. The facility pulled the out of temperature items but did not have replacements to serve residents. Multiple plate lids and bottoms were observed to be very worn, cracked, and warped. Four plastic containers of applesauce in walk in cooler were undated. In the walk in freezer, five bags of previously opened foods were not labeled or dated. A package of pie crust was opened but not covered in the walk in freezer. The blade on the Robo Coupe had chips on various parts of the blade. A staff purse was observed under the tray line during tray line setup. The Certified Dietary Manager confirmed that staff personal items should not be in tray line area.",2014-11-01
9837,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2011-04-13,441,D,0,1,3N8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, facility staff failed to clean dining/overbed tables between resident use. There was one random observation of a staff member handing peeled banana pieces to residents using her bare hands. The findings included: Observations during lunch service on 4/12/11 on Unit 605 revealed staff using residents' overbed tables to transport food trays from the tray cart located outside the second Day Room to residents in both Day Rooms and to residents eating in the halls. Observation of the first Day Room on 4/12/11 at 12:12 PM revealed residents sitting at both tables eating lunch. At 12:15 PM, one resident left the table. The staff member moved the food tray the resident had eaten off of to the side of the the table and seated another resident at his empty spot and served this resident his food tray without cleaning off the table first. Food trays that had been eaten off of and left by residents were placed on overbed tables and wheeled to and placed on an empty tray cart next to the tray cart containing the second service of food trays for the second lunch dining. Staff were observed then serving new lunch trays to residents on these same overbed tables without cleaning them in between. Observations at 12:32 PM revealed a staff member removing an overbed table from Day room [ROOM NUMBER] that a resident had just eaten off of and placed it in room [ROOM NUMBER] without cleaning it first. Observation at 12:34 PM revealed a staff member (CNA #1) requesting an overbed table from another staff member. The 2nd staff member brought a visibly soiled overbed table (with food spills) into the Day Room and the first staff member placed a new food tray on it and fed a resident off of it. At 12:38 PM, a staff member transported 2 food trays residents had eaten off of by using an overbed table and transferred them to the used (dirty) tray cart. She placed a new clean tray from the other cart onto the same overbed table without cleaning it in between and sat down and started feeding a resident from it. At 12:47 PM, staff were observed placing overbed tables randomly into residents' rooms on the unit without cleaning them first. These same overbed tables had been used to transport multiple used food trays and also had been used for residents who had eaten their meals off them in the hallways and Day Rooms. During an interview on 4/12/11 at 1:10 PM, Certified Nursing Assistant (CNA) #3 stated that the overbed tables had been cleaned in the morning after breakfast by housekeeping. She stated that staff take whatever overbed tables are available from the residents rooms and used these to serve the residents their meals. She stated she did use regular soap and water and also used wipes to clean off the tables and clean the faces and hands of the residents after eating. She stated she usually cleaned the tables off before putting them in the residents' rooms but verified she hadn't cleaned them today before placing them in their rooms. During an interview on 4/12/11 at 1:15 PM, CNA #1 stated that housekeeping cleaned the overbed tables in the morning before and after breakfast. She stated that staff did not do any cleaning of the tables while serving food. She stated once all the food trays had been served they would clean tables afterwards. She pulled a bottle of hand sanitizer out of her pocket and stated she squeezed sanitizer on the overbed tables while she put them in residents rooms and cleaned them with a paper towel. She stated that staff sometimes used wipes to clean the tables, but that there were no wipes available on the unit that day so she could not use them. She did not remember not cleaning the visibly soiled overbed table before feeding Resident #4 off of it in the second Day Room. Observation on 4/11/11 at 5:39 PM revealed a staff member handing pieces of a peeled banana to two residents in geri-chairs in the second Day Room on Unit 605 using her bare hands. Observation in the hall of Unit 605 outside the Day Room revealed the staff member handing part of a peeled banana to a resident in a wheelchair using her bare hands. During an interview on 4/13/11 at 8:35 AM, the staff member verified she had given the residents the banana pieces using her bare hands. She stated she didn't leave the peel on since the residents may eat the peel. She didn't want to use gloves since she didn't think they could be used outside patient care areas. On 4/11/11 at 5:30 PM, a Certified Nursing Assistant (CNA) was observed taking a bedside table out of a residents room that was visibly dirty. The CNA then took the table to another residents room and placed a new meal tray on it. On 4/12/11 at 11:30 AM, during the main dining room lunch service, Activities Assistant #2 was observed clearing dirty trays off of tables. The Activities Assistant #2 who did not sanitize her hands, was observed to touch a resident on the arm, get the resident a drink, and then served a bowl of soup and a tray of food to a resident. The Activity Assistant was observed to remove a dirty tray from a table covered with a table cloth. She then placed a new resident in the same spot at the table and provided that resident with a tray. The table cloth was not removed after the previous resident left the table.",2014-11-01
9838,GRAND STRAND HEALTHCARE,425323,4452 SOCASTEE BLVD,MYRTLE BEACH,SC,29588,2011-05-04,322,D,0,1,SPDG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to provide the water flush as ordered for Resident #8, 1 of 5 residents reviewed for PEG (Percutaneous Endoscopic Gastrostomy) tube flushes. The findings included: The facility admitted Resident #8 on 4/15/11 with [DIAGNOSES REDACTED].#1 stated she had already measured the water for the flush, (50 ml. (milliliters.) LPN #1 was asked to re-measure the flush for observation of the amount of water being administered and she measured 50 ml. into a cup. During the observation, 50 ml of water was observed being administered. On 5/3/11 at 3:55 PM, record review revealed orders on the April and May monthly physician's orders [REDACTED]. Further review revealed the tube flush was listed on the April and May MAR (Medication Administration Record) as 150 ml of water every 4 hours. Review of the MAR indicated [REDACTED]. Additional review revealed the resident was receiving antibiotic therapy since 4/27/11 for a urinary tract infection. On 5/4/11 at 9:40 AM, LPN #1 confirmed that she administered 50 ml of water during the observation and stated that 50 ml was what she had been giving the resident. RN (Registered Nurse) #1 confirmed the order was for 150 ml of water and that the order on the MAR indicated [REDACTED]",2014-11-01
9839,GRAND STRAND HEALTHCARE,425323,4452 SOCASTEE BLVD,MYRTLE BEACH,SC,29588,2011-05-04,225,D,0,1,SPDG11,"**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 to all appropriate State agencies (Bureau of Certification) an injury of unknown origin for 1 of 1 residents reviewed for an injury of unknown origin (Resident 14). The findings included: Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 5/3/11 at approximately 4:45pm revealed Nursing Notes dated 4/20/11 at 12:47 PM:.."" resident noted with generalized swelling to left forearm and hand. no increased warmth or redness, some faint discoloration noted to inner aspect of left hand."" physician's orders [REDACTED]."" A Discharge Summary from the hospital dated 4/22/11 stated under the section ""PROCEDURES: 1. Left elbow three views on April 20: Elbow joint effusion. Proximal radial head fracture, suspected....HOSPITAL COURSE: Orthopedic Surgery was consulted, and her left arm was placed in splint for radial head fracture."" The Consultation Report from the hospital dated 4/20/11 was also in the record and stated ""REASON FOR CONSULTATION: Left radial head fracture."" The MEDICAL HISTORY AND ADMISSION EXAMINATION completed on 4/27/11 by the facility stated ""fx (fracture) L proximal radial head."" A Minimum (MDS) data set [DATE] stated under section C. Brief Interview for Mental Status a score of 9 indicating moderate impairment. Interview on 5/3/11 at approximately 5:40pm with the Director of Nursing (DON) indicated the resident was incapable of telling how the injury occurred. As far as the facility was aware, no incident had occurred which may have caused the fracture, therefore the injury was unwitnessed. When asked why the facility did not report the incident to the Bureau of Certification, it was stated that they felt the injury did not meet both criteria outlined in S&C (Survey and Certification)Transmittal 05-09 (""Injuries of unknown source"") The DON felt the injury was not suspicious because of the location of the injury and felt a fracture was not an extensive injury. Interview on 5/4/11 at approximately 11:50am with the Administrator indicated that the fracture was not reported as he also felt it did not meet both criteria outlined in S&C Transmittal 05-09. He did feel the injury was of unknown origin because the injury was unwitnessed and the resident could not tell what happened to cause the injury, but did not consider the fracture an extensive injury.",2014-11-01
9840,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2011-05-04,281,E,0,1,RTYI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, review of manufactures specification and interview, the facility failed to maintain professional standards related to the application of medication patches for 3 of 3 residents receiving [MEDICATION NAME]es. Resident's A, # 3 and # 9 all received [MEDICATION NAME]es which were not rotated per the manufactures specification. The findings included: The facility admitted Resident # 9 on 2-14-09 with [DIAGNOSES REDACTED]. Review of Medical Record revealed Resident # 9 was prescribed [MEDICATION NAME] 9.5 mg Patch to be applied daily. Review of the MAR for February, March and April revealed that while the location was rotated to different sites, it was not done according to the recommended rotation of the manufacturer. Multiple entries were made for the same location, as many as 9 per month and many of the sites were unreadable. The facility admitted Resident # 3 on 12-14-10 with [DIAGNOSES REDACTED]. During observation of medication pass on 5-3-11 at approximately 9:00 AM, Licensed Practical Nurse (LPN) # 3 was observed to remove an [MEDICATION NAME] Patch from the left upper arm and apply a new [MEDICATION NAME] Patch 4.6 mg (milligram) to the right upper mid arm. Review of the Medication Administration Record [REDACTED]. Multiple entries were made for the same location, and on some days the location of the patch was not identified. During observation of medication pass on 5-3-11 at approximately 10:00 AM, Resident A was observed to receive an [MEDICATION NAME] Patch 9.5 mg, LPN # 3 was observed to remove the old patch from the right back area and the new patch was applied in a lower area of the right back. Review of the MAR for March and April revealed that while the location was rotated to a total of 3 different sites, it was not done according to the recommended rotation of the manufacturer. Multiple entries were made for the same location and 26 sites were unreadable. When questioned by this surveyor about the placement of the patches, LPN # 3 stated that she rotated them daily to a different location. She was not aware that each site should be used only once every 14 days. During an interview with the Director of Nursing on 5-3-11 at approximately 5:00 PM, he stated he was unaware that the [MEDICATION NAME] Patch should not be applied to the same area for at least 14 days. Review of the manufacturer's prescribing information for the [MEDICATION NAME] Patch revealed the following statement: ""[MEDICATION NAME] Patch should be applied once a day to clean, dry, hairless, intact healthy skin in a place that will not be rubbed against by tight clothing. -- The patch should be replaced with a new one every 24 hours. Do not apply a new patch to that same spot for at least 14 days. Patients and caregivers should be instructed accordingly.""",2014-11-01
9841,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2011-05-04,323,D,0,1,RTYI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review, observation, and interview, the facility failed to ensure 2 of 2 residents who smoked received adequate supervision to prevent accidents (Residents # 1 and #7). There was documentation in the medical record of Resident #1 and also an observation during the survey of unsupervised smoking. There was 1 observation of Resident #7 smoking unsupervised. The findings included: The facility admitted Resident #7 on 9/21/10 with [DIAGNOSES REDACTED]. The resident was identified by the facility as interviewable, although her recent quarterly Minimum Data Set (MDS) assessment of 3/14/11 documented her Brief Interview for Mental Status (BIMS) as 99 (unable to interview). A smoking assessment dated [DATE] determined the resident was an unsafe smoker and needed constant supervision while smoking. The resident was observed twice on 5/3/11 with appropriate supervision. On 5/4/11 at approximately 10:00 AM, the resident was observed in the smoking area unsupervised and not wearing a smoking apron. An observation was made shortly after 10:00 AM of the resident being signed out of the facility by her nephew. Interview with the Director of Nursing (DON) on 5/4/11 at 12:20 PM revealed he hadn't had a chance to talk with the nephew, but believed he was the one who gave her the cigarette. There was no additional documentation in the nursing notes from 12/8/10-4/30/11 of any inappropriate smoking. The facility admitted Resident #1 on 2/14/11 with [DIAGNOSES REDACTED]. The Resident's Admission MDS documented the resident's BIMS as ""12"" or moderate cognitive impairment. A smoking assessment dated [DATE] determined the resident was an unsafe smoker and needed constant supervision. On 5/3/11 at 2 PM (a scheduled smoking time), the resident was observed in the smoking area with 2 other residents (from Assisted Living) unsupervised and without wearing a smoking apron. At 2:10PM, a staff member came out with the smoking aprons and smoking materials and counseled Resident #1 about waiting. Another observation of the smoking area at 4:15 PM revealed Resident #1 being supervised. A review of the nursing notes from 2/14/11-4/27/11 documented on 3/16/11 at 7:30 PM ""Res. discovered in courtyard smoking a cigarette. CNA brought resident back in facility. Nurse reminded him that he should not go outside without staff present and was reminded of designated smoke break times. Res. verbalized understanding."" An interview with the DON on 5/3/11 at 4:00 PM revealed a resident from Assisted Living (AL) had given Resident #1 a cigarette and lit it. The DON stated the AL residents had been repeatedly told not to give skilled residents cigarettes. This information was also in the AL admission packet and was posted.",2014-11-01
9842,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2011-05-04,314,D,0,1,RTYI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to provide care and services to promote healing for 1 of 1 residents observed for pressure ulcers, (Resident # 1). Concerns were identified related to not cleaning scissors, cleaning repeatedly over the same area with contaminated material, storing supplies on the treatment cart that had been used for a treatment. The findings included: The facility admitted Resident # 1 on 2-14-11 with [DIAGNOSES REDACTED]. An admission assessment of Resident # 1 on 2-14-11 included the following skin assessment: ""Skin warm dry and intact, no breakdown noted, ---Heels soft, but blanchable."" Review of the resident's Care Plan revealed the problem of ""Risk for pressure Ulcers/impaired skin integrity"" dated 3-4-11 with hand written interventions of : ""Protective Bootie Bilaterally, skin Prep to L(eft) heel as ordered, and Elevate lower extremities PRN (as needed)."" Additional hand written interventions with dates beginning 3-5-11 and ending with 4-13-11 were noted on the care plan. Review of the Nurse's Notes of 3-29-11 revealed the following: ""Phoned MD (physician) to report odor from heel, c (with) bloody drainage, N/O (New Order) [MEDICATION NAME] DS- PO (by mouth) BID (twice daily) x (times) 7 days, place on MD review list, --"" On 4-11-11 a Nurse's Note indicated ""-- resident non-compliant with the treatments to foot."" On 4-12-11 the Nurse's Note stated: ""Resident restarted ABT - no adverse reaction noted -- odor continues."" The physician's orders [REDACTED]."" During observation of wound care on 5-3-11 at approximately 11:25 AM, Licensed Practical Nurse (LPN) # 1 removed supplies from the treatment cart and set them on the over the bed table in Resident # 1's room. Both LPN # 1 and Certified Nursing Assistant (CNA) # 1 washed hands and donned gloves. CNA # 1 then lifted Resident # 1's foot from the wheel chair and removed the Protective Bootie. LPN # 1 removed scissors from her uniform pocket and cut the bandage wrap and then laid the scissors on the over the bed table with the other supplies. LPN # 1 used wound cleaner spray to remove the 4 x 4 gauze which was covering the wound. The gauze was saturated with a bloody drainage. LPN # 1 took an unidentified number of 4 x 4 gauze pads from the package on the over the bed table, continued to spray the wound with the wound cleaner spray, and patted the wound to the heal repeatedly with the same gauze bundle. LPN # 1 discarded the gauze bundle and again reached into the package for more 4 x 4 gauze pads. The wound was again sprayed with wound cleanser and she patted the area to the heal repeatedly with the 2nd bundle of gauze, which was then discarded. LPN # 1 removed gloves, washed hands/donned sterile gloves, applied Santyl and covered the heel with a clean 4 x 4 gauze. She then began wrapping the wound with Kling wrap, picked up the previously used scissors from the over the bed table, cut the wrap and replaced the scissors on the over the bed table. The LPN took a pen from her pocket and dated some tape to secure the bandage. After using the pen it, it dropped on the floor. LPN # 1 removed gloves, picked up the pen and placed it in her pocket and bagged the trash while CNA # 1 replaced the Protective Bootie on the resident. LPN # 1 then washed her hands and put the scissors back into her uniform pocket and the supplies back into the Treatment Cart including the opened package of 4 x 4 gauze pads which had been contaminated during the treatment observation. During an interview with LPN # 1 on 5-3-11 at approximately 5:30 PM, she confirmed that she had not cleaned the scissors, and that she had repeatedly patted the wound area with 4 x 4 gauze. During an interview with the Infection Control Nurse on 5-3-11 at approximately 4:30 PM, she confirmed that Resident # 1 had entered the facility with no heel wounds and had received antibiotic therapy twice for foul smelling odor related to the pressure area on the left heel since admission.",2014-11-01
9843,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2011-05-04,309,D,0,1,RTYI11,"**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 ensure that professional standards of quality were met for 1 of 1 resident receiving [MEDICAL TREATMENT]. The documentation of thrill and bruit for Resident #7 was inconsistent. The findings included: The facility admitted Resident #7 on 9/21/10 with [DIAGNOSES REDACTED]. The resident was identified by the facility as interviewable, although her recent quarterly Minimum Data Set (MDS) assessment of 3/14/11 documented her Brief Interview for Mental Status (BIMS) as 99 (unable to interview). The resident was dialyzed every Tuesday, Thursday, and Saturday. A review of the medical record revealed a [MEDICAL TREATMENT] care plan (Problem #4) effective 9/26/10 with a review date of 6/21/11. Approach #3 documented ""Monitor Thrill and Bruit."" Documentation in the nursing notes from 12/1/10-4/30/11 revealed thrill and bruit checked 36 times out of 65 visits. On 5/4/11 at 9:20 PM Unit Manager #1 stated there was no other record of thrill and bruit check. On 5/4/11 at 12 noon, the Director of Nursing (DON) stated there was no written policy, but the thrill and bruit should be checked every shift.",2014-11-01
9844,EMERITUS AT ANDERSON PLACE HEALTH CARE CENTER,425398,311 SIMPSON RD,ANDERSON,SC,29621,2011-04-19,333,D,0,1,F45F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interview, the facility failed to ensure that a resident observed during medication pass (Resident A) was free of a significant medication error. The findings included: On 4/19/11 at 8:05 AM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer one [MEDICATION NAME] 125 microgram (mcg) tablet and 11 other medications to Resident A. After administering the medications, LPN #1 returned to the medication cart and began to record the medications on the Medication Administration Record [REDACTED]""I forgot to take the resident's pulse. I will go back and take it"". Review of the current ""physician's orders [REDACTED].*HOLD IF PULSE LESS THAN 60*"". During an interview on 4/19/11 at 8:19 AM, LPN #1 stated that she knew she should have taken the pulse ahead of time for the [MEDICATION NAME].",2014-11-01
9845,EMERITUS AT ANDERSON PLACE HEALTH CARE CENTER,425398,311 SIMPSON RD,ANDERSON,SC,29621,2011-04-19,250,D,0,1,F45F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the days of the survey, based on interview, and record review, the facility failed to provide social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 6 residents reviewed for social services. Resident #6 was not provided with counseling services after thedeath of a spouse. The findings included: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. On [DATE] at 3:30 PM, an interview with Resident #6's Power of Attorney (POA) was conducted. The POA stated that resident had shared her room with her husband who was also a resident at the facility. The spouse was actively involved in the resident's needs. The resident's husband died while a resident at the facility in [DATE]. On [DATE] at 9:00 AM per review of the social services progress notes from [DATE] to [DATE], it was revealed that no documentation addressing the death of Resident #6's spouse was done. There was no evidence of grief counseling or other supportive services having been provided. On [DATE] at 11:10 AM, an interview with the Social Service Director was conducted. She verified that she can not locate any documentation addressing the death of the residents husband and what was done to help resident through the grieving process.",2014-11-01
9846,EMERITUS AT ANDERSON PLACE HEALTH CARE CENTER,425398,311 SIMPSON RD,ANDERSON,SC,29621,2011-04-19,279,D,0,1,F45F11,"**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 develop a comprehensive care plan that included measurable objectives and timetables to meet resident's nursing needs for 1 of 6 resident care plans reviewed. The care plan for Resident # 6 failed to describe the services that were to be provided to maintain the resident's highest level of her activities of daily living. The findings included: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. On 4/18/11 at 3:30 PM, an interview with Resident #6 Power of Attorney (POA) was conducted. She stated that the resident was afraid to ask staff to take her to the bathroom because she was afraid the staff might scold her. She stated that the resident wore adult briefs due to having ""accidents"" related to not getting to the bathroom in enough time. She also stated that the resident's husband use to clean her dentures after each meal but that staff does not do this for the resident. The POA stated that she had previously discussed these issue with the facility. Review of the interviewable residents provided by the social service director on 4/19/11 documented that Resident # 6 was not considered interviewable by the facility. The Certified Nursing Assistant (CNA) ""Resident Care Plan"" documented the resident was an assist of one with toileting. The comprehensive care plan documented that the resident was care planned for extensive assist with personal hygiene. The non-specific approaches included ""keep resident clean and dry; assistance with her ADL's; notify MD/family of any significant change in condition..."" No information on the care plan addressed how the facility was toileting the resident or how the residents oral hygeine was provided. An interview on 4/19/11 at 11:00 PM, was conducted with the MDS Coordinator. She stated that she does not want ""to be specific on the comprehensive care plan"". On 4/19/11 at 11:10 AM, an interview with the Director of Nursing (DON) was conducted. She stated that the resident was toileted upon her request but acknowledged that the resident was not an interviewable resident. The DON stated that the resident was not asked if she needed to go to the bathroom and was not on a toileting schedule.",2014-11-01
9847,EMERITUS AT ANDERSON PLACE HEALTH CARE CENTER,425398,311 SIMPSON RD,ANDERSON,SC,29621,2011-04-19,363,E,0,1,F45F11,"During the days of the survey, based on observation and interview, the facility failed to provide proper serving sizes to meet residents needs who were receiving pureed diets needs. Inappropriately sized serving/measurement utensils were being used during observation of the tray line. The findings included: On 4/18/11 at 5:00 PM, observation of the supper meal tray line was conducted. It was observed that a #6 serving scoop was used to serve the puree fish and a #16 serving scoop was used to serve puree peas to residents on pureed diets. On 4/18/11 at 5:05 PM, an interview with Dietary Cook #1 was conducted. She stated that she does not have the proper serving scoops to serve the pureed foods. She stated that she ""estimated"" the serving size. On 4/18/11 at 5:15 PM, a review of the diet spreadsheet was conducted for the puree diet. It was revealed that the serving size for the puree fish was 3 ounces which would be a #12 serving scoop. The serving size for the puree peas was a half cup which would be a #8 serving scoop.",2014-11-01
9848,EMERITUS AT ANDERSON PLACE HEALTH CARE CENTER,425398,311 SIMPSON RD,ANDERSON,SC,29621,2011-04-19,371,F,0,1,F45F11,"During the days of the survey, based on observation, interview, and review of the facility policy entitled ""Using Plastic Gloves"", the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Findings included: On 4/18/11 at 12:15 PM, dining room observation was conducted. It was observed that staff was taking trays off of the closed tray cart, and then placing the used trays and lids back onto the tray cart above trays that had not yet been served. Certified Nursing Assistant (CNA) #1 was observed to take a new tray out, hand the tray to a staff member, take dirty trays from staff and placed them back on the tray cart, and then take another new tray out and hand it to a staff member to give to a resident. On 4/18/11 at 4:25 PM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). It was observed that a plastic container of powdered milk had the scoop inside it with the handle touching the powdered milk. The lid of the container was visibly dirty. A dirty tray was observed on top of the steamer. A rack was observed with food cooling on the top and clean pans drying below the food. The can opener was visibly dirty. A container with chicken batter was observed with the scoop inside the container. Two drawers were visibly dirty with food stains, one contained cooking utensils. A bin containing sugar had dried sugar around the rim that had hardened due to moisture being around rim. The sealing on the hot box was shredded. The plate warmer was visibly stained. The CDM verified findings. On 4/18/11 at 5:20 PM, the dietary cook was observed placing ground fish onto a plate and then scraped ground fish back into the steam table pan of fish. The cook was observed using gloved hands to pick up fried fish and sweet potato fries. The cook was then observed answering the telephone with her gloved hand. The cook returned to the steam table and continued to touch fried fish, sweet potato fries, peas, and ground fish with same gloved hand. The cook was observed opening the trash can lid with her gloved hand, she dumped food into the trash can, closed the lid of the trash can with gloved hand, and grabbed a bag of frozen onion rings. The cook placed onion rings into the fryer and then returned to the steam table and continued to use the same gloved hand to place food on plates. The cook did not change gloves at any time. On 4/18/11 at 5:40 PM, a plate with puree sweet potato and puree vegetables was placed in the service window, under the heat lamps. The resident did not like fish and the facility did not have a backup pureed meat. A pureed substitute was finally placed on the plate at 6:03 PM and the tray was was sent to the floor at 6:10 PM. Per review of the policy called ""Using Plastic Gloves"" on 4/19/11 at 10:00 AM, which states that ""once the gloves come in contact with a contaminated surface or you change the type of food being handled, they must be discarded and replaced with clean gloves. Any activity requiring hand washing, would also require clean gloves. For example, if an employee covers a sneeze with a gloved hand, touches a garbage can....Tongs, spatulas and other tools should be used wherever possible to pick up food...""",2014-11-01
9696,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-08-23,520,E,1,0,TYZ711,"On the day of the Complaint Survey based on observation, record review and interview the facility failed to implement a plan of action related to a substantiated allegation of neglect. A resident was transferred inappropriately resulting in a fracture. The facility failed to implement a new policy on lift battery charging and failed to provide inservices for the staff. The findings included: Initial Tour of the facility on 8/23/2011 at 9:20 AM revealed seven hoyer lifts and two stand up lifts. The facility had 5 battery charge docking stations with four batteries charging. No date and time were written on the batteries. No resident was observed to be transferred inappropriately during the survey. Review of the Five Day Report revealed ""CNA transferred resident from geri chair to bed using a sling lift. During transfer resident right femur was fractured."" Interventions in place prior to the incident: ""all residents who are transferred by sling lift must have the assistance of 2 people. This is a P+P (policy and procedure) which was put in place 2 years ago, and the CNA Basic Care Sheet states that."" Immediate Corrective Actions: ""The CNA did not follow policy the system in place failed because of that. Resident was assessed immediately, GNP was called and authorized x-ray and resident went out that day. She has an immobilizer."" Interventions put in place to prevent further injury/abuse: ""Safe Patient handling re-education, gait belt re education, follow policy for transferring residents via sling lift."" Review of the Continuation Explanation to DHEC revealed: ""During the demonstration the lift did not go very high and the aide commented that that is what is wrong with this lift, it does not go high enough to clear resident from the bed. After some insistence from the DON (Director of Nurses) the battery was changed on the machine and indeed it went up much higher. So we discovered another hole in our system, the fact that the batteries are not being put on the chargers at night to be fully recharged for the next day. A simple policy and procedure was immediately put in place by the DON for the recharging of the batteries. A copy of it is attached. This policy will be the responsibility of the lead CNA's to make sure the policy is followed. WE are formulating a tool to keep a record but at this time 3rd shift is sticking a note on the batteries that they were put on the chargers at a particular time, initial of the person doing that etc. So far its is working well...As luck would have it, our safety company was due for a visit on Tuesday June 28, and he did a re-education on Safe Patient Handling. We have not reached everyone yet but the plan is to do that."" Two CNAs were interviewed that were on duty at the time of the incident. Both CNA #2 and CNA #4 stated that the lift batteries were not fully charged. Observation of the Battery Charge Stations on 8/23/2011 at 1 PM revealed 4 batteries were charging (three on unit one and one on unit two). Only the battery on Unit 2 was initialed with a time. CNA #3 confirmed that there was no date, time or initials on the other three charging batteries. CNA #3 stated that whenever the batteries were placed on the chargers, a sticker should be placed with the time and initials. She also stated that when the battery was removed from the charger then the sticker would be thrown away and the staff would not know how long the battery had been off the charger and if the battery was fully charged. CNA #3 confirmed that there was no sign off sheet or other method of knowing if and when the batteries had been charged. A CNA Monitoring Tool for Resident Lift Batteries was initiated on 8/23/2011 per the DON. During an interview on 8/23/2011 at 1:10 PM, the (Director of Nurses) DON stated that no audits were completed to assure the plan put in place was effective. She also confirmed that there was not a check off sheet related to battery charging. The DON stated that no in-service sign in sheets were kept for the 6/28/2011 in-service. She also stated that the only staff to attend were the staff that was physically in the building on 6/28, first and second shifts only. The DON confirmed that no in service for Abuse or Neglect was conducted following the incident on June 22, 2011.",2014-12-01
9697,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-08-15,157,G,1,0,P60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on record review and interview the facility failed to ensure two of five residents reviewed with sliding scale insulin had their physician notified of a low blood sugar. Resident #2's physician was not notified for 10 days of low blood sugars. Resident #5's physician was not notified of a low blood sugar. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #2 revealed the Medication Administration Record [REDACTED]. Review of Resident #2's June 2011 physician's orders [REDACTED]. Further review revealed, Resident #2 was prescribed [MEDICATION NAME] 8 units every night. On 5/26/2011 the sliding scale insulin coverage was discontinued, however the blood sugars were to be monitored twice daily. There was no evidence the physician was notified of the low blood sugars. No orders were written between 6/13 and 6/25 related to insulin or blood sugars. During an interview on 8/15/2011 at 10:50 AM, the Director of Nurses (DON) confirmed the low blood sugars. The DON also confirmed the physician was not notified of the low blood sugars and the nurses should have notified the physician for order changes and/or clarification orders. The DON also confirmed there were no orders or notes written regarding the low blood sugars. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Resident #5's, August 2011 physician's orders [REDACTED]. 500... Insta Glucose 40% Gel contents 1 tube po (by mouth) prn (as needed) BS <50..."" Further review revealed none of the above orders were followed related to the blood sugar of 49. No interventions were implemented. There was no evidence the physician was notified of the low blood sugar. During an interview on 8/15/2011 at 1:10 PM the DON confirmed the low blood sugar on 7/3/2011 and confirmed that there were no interventions implemented and the physician was not notified.",2014-12-01
9698,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-08-15,280,G,1,0,P60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on record review and interview the facility failed to ensure one of six residents care plans were updated to reflect the current status of each resident. Resident #2's care plan did not include specific interventions related to high and low blood sugars. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan revealed a problem area related to Diabetes Mellitus and low blood sugar was identified however the approaches were to ""monitor for s/s of [DIAGNOSES REDACTED]"". No interventions were included on the care plan. During an interview on 8/15/2011 at 2:15 PM, the Resident Assessment Coordinator (RAC) confirmed there was a care plan related to Diabetes for Resident #2 and she confirmed there were no specific interventions or follow up related to low blood sugars.",2014-12-01
9699,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2011-08-15,309,G,1,0,P60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on record review and interview, the facility failed to ensure 2 of 5 residents receiving insulin had interventions implemented according to the physician's orders [REDACTED]. Resident #2's blood sugar was below 50 six times between 6/14 and 6/25/2011 without the ordered interventions implemented and on 6/25 had 100 Units of Regular Insulin administered in error. Resident #5 had a blood sugar below 50 without any interventions implemented. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. No [MEDICATION NAME] was given for the low blood sugars between 6/13 and 6/24/2011. Further review revealed, Resident #2 was prescribed [MEDICATION NAME] 8 units every night. On 5/26/2011 the sliding scale insulin coverage was discontinued, however the blood sugars were to be monitored twice daily. Review of the Nurse's Notes revealed no documentation related to the low blood sugars until a note dated 6/25/2011 at 5:45 AM stated, ""Res(ident) in bed c (with) eyes open. FS (finger stick) 36. 100 U (units) of Humalog (insulin) was given. Three Insta Glucose gel was given along c a snack. MD called made aware of what happened. Blood sugar was checked while on phone c MD- FS 61. (Physician) said to watch her it was coming up and that's what we want. Call back to be sure he didn't want anything else. No orders given. "" At 7:05 AM, Resident #2 was sent to the emergency room for ""low blood sugar"". During an interview on 8/15/2011 at 10:50 AM, the Director of Nurses confirmed the low blood sugars. The DON also confirmed the physician was not notified of the low blood sugars and the nurses should have notified the physician for order changes and/or clarification orders. The DON confirmed the resident was on a long acting insulin at night, and there had not been any changes since May 2011. The DON also confirmed there were no orders or notes written regarding the low blood sugars. The DON confirmed that LPN #1 administered 100 U of Regular Insulin to Resident #2. She also confirmed that Resident #2 did not have orders for Insta Glucose. She also confirmed that Resident #2's orders were not followed related to low blood sugars. She confirmed that if the nursing staff could not not follow the physician's orders [REDACTED]. During an interview on 8/15/2011 at 12:30 PM, LPN #1 stated that she checked Resident #2's blood sugar on 6/25/2011 at 5:30 AM. She stated that she thought the glucometer read 336. LPN #1 stated that she had administered 35 U of regular insulin per the sliding scale coverage. (Review of the Sliding Scale Coverage revealed 35 U was not an ordered amount). She stated that after she administered the 35 U she realized that was wrong and double checked the glucometer and realized the blood sugar was 36. She stated that she gave Resident #2 three Insta Glucose, and a snack. LPN #1 then reported the incident to the Supervisor who informed her to give the IM [MEDICATION NAME] and call the doctor. LPN #1 stated that she did not give 100 U of Regular Insulin and that she must have ""panicked "" and that was why she had said that. LPN #1 also stated that Resident #2 was receiving Sliding Scale Insulin coverage and stated that Resident #2 had an order for [REDACTED]. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed none of the above orders were followed related to the blood sugar of 49. No interventions were implemented. There was no evidence the physician was notified of the low blood sugar. During an interview on 8/15/2011 at 1:10 PM the DON confirmed the low blood sugar on 7/3 and confirmed that there were no interventions implemented.",2014-12-01
9700,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,278,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Surveys, based on record reviews and interviews, the facility failed to accurately assess 2 of 14 residents for Comprehensive Assessments. Resident #9 had a trunk restraint that was not coded on the most recent Comprehensive Minimum Data Set (MDS) therefore the Resident Assessment Protocol (RAP) was not triggered and the resident was not reviewed for restraint use. Resident #14's weight was incorrectly coded on the MDS by 89.1 pounds indicating a significant weight loss rather than the actual significant weight gain of 34.5 pounds. The findings included: The facility admitted Resident #9 on 4/27/09 with [DIAGNOSES REDACTED]. Observations of the resident on 2/28/11 at approximately 11:45 AM and 2:40 PM and on 3/1/11 at 11:30 AM and 3:45 PM revealed the resident sitting in a wheelchair with a lap belt tied behind the wheelchair. Record review on 2/28/11 at 5:50 PM revealed an order for [REDACTED]."" No other documentation, the original order for seat belt or lap belt, was provided by the facility. Review of the most recent Comprehensive MDS dated [DATE] Section P4, Devices and Restraints, was coded for other types of side rails used daily but was not coded for a trunk restraint. During an interview on 3/2/11 at 3:30 PM, the RN (Registered Nurse) MDS Coordinator confirmed that the MDS should have been coded for a trunk restraint. She verified that without coding the restraint on the MDS, the RAP would not be triggered and the use of the restraint would not be reviewed. The findings included: The facility admitted Resident #14 on 10/23/2009 with [DIAGNOSES REDACTED]. On 3//1/11 the resident's medical record was reviewed. The annual full assessment was completed on 10/12/2010. Section ""K"" was completed concerning the resident's nutritional status. The resident's weight was recorded as 188 pounds (lbs.) Review of the resident's Vital Flow Sheet that listed vital signs and the resident's weights revealed that on 9/7/2010, the resident's weight was recorded as 261.6 lbs and on 10/11/2010 the weight was 277.1 lbs. There were no weights recorded since May 2010 of any weights below 200 lbs. The quarterly assessment dated [DATE] coded the resident as weighing 311 lbs. A 123 lb weight gain from the annual MDS of 10/12/10, over a 90 day period. The resident had monthly weights recorded of 9/7/2010=261.6 lbs, 10/12/10=277.1 lbs., 11/9/10=290.6 lbs., 12/14/2010=310.6 lbs, 1/12/2011=316.6 lbs and on 2/9/2011 weight was 322.6 lbs. He had a total of 60.1 lbs ( 19 % ) of weight gain over a 5 month period. On 3/2/2011 at 9:50 am, the MDS (Minimum Data Set) RN and LPN were interviewed. They both confirmed that the weight recorded on the MDS was not the weight that was recorded in the chart. Neither MDS nurses could state from where the 188 lb documented weight was obtained. There was no care plan on the medical record at the time of the survey for weight gain or loss. The facility provided a copy of the care plan that the Assistant Administrator identified as ""having been in the computer"". The care plan stated: ""Problem Start Date: 10/08/2010. "" The problem that was identified on the plan of care was: ""potential for decreased weight and dehydration R/T (related to) [MEDICAL CONDITION]."" Medical record review revealed that the resident had a continuous/steady, significant weight gain each month that was not identified during his annual or quarterly assessments. The annual assessment had an incorrect weight that was used to form a plan of care the opposite of the needs of the resident. There was no care plan to address the weight gain and potential health risks of the weight gain.",2014-12-01
9701,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,325,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews the facility failed to ensure that 1 of 1 sampled resident's (Resident #14) with significant weight gain received nutritional intervention. At the time of the survey Resident #14 weighed 322.6 pounds and had incurred a 19% weight gain. The findings included: The facility admitted Resident #14 on 10/23/2009 with [DIAGNOSES REDACTED]. On 3/1/11 the resident's medical record was reviewed. The annual full assessment was completed on 10/12/2010. Section ""K"" was completed concerning the resident's nutritional status. The resident's weight was recorded as 188 pounds (lbs.) The resident had monthly weights recorded of 9/7/2010=261.6 lbs, 10/12/10=277.1 lbs., 11/9/10=290.6 lbs., 12/14/2010=310.6 lbs, 1/12/2011=316.6 lbs and on 2/9/2011 weight was 322.6 lbs. He had a total of 60.1 lbs ( 19 % ) weight gain over a 5 month period, Review of the dietary notes dated 10/5/10, ""Annual Assessment and RAPS"" form, had the resident's weight documented as 187.8 lbs. (The correct weight that would have been used dated 9/7/2011 was 261.6 lbs.) The dietary note stated, ""...Intake of 75-100%. Snacks often wants to eat all night rather than sleep....Regular diet. Wgt (weight) 187.8 # (lbs.) a sig (significant) decrease 6 months"" ( which was subsequently determined to be in error.) The resident actually had a significant weight gain of 19%. The last documented nutritional note by a Registered Dietician was dated 3/29/10. There were no dietary interventions/recommendations related to the resident's significant and steady weight gain by the Food Service Director nor a Registered Dietician. A Nutrition Recommendations form was provided by the facility. The form was completed by the Dietary Consultant, a Registered Dietician. The form was dated 12/22/2010. Recommendations for the resident stated, ""continue POC (Plan of Care)."" There was no care plan on the medical record at the time of the record review for weight gain or loss. The facility provided a copy of the care plan that the Assistant Administrator identified as having ""been in the computer."" The care plan stated: ""Problem Start Date: 10/08/2010. "" The problem that was identified on the plan of care was, ""potential for decreased weight and dehydration R/T (related to) [MEDICAL CONDITION]. The goal for the careplan had a target date of 1/8/11.",2014-12-01
9702,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,333,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interview, the facility failed to ensure that a resident observed during medication pass (Resident A) was free of a significant medication error. The findings included: On 3/1/11 at 8:05 AM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer one [MEDICATION NAME] 50 milligram (mg) tablet and 8 other medications to Resident A. After administering the medications LPN #1 returned to the medication cart and began to record the medications on the Medication Administration Record [REDACTED]"". She then returned to the resident's room and took the resident's pulse. Review of the current ""physician's orders [REDACTED].* (hypertension) --HOLD IF PULSE < (less than) 40 - RECORD BLOOD PRESSURE & PULSE-"". During an interview on 3/1/11 at 8:25 AM, LPN #1 stated that she knew she should have taken the pulse ahead of time for [MEDICATION NAME].",2014-12-01
9703,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,356,D,0,1,5U4I11,"On the days of the survey based on observations the facility failed to post the daily staffing for each shift in a timely manner. The findings included: On 2/28/2010 at 6:10 PM, the daily staffing that was posted contained only the 7-3 shift posting for 2/28/2011, 2/27/2011 and 2/25/2011. There was no posting for any shift on 2/26/2011. There was no 3/11 posting for 2/28/2011 (3 hours into the shift). There was no posting for either 3-11 or 11-7 shift on 2/27/2011 or 2/25/2011. On 3/1/11 at 5:30 PM, the only posting was for the 7-3 shift. There was no posting for the 3-11 shift, two and one half hours after the shift had started.",2014-12-01
9704,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,221,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interviews the facility failed to ensure that each resident had the right to be free from any physical restraints imposed for convenience, and not required to treat the resident's medical symptom for 3 of 5 residents reviewed for restraints. Resident # 20 was observed wearing a restraint. There was no documented assessment nor consent for the use of the restraint. Resident # 19 was using dual restraints without an assessment. Resident # 18 was not wearing a physical restraint as ordered by the physician. The findings included: Resident #20 with [DIAGNOSES REDACTED]. Record review on 3/1/2011 revealed the residents care plan listed a soft lap belt was to be used when the resident was up in his wheel chair related to poor safety awareness. Review of Nurses Note dated 12/20/2010 revealed ""Torso support D/C (discontinued) + (and) lap belt added. Observation on 3/1/2011 at 11:40 AM revealed Resident #20 up in his wheel chair with a lap belt attached which fastened in the rear of the chair. Interview with the Assistant Administrator at 12:35 PM revealed the facility did not have an assessment that addressed restraints and that at present there was a blanket restraint consent but it was not client specific. The Assistant Administrator verified that there were currently no assessments in place. Interview with Licensed Practical Nurse # 5 on 3/2/2011 at 3:25 PM revealed the resident's family had not been notified of the change in the resident's treatment plan related to restraint use. The facility admitted Resident #18 on 3-23-07 with [DIAGNOSES REDACTED]. Record review on 3-2-11 at 9:30 AM revealed 2-11 physician's orders [REDACTED]. Observations on 3-1-11 at 11:25 AM and on 3-2-11 at 9:30 AM revealed the resident in the community area near the nursing station in a wheelchair with the seatbelt unfastened, hanging down on the sides of the chair. Review of the Certified Nursing Assistants' ""device list"" provided for review by the Unit Manager at 9:45 AM revealed that Resident #18 was to have a ""Seatbelt to w/c (wheelchair)"". During an interview and observation on 3-2-11 at 10 AM, the Unit Manager verified that the seatbelt was not in place as ordered. She stated, ""The students got him up."" The facility admitted resident #19 on 10/28/10 with [DIAGNOSES REDACTED]. On 3/2/2011 at 1:30 PM, record review revealed an order for [REDACTED]. The Nurses Notes reflected a note dated 2/22/11 that the resident slid out of the chair. A new order was received on 2/22/11 for a Pommel cushion to the wheelchair related to safety. There was no order to discontinue the seat belt alarm to the wheelchair and no assessment, evaluation or therapy notes were located on the chart. At 1:50 PM on 3/2/11, the resident was observed with a Pommel cushion and a seat belt that alarmed when disconnected. During an interview on 3/2/11 at 2:20 PM, the Restorative Nurse confirmed that she had visually observed the resident but did not perform a formal restraint assessment. She confirmed that she recommended the Pommel cushion and had not discontinued the seat belt alarm. She further verified that the resident did not require both and confirmed that she should have discontinued the seat belt alarm when the Pommel cushion was implemented.",2014-12-01
9705,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,365,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Surveys, based on observation, record review and interviews, the facility failed to provide thickened liquids as ordered for 1 of 2 residents reviewed for thickened liquids. Resident #12 with an order for [REDACTED]. The findings included: The facility admitted Resident #12 on 1/29/10 with [DIAGNOSES REDACTED]. On 2/28/11 at 3:05 PM, record review revealed an order on the 2/1/11 monthly physician's orders [REDACTED]. Review of the Therapy Summary for 9/1/10-10/23/10 indicated the resident had just completed treatment for [REDACTED]. On 3/1/11 at 12:55 PM during observation of lunch, a water pitcher was noted on the over-bed table in front of the resident. After obtaining permission from the resident, the pitcher was opened to reveal ice water without thickener. During an interview at that time, Certified Nursing Assistant (CNA) #2 confirmed that the resident had ice water without thickener at the bedside. She stated that the Helping Hand (Nursing Assistant) had passed out water that morning. She stated that the Helping Hand came on Mondays and Tuesdays but when she is not there, the staff pass out ice water to all of the residents. She confirmed that Resident #12 receives ice water without thickener daily. CNA #1, and 4 other CNA's in the hallway during the interview, also confirmed that the resident received ice water daily. During an interview on 3/1/11 at 3:35 PM RN (Registered Nurse) #1, Unit Manager, stated she was not aware Resident #12 was receiving ice water. On 3/2/11 at 2:53 PM, RN #1 stated she makes rounds daily but that she did not check for the presence of water at the bedside of residents with orders for thickened liquids.",2014-12-01
9706,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,371,F,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complain Survey, based on observation and interviews, the facility failed to maintain the correct concentration of the chemical sanitizing solution for cleaning food contact surfaces. The findings included: On 3/2/11 at 9:05 AM, Dietary Aid #1 tested the sanitation bucket used for cleaning work surfaces upon request of the surveyor. The Quaternary sanitation solution tested at 500 ppm (parts per million) and was confirmed by the CDM (Certified Dietary Manager.) A poster with the manufacturer's recommended concentration of 150-400 ppm was posted above the 3 compartment sink and the CDM stated that the correct concentration was 200-400 ppm. During an interview at that time, the Dietary Aid stated she was instructed to use 2 cups (30 milliliter medicine cups) to a bucket of water by the previous supervisor. She further confirmed that she routinely used 2 (medicine) cups of sanitizer in a bucket of water. A test bucket of sanitizer solution was requested with 1 medicine cup and 2 medicine cups of sanitizer. The Dietary Aid poured the sanitizer from a large container into 1 medicine cup and added the sanitizer to the bucket with approximately 10 quarts of water. The resulting solution had a concentration of 200 ppm. A second medicine cup of sanitizer was added to the bucket and stirred which resulted in a concentration of 500 ppm. During an interview at approximately 9:25 AM, the Assistant Kitchen Manager confirmed that he consistently obtains results greater than 400 ppm. He confirmed that he had the staff change the bucket when concentration was greater than 400 ppm but confirmed that he only checks twice a week. The Assistant Kitchen Manager stated an in-service had been done regarding the appropriate concentration of the sanitation solution. Upon request for copies of the in-service, the Assistant Kitchen Manager provided an in-services provided by the sanitizer supplier on August 23, 2010. The in-service stated it ""covered the proper use of Solitaire (one button push-[MEDICATION NAME] approx.(imately) 19 sec(onds), then filling sink with hottest water possible, and proper use of 146 sanitizer. It dispenses premixed at 150-400 ppm for submerged and 400 ppm for table surfaces.) The in-service was attended by 14 employees. No other in-service information was provided by the facility.",2014-12-01
9707,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,502,D,1,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Surveys, based on record review, observation and interviews, the facility failed to obtain laboratory tests as ordered for 3 of 14 residents reviewed for labs. A Urinalysis with culture and sensitivity was not obtained for resident # 1 and a Hemoglobin was not obtained for Resident #3 as ordered. [MEDICATION NAME] levels were not obtained every four months as ordered for Resident #6. The findings included: The facility admitted Resident #3 on 6/8/99. Her [DIAGNOSES REDACTED]. Record review on 3/1/11 at approximately 10:35 AM revealed a progress note by the Physician dated 1/12/11 that stated ""Hemoglobin 8.6. We need to recheck that."" Further review at approximately 12:05 PM revealed a Physician's Interim Order for a ""(check) hgb (hemoglobin)... next lab day."" Review of the resident's labs revealed a Hemoglobin test done 11/16/10 with a result of 8.6 g/dl (grams per deciliter). Review of the Nurses Notes revealed documentation of the ""order to (check) hgb."" No results could be located on the record. During an interview on 3/2/11 at 10:35 AM, the charge nurse for Eastside Village unit stated no results could be located and confirmed that the laboratory also had no record of receiving a specimen for the hemoglobin test. At 11:43 AM on 3/2/11, the Charge Nurse stated that when an order was received a 2 part lab slip was completed and taken to the nursing office. The laboratory then picked up the white copy and obtained the labs for the day. The Register Nurse (RN) Supervisor received the yellow copy to check when the lab was done. At 11:58 AM on 3/2/11, the RN Supervisor stated that when the results were received, via fax in the nursing office, results were checked against the yellow copy of the lab slip. She further stated that the results were received between 1:00-2:00 PM each day. She further stated that if the results were not received by the end of the day, she called the laboratory. She was unable to state why the hemoglobin was not obtained. The facility admitted Resident #1 on 12-16-10 with [DIAGNOSES REDACTED]. Review of Nurse's Notes and Physician's Progress Notes on 2-28-11 at 3:25 PM revealed that the resident was evaluated by the physician on 1-5-11 for a low-grade fever of unknown origin. He ordered ""(Check) U/A (Urinalysis) c (with) C&S (Culture & Sensitivity), CBC (Complete Blood Count) in AM."" No results for the urinalysis could be located. Further review of Nurse's Notes revealed that an attempt to do an in and out catheterization to obtain the specimen on 1-6-11 at 0415 was unsuccessful. No further attempts to obtain the urine specimen were documented and there was no indication in the record that the physician was made aware. Physician's Progress Notes dated one week later (1-12-11) noted that the resident had ""continued fever"" and that he was ""awaiting...UA"". Antibiotic therapy was ordered on 1-12-11. During an interview on 2-28-11 at 4:50 PM, Licensed Practical Nurses #2 and #3 attempted to locate the UA C&S report in the chart, in the physician's communication book, in the ""to be filed"" chart, and in Medical Records, without result. During an interview on 3-2-11 at 9:10 AM, the Unit Manager reviewed the medical record and the calendar where labs were logged. She verified that the lab had not been done as ordered. The facility admitted Resident #6 on 8-25-99 with [DIAGNOSES REDACTED]. Further review revealed monthly cumulative physician's orders [REDACTED]. Review of laboratory reports revealed that [MEDICATION NAME] levels were drawn on 1-6-10, 7-21-10, and 12-16-10. During an interview on 3-2-11 at 11:20 AM, the Assistant Administrator provided copies of all laboratory reports for blood levels of [MEDICAL CONDITION] medications completed in the prior year. No additional [MEDICATION NAME] levels were provided.",2014-12-01
9708,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,157,E,1,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to immediately notify the physician and/or family of significant changes in residents' conditions potentially requiring interventions for five of twenty-five sampled residents reviewed. The facility failed to notify the physician and/or family in a timely manner for Residents #1, #5, #6, #18, and #23 who had documented [MEDICAL CONDITION] activity. All residents with noted deficient practice were located on the 300 Hall. The findings included: The facility admitted Resident #1 on 12-16-10 with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 2-28-11 at 3:25 PM revealed an entry on 2-16-11 at 1930: ""Resident having [MEDICAL CONDITION] activity [MEDICATION NAME] approx(imately) 4 min(ute)s - jerking and tremors - eyes rolled back. VS (vital signs) = 98.4-100/72-56-18. Will cont(inue) to monitor."" There was no evidence in the medical record that the physician or family was notified of the [MEDICAL CONDITION] until the following day when a [MEDICATION NAME] level was ordered. [MEDICATION NAME] was also ordered to be administered as needed for [MEDICAL CONDITION] over three minutes. Further review revealed that this was the first documented [MEDICAL CONDITION] since admission to the facility two months previously. This was confirmed during an interview with the Unit Manager on 3-1-11 at approximately 10 AM. When asked where the physician/family notification would be found, the Unit Manager stated that the only place it should be documented was in the Nurse's Notes. During an interview on 3-2-11 at 11 AM, the Assistant Administrator stated that the physician and family should have been notified immediately and that this had been reviewed with the staff repeatedly. The facility admitted Resident #5 on 7-26-07 with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 2-28-11 at 2:15 PM revealed that Resident #5 had documented [MEDICAL CONDITION] involving the torso and all extremities on 12-14-10 at 8:30 AM ([MEDICATION NAME] one minute 40 seconds) and at 10:40 AM ([MEDICATION NAME] 35 seconds). The resident was evaluated by the Nurse Practitioner that day and a Neurology follow-up consult was ordered. There was no evidence in the record that the family was made aware of the [MEDICAL CONDITION] or Neurology appointment. On 12-23-10 at 1400, an entry in the Nurse's Notes stated: ""Resident had [MEDICAL CONDITION] activity [MEDICATION NAME] approx. 50 seconds. Total body involved - jerking, shaking, and rapid respirations...Will cont. to monitor."" There was no evidence in the record that the physician or family was notified of the [MEDICAL CONDITION]. Further review of Nurse's Notes revealed that the resident had ""what appeared to be [MEDICAL CONDITION] activity"" on 2-1-11 while out of the facility for a Dermatology consult, on 2-3-11 at 1300 ""[MEDICATION NAME] approx. 1 1/2 minutes"", and on 2-22-11 at 1340, [MEDICATION NAME] 40 seconds. There was no evidence in the record that the physician or family was notified of the [MEDICAL CONDITION]. During an interview on 3-1-11 at 10:20 AM, the Unit Manager reviewed the medical record and found no documentation that the physician and/or family had been notified of the [MEDICAL CONDITION] as noted above. She stated that, in the event of a [MEDICAL CONDITION], the resident should be kept safe, medication given as ordered/necessary, and the physician and family should be notified. She stated the information should be charted in the Nurse's Notes, ""nowhere else"". During an interview on 3-1-11 at 4:30 PM, the Assistant Administrator stated she had reviewed the medical record and could locate no further information related to physician/family notification. The facility admitted Resident #6 on 8-25-99 with [DIAGNOSES REDACTED]. R(ight) upper extremity c (with) L(eft) sided weakness...unable to focus when name called..."" There was no evidence in the record that the physician was notified until the resident was seen on a ""routine visit"" three days later at which time [MEDICATION NAME] and [MEDICATION NAME] levels were ordered. There was also no evidence in the record that the family was notified of the [MEDICAL CONDITION]. During an interview on 3-1-11 at 11:20 AM, the Unit Manager reviewed the medical record and verified that there was no documentation of family notification of the resident's [MEDICAL CONDITION]. She also confirmed that the physician was not notified until three days after the incident. The facility admitted Resident #18 on 3-23-07 with [DIAGNOSES REDACTED]. Record review on 3-2-11 at 9:30 AM revealed that on 11-28-10 at 2100, the resident had ""[MEDICAL CONDITION] activity; repetitive movement of BLE (bilateral/both lower extremities), as well as BUE (bilateral/both upper extremities), [MEDICATION NAME] 2 min. 45 sec(onds)"". The family was notified the following morning prior to the resident leaving the facility for a Dermatology appointment, but there was no evidence that the physician was notified until 11-30-10 (2 days later) when a [MEDICATION NAME] level was ordered. During an interview on 3-2-11 at 11 AM, the Assistant Administrator verified that the physician had not been notified in a timely manner. The facility admitted Resident #23 on 10-2-09 with [DIAGNOSES REDACTED]. to... for eval(uation) + Tx (treatment) of fever + [MEDICAL CONDITION]"". Review of Nurse's Notes on 3-2-11 at 1:45 PM revealed that on 12-14-10 at 1845 ""Resident sitting up in w/c (wheelchair) in hall in front of his room + noted c uncontrollable shaking."" There was no evidence in the medical record that the physician or family was notified. The last Physician's Progress Note in the record was dated 12-2-10. No medical history of [REDACTED]. Further review revealed that on 12-19-10 at 1400, the resident ""had moment of shaking [MEDICATION NAME] about 20 seconds per daughter-face flushed, VS= 170/110, 98.1 ax(illary)-113-22."" The physician was notified after ""Daughter stated that father had this type of jerking when he had a stroke before."" During an interview on 3-2-11 at 2:15 PM, the Director of Nurses confirmed that the physician nor family had been notified of the 12-14-10 [MEDICAL CONDITION].",2014-12-01
9709,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,242,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews, the facility failed to adhere to resident choices for care for one of one residents reviewed with a [MEDICATION NAME]. Resident choice of time and type of [MEDICATION NAME] care was not adhered to for Resident #7. The findings included: The facility admitted Resident #7 on 2-13-04 with [DIAGNOSES REDACTED]. Record review on 3-1-11 at 8:55 AM revealed physician's orders [REDACTED]."" During an interview on 2-28-11 at 6 PM, Resident #7 stated that she had expressed concerns to the facility staff over the last six months about the care of the ostomy not being done as ordered on a weekly basis and the desire to have her [MEDICATION NAME] care provided on the night shift because she worked outside the facility and was very active in the daytime. She stated that a family member had conducted an inservice for the staff on care of the ostomy, but that there was only one nurse on the night shift that could provide the required care. She preferred not to have a male nurse perform the care. She stated the family member had been providing the care because the facility had failed to provide qualified/trained staff on the preferred shift. The resident expressed ongoing concern regarding the health of the family member and that the facility should be providing the care, not the family. When asked if the end of the 7AM-7PM shift was acceptable for the [MEDICATION NAME] care, the resident stated that this had been discussed, but that she had been told ""they didn't have time"". Review of the 1-11 and 2-11 Treatment Records on 3-1-11 at 8:55 AM revealed that the weekly [MEDICATION NAME] care scheduled for the 7PM-7AM shift was left blank or was circled without explanation as to why the treatment was omitted five of the nine scheduled times. Review of the medical record and Resident Issues/Concerns (Grievance) Log revealed no reference to the concerns identified by the resident although during an interview on 3-2-11 at 11:15 AM, the Assistant Administrator stated that they had met with the resident and Ombudsman regarding the concerns. The lack of documentation in the record and on the log was attributed to Social Services not being involved in the process. Although no documented training was provided upon request, the Assistant Administrator stated that of the five staff who were trained in [MEDICATION NAME] care by the family, two no longer worked at the facility, two worked 7AM-7PM, and there was only one left on nights who had been trained. She reviewed and verified that the Treatment Records did not indicate that the [MEDICATION NAME] care had been done as ordered.",2014-12-01
9710,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,309,D,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide necessary care and services for two of five residents reviewed with [MEDICAL CONDITION]. A Neurological consult was not done as ordered for Resident #5. The facility staff failed to adequately assess Resident #23 following a [MEDICAL CONDITION]. The findings included: The facility admitted Resident #5 on 7-26-07 with [DIAGNOSES REDACTED]. Review of Nurse's Notes on 2-28-11 at 2:15 PM revealed that Resident #5 had documented [MEDICAL CONDITION] involving the torso and all extremities on 12-14-10 at 8:30 AM ([MEDICATION NAME] one minute 40 seconds) and at 10:40 AM ([MEDICATION NAME] 35 seconds). The resident was evaluated by the Nurse Practitioner that day and a Neurology follow-up consult was ordered. There was no evidence in the record that the resident was seen by Neurology since 11-19-10. Further review of Nurse's Notes revealed that the resident had subsequent [MEDICAL CONDITION] on 12-23-10 at 1400, on 2-1-11 while out of the facility for a Dermatology consult, on 2-3-11 at 1300, and on 2-22-11 at 1340. During an interview on 3-1-11 at 10:20 AM, the Unit Manager reviewed the medical record and found no evidence that the resident was seen by Neurology after the consult order was written. During an interview on 3-1-11 at 4:30 PM, the Assistant Administrator stated she had reviewed the medical record and provided a copy of the most recent Neurology report which was dated 11-19-10.",2014-12-01
9711,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,315,E,0,1,5U4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide appropriate treatment and services to one of one sampled residents with a [MEDICATION NAME]. physician's orders [REDACTED].#7. The findings included: The facility admitted Resident #7 on 2-13-04 with [DIAGNOSES REDACTED]. Record review on 3-1-11 at 8:55 AM revealed physician's orders [REDACTED]."" During an interview on 2-28-11 at 6 PM, Resident #7 stated that she had expressed concerns to the facility staff over the last six months about the care of the ostomy not being done as ordered on a weekly basis. She stated that a family member had conducted an inservice for the staff on care of the ostomy, but that the family member had continued to provide the care intermittently because the facility had failed to provide qualified/trained staff. Review of the 1-11 and 2-11 Treatment Records on 3-1-11 at 8:55 AM revealed that the weekly [MEDICATION NAME] care scheduled for the 7PM-7AM shift was left blank or was circled without explanation as to why the treatment had been omitted five of the nine scheduled times. Although no documented training was provided upon request on 3-2-11, the Assistant Administrator stated that of the five staff who were trained in [MEDICATION NAME] care by the family, two no longer worked at the facility, two worked 7AM-7PM, and there was only one left on nights who had been trained. She reviewed and verified that the Treatment Records did not indicate that the [MEDICATION NAME] care had been done as ordered. Cross Refer CFR 483.15(b) Related to facility failure to provide designated health care consistent with resident choices.",2014-12-01
9712,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,441,F,0,1,5U4I11,"On the days of the survey, based on observation and interviews, the facility failed to handle clean linens to prevent recontamination. Staff were observed to transport clean linen against their uniforms. The findings included: During review of the laundry process, it was noted that the facility had a contractual agreement with an outside provider for linen services. Observation and interview with the Housekeeping/Laundry Supervisor on 3-2-11 at 8:40 AM revealed that the contractor delivered large bins of clean bagged linen to the facility. Two facility staff members were observed in the ancillary hallway removing the plastic covers from the linen bundles and then carrying the linen against their uniforms from the hall into the linen storage room and placing them on the shelf. During an interview at that time, the Housekeeping/Laundry Supervisor verified the observation and identified the staff as one Laundry Aid and one Housekeeping Aide.",2014-12-01
9713,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,496,D,0,1,5U4I11,"On the days of the survey, based on review of personnel files and interviews, the facility failed to verify certification prior to hire for one of three newly hired Certified Nursing Assistants (CNAs) reviewed. The findings included: Review of three personnel files of newly hired CNAs on 3-1-11 at 5 PM revealed that one of the three was hired on 8-24-10. No record could be found that the Nurse Aide Registry had been checked prior to hire. An employee in the front office was advised of this on 3-1-11 at approximately 6 PM. During an interview on 3-2-11 at 11:30 AM, the Assistant Administrator was advised of the missing certification verification and a copy of one completed on 3-2-11 was presented by the Human Resource representative. The Assistant Administrator stated that a concern had been identified with timely verification of certification for Certified Nursing Assistants, but she did not explain the reason that one of the three files checked was not in compliance.",2014-12-01
9714,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2011-03-02,492,D,0,1,5U4I11,"On the days of the survey, based on personnel file reviews and interviews, the facility failed to ascertain appropriate licensure prior to hire for two of two newly hired nurses reviewed. The findings included: Review of two personnel files of newly hired nurses on 3-2-11 at 8:30 AM revealed that Licensed Practical Nurse #1 had been hired on 8-3-10, but license verification was not done until 9-10-10. Registered Nurse #2 was hired on 9-14-10, but her license was not verified until 9-16-10. During an interview on 3-2-11 at 11:30 AM, the Assistant Administrator verified that the licenses had not been checked until after their hire dates. She stated that a concern had been identified with timely verification of certification for Certified Nursing Assistants, but that the staff had not checked the licensed nurses files for compliance.",2014-12-01
9715,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,441,E,0,1,CHLV11,"On the days of the survey, based on observation, record review, and interview, the facility laundry failed to hygienically cleanse personal colored clothing. The findings included: Observation on 4/20/11 at 7:00 AM revealed 3 washers in the wash cycle with personal colored clothes being cleaned. Laundry Aide #1 was asked the temperature reading of each washer. She pressed the temperature indicator of the 1st washer which read 0 degrees Fahrenheit. She stated that this reading was incorrect and stated there was something wrong or broken with the temperature indicator. The temperature reading of the 2nd washer was 90 degrees, and the third washer temperature reading was 100 degrees. During the rinse cycle on the 3rd washing machine, the temperature indicator read 94 degrees Fahrenheit. Further interview with Laundry Aide #1 revealed the laundry staff used setting #19 on the washers when doing residents' personal clothes which did not contain bleach. She verified these two numbers (19) appeared on the last two digits of the digital readout of each washer indicating that the colored clothes had been washed on that setting. She stated Laundry Staff have no way other than the temperature indicators to know what temperature the laundry is being washed in, and that they do not keep any logs of the temperature readings. Further observation revealed the chemicals used for the laundry were ChlorBrite-(Bleach), Conquest II- which staff stated was a pre-soak, Reliance- which staff stated was the detergent, and Complete- a pink fabric softener. During an interview on 4/20/11 at 7:40 AM, the Laundry Supervisor stated the colored personal clothes were washed at a temperature of 130 degrees Fahrenheit. However, review of the temperatures of the machines while washing personal colored clothes revealed the 2nd washing machine temperature was 96 degrees Fahrenheit, and the 3rd washing machine indicated the temperature was 98 degrees while washing the personal colored clothes. Observation of the water heater supplying the Laundry's water revealed it had been set at a temperature of 130 degrees Fahrenheit. This was verified by the Laundry Supervisor. Review of the Laundry Service Report for October 2010 revealed the temperatures of each washer had been 140 degrees at the time of the service check. An entry in ""Section 2 Follow-Up Needed and Comments"" stated ""...Water Temp(erature) needs to be 160 + or a sanitizer for the color(ed) linen"". It listed the ""Detergent Supply Inventory"" for the products used which included ""Detergent Break- Reliance, Brightener-Builder- Conquest, Chlor(ine) Bleach- ChlorBrite, Softener- Complete"". These were the same chemicals observed currently being used in the Laundry. The Material Safety Data Sheets for these chemicals were requested but not provided. Review of the November 2010 ""Laundry Service Report"" revealed the temperatures on all three washers had been 152 degrees. Under ""Follow-Up Needed and Comments"" was written "" Please note that water Temp(erature) reading on machines only read 152 degrees Fahrenheit, On formulas that don't get bleach (chlorine), Temp(erature) needs to be 160 degrees (Fahrenheit)"". Review of the Laundry Service Report dated 4-18-11 revealed the same chemicals were currently used and that the Chlorine PPM (Parts Per Million) for each machine was at the correct concentration. However, entries where temperatures of the washers were to be logged had been left blank. These were reviewed and verified with the Laundry Supervisor. During an interview on 4/20/11 at 9:00 AM, the sales consultant for the facility's laundry service verified the facility couldn't get the water temperature up to 160 degrees Fahrenheit. He stated they serviced other facilities and had started using a Quat Solution Sanitizer for the colored clothes in those facilities and would put one in place here for use with personal colored clothes so the laundry could be hygienically sanitized.",2014-12-01
9716,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,456,F,0,1,CHLV11,"On the days of the survey, based on observation and interview, the facility failed to properly maintain laundry equipment. Six dryers were observed in use with an excessive build-up of lint in the dryer filters. The findings included: Observation on 4/19/11 at approximately 9:00 AM revealed Dryer #3 and Dryer #4 in use with heavy lint buildup. Dryer #4 also had lint on the floor underneath the dryer filter. This was verified with Laundry Aide #2. She stated that these dryer filters were cleaned twice a day, once in the morning and after the last load at around 1:45 PM. She stated they usually stared the laundry process around 6:30 - 7:00 AM in the morning. She stated that staff do not maintain a log when the dryer filters are cleaned. Observation on 4/19/11 at 11:42 AM revealed Dryers #1, #2, #3, #4, #5, and #6 with heavy lint buildup and lint on the floor beneath the dryer filters. Dryers #1 and #4 had lint billowing out from the filter. This was verified by Laundry Aide #1, who stated the lint filters had not been cleaned since the dryers had been started that morning. She stated they usually cleaned them in the morning and before they left for the day. During an interview on 4/20/11 at approximately 8:00 AM, the Laundry Supervisor stated the dryer filters were only cleaned once a day at the end of the shift.",2014-12-01
9717,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,156,C,0,1,CHLV11,"On the days of the survey, based on review of Medicare Denial Letters/ Liability Notices and interviews, the facility failed to provide the required Liability Notice to Residents A, B, and #20 upon completion of therapy, but having Medicare days left and remaining in the facility. ( 3 of 3 residents reviewed with liability notices.) The findings included: Review of Medicare Denial letters with the Business Office Manager on 4/20/11, revealed that Resident A, Resident B and Resident #20 had not been issued the correct Liability Notice (Form or 1 of the 5 approved forms) upon completion of their therapy. The residents had Medicare days left and were remaining in the facility. The Business Office Manager had issued the Form but stated she was not aware that she also needed to issue the other form.",2014-12-01
9718,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,160,C,0,1,CHLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random review of funds and interview, the facility conveyed funds upon death to the Responsible Party for Residents C, D, E, F and #26 without proper authorization. ( 5 of 5 resident records reviewed for conveyance of funds). The findings included: Review of funds conveyed upon death for Residents C, D, E, F, and #26 on [DATE] revealed that the balance of resident trust accounts for these five residents were made out to each resident's Responsible Party. Resident C expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident D expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident E expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident F expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident #26 expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Regulations stipulate that the funds should be conveyed within 30 days to the individual or probate jurisdiction administering the resident estate. The Business Office Manager had no documentation to show that the persons acting as the Responsible Party prior to death had been appointed Executor of these estates.",2014-12-01
9719,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-08-03,281,G,1,0,EL7K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews, interviews, observations, and review of facility files, the facility failed to ensure the services they provided to residents met professional standards of quality related to managing resident medication allergies and/or sensitivities for 3 of 7 resident records reviewed (Resident #1, #6, and #7); and failed to ensure that a resident sensitive to a medication did not receive that medication for 1 of 1 resident administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes showed the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). The resident returned to the facility on [DATE]. Review of the hospital discharge summary revealed a primary discharge [DIAGNOSES REDACTED]. ""... [MEDICAL CONDITION] was thought to be secondary from Bactrim. The patient was also on [MEDICATION NAME], which could be contributing. .... Nephrology was consulted and confirmed that they suspected Bactrim was the cause of patient's [MEDICAL CONDITION] and not to use Bactrim again..."" The hospital physician orders [REDACTED]. The resident's other allergies were also noted: [MEDICATION NAME] G, [MEDICATION NAME], and [MEDICATION NAME]. Review of the Nursing Data Collection Tool completed on the resident's return showed allergies to [MEDICATION NAME], and [MEDICATION NAME]. It did not note the direction to not use Bactrim again. Review of the Physician order [REDACTED]. Review of the readmission History and Physical completed by the physician's assistant on 2/3/11 showed the note ""... Bactrim is not to be used in this patient again. ..."" Under the section titled Allergies was noted ""PCN ([MEDICATION NAME]), [MEDICATION NAME]. She is not to be given Bactrim."" Review of the medical record failed to show that Bactrim was added to the resident's list of allergies after her return to the facility on [DATE]. The resident was started on [MEDICATION NAME] for knee and back pain on 3/15/11. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop the [MEDICATION NAME], avoid all Nsaids (non-steroidal anti-[MEDICAL CONDITION] agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the Nurses' Notes on 3/31/11 showed the nephrologist's order was received and confirmed by the facility physician. The [MEDICATION NAME] was discontinued. Review of the medical record showed no update to the resident's allergy list for the Bactrim, sulfa, [MEDICATION NAME], Nsaids, ACE, or ARBs as a result of the nephrologist's directions and facility physician's orders [REDACTED]. Review of the pharmacy consultant monthly reports for 2/9/11, 3/14/11, 4/15/11, 5/16/11, and 6/13/11 showed no documentation alerting the staff of the resident's new allergy listings. Review of the Pharmacy Consultant Agreement showed under Medication Regimen Review (MRRs): ""(b) factors to be considered in Conducting MRRs. In conducting the MRR, CONSULTANT shall consider whether: ... (ii) the physician and staff have identified and acted upon, or should be notified about, the resident's allergies and/or potential side effects and significant medication interactions; ..."" On 6/28/11, the resident was started on Bactrim DS (double strength) for a raised, hard area on her left inner wrist, suspicious of [MEDICAL CONDITION]. Blood work done on 7/6/11 showed potassium of 7.2 but the specimen was hemolyzed so a repeat potassium was drawn. The repeat potassium result was 6.6 (normal range 3.5 to 5.1). As a result of the elevated potassium level, the resident required treatment with two doses of [MEDICATION NAME] 30 grams on 7/6/11, 15 grams on 7/7/11, and 30 grams on 7/18/11. The resident's medical record was updated to show her allergies and the medications to avoid after the bout of elevated potassium in July 2011. Review of the medical record revealed the Bactrim DS was ordered on [DATE] to be given twice a day for ten days. The resident took the medication for approximately 8 days, not the four days reported. The Bactrim was discontinued on 7/6/11 after the resident's potassium reached 6.6. An interview with the Director of Nurses (DON) on entering the facility revealed she concluded her audit of readmission charts on 7/22/11 and found only one resident whose chart did not reflect all her allergies (#7). Resident #7 arrived at the facility in September 2010. Her [DIAGNOSES REDACTED]. The resident returned to the facility from a hospitalization on [DATE] and again on 7/28/11. Review of the medical record revealed a History and Physical dated 9/7/10 that showed the physician identified the resident's allergies as: shellfish, [MEDICATION NAME], and [MEDICATION NAME]. The History and Physical of 7/28/11 noted allergies to ammonia, [MEDICATION NAME], shellfish, and [MEDICATION NAME]. The monthly cumulative physician orders; hospital discharge documents; and Nursing Data Collection Tools of 9/2/10, 3/5/11, 7/14/11, and 7/28/11 all showed allergies to ammonia water, [MEDICATION NAME], and shellfish. The resident's record was not updated as a result of the DON's audit completed on 7/22/11. A telephone order dated 8/3/11 at 11:45 AM stated: ""Order clarification Resident is allergic to [MEDICATION NAME]."" Handwritten allergy notices were added to the printed monthly physician's orders [REDACTED]. The medical records of five residents admitted to the facility after 7/22/11 revealed one resident with conflicting allergy medication (#6). Resident #6 arrived at the facility on 7/26/11. His [DIAGNOSES REDACTED]. Review of the hospital discharge information revealed the resident was allergic to [MEDICATION NAME], and Rosuvastatin. The physician's orders [REDACTED]. Continued record review showed an additional allergy to [MEDICATION NAME] on the medical record face sheet, Medication Administration Record, [REDACTED]""OK per Brian in pharmacy."" Review of the medical record failed to show any source for the information that the resident was allergic to [MEDICATION NAME]. The DON was asked to assist in determining the resident's allergy status. She reported that the Admissions Director received the information and documented it in the admission intake notes, which was not part of the permanent medical record. The Admissions Director stated the resident's daughter told her that [MEDICATION NAME] caused confusion in the resident. Review of the facility's Nursing Policies and Procedures Subject: Allergy History revealed the admitting nurse was to obtain the allergy history, document, and communicate findings with the appropriate staff. Allergies were to be recorded on the plan of care, nurse's assessment form, Minimum Data Set, Medication Administration Record, [REDACTED]. An allergy label was to be attached to the front of the chart. Dietary was to be notified of food allergies. The nurse was to advise the physician of any allergies when notifying him of the admission. Any adverse reactions or suspected allergies were to be documented and reported to the physician. A resident's allergies were to be included in the discharge summary and responsible party information at discharge. An interview with the DON at 10:30 AM revealed the floor nurses did the admission paperwork. They followed two separate checklists, one for the physician and one developed by the DON in effect since Spring 2011. The condition alert was done first. Orders from the hospital were then transcribed onto the physician's orders [REDACTED]. Allergies were to be noted on the transcribed physician orders. Cross Refer to F-333 as it related to the failure of the licensed staff to follow facility policy in ensuring all allergies were noted at the time of admission and documentation of any current or newly identified allergies was present and notification to appropriate staff was completed.",2014-12-01
9720,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-08-03,333,G,1,0,EL7K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interviews, the facility failed to ensure that a resident sensitive to a medication did not receive that medication for 1 of 1 resident who was administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes showed the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). Resident #1 returned to the facility on [DATE]. Review of the hospital discharge summary revealed a primary discharge [DIAGNOSES REDACTED]. ""... [MEDICAL CONDITION] was thought to be secondary from Bactrim. The patient was also on [MEDICATION NAME], which could be contributing. .... Nephrology was consulted and confirmed that they suspected Bactrim was the cause of patient's [MEDICAL CONDITION] and not to use Bactrim again. ..."" The hospital physician orders [REDACTED]. The resident's other allergies were also noted: [MEDICATION NAME] G, [MEDICATION NAME], and [MEDICATION NAME]. Review of the Nursing Data Collection Tool completed on the resident's return showed allergies to [MEDICATION NAME], and [MEDICATION NAME]. It did not note the direction to not use Bactrim again. Review of the Physician order [REDACTED]. Review of the readmission History and Physical completed by the physician's assistant on 2/3/11 showed the note ""... Bactrim is not to be used in this patient again. ..."" Under the section titled Allergies was noted ""PCN ([MEDICATION NAME]), [MEDICATION NAME]. She is not to be given Bactrim."" Review of the medical record failed to show that Bactrim was added to the resident's list of allergies after her return to the facility on [DATE]. The resident was started on [MEDICATION NAME] for knee and back pain on 3/15/11. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop the [MEDICATION NAME], avoid all Nsaids (non-steroidal anti-[MEDICAL CONDITION] agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the Nurses' Notes on 3/31/11 showed the nephrologist's order was received and confirmed by the facility physician. The [MEDICATION NAME] was discontinued. Review of the medical record showed no update to the resident's allergy list for the Bactrim, sulfa, [MEDICATION NAME], Nsaids, ACE, or ARBs as a result of the nephrologist's directions and facility physician's orders [REDACTED]. Review of the pharmacy consultant monthly reports for 2/9/11, 3/14/11, 4/15/11, 5/16/11, and 6/13/11 showed no documentation alerting the staff of the resident's new allergy listings. Review of the Pharmacy Consultant Agreement showed under Medication Regimen Review (MRRs): ""(b) factors to be considered in Conducting MRRs. In conducting the MRR, CONSULTANT shall consider whether: ... (ii) the physician and staff have identified and acted upon, or should be notified about, the resident's allergies and/or potential side effects and significant medication interactions; ..."" On 6/28/11, the resident was started on Bactrim DS (double strength) for a raised, hard area on her left inner wrist, suspicious of [MEDICAL CONDITION]. Blood work done on 7/6/11 showed potassium of 7.2 but the specimen was hemolyzed so a repeat potassium was drawn. The repeat potassium result was 6.6 (normal range 3.5 to 5.1). As a result of the elevated potassium level, the resident required treatment with two doses of [MEDICATION NAME] 30 grams on 7/6/11, 15 grams on 7/7/11, and 30 grams on 7/18/11. The resident's medical record was updated to show her allergies and the medications to avoid after the bout of elevated potassium in July 2011. The facility reported to the State survey and certification agency on 7/21/11 that the resident's allergies had not been updated after the January 2011 hospitalization , resulting in the administration of Bactrim again in June and July 2011. ""... The contraindication was not brought forward to the record/MAR (medication administration record). On June 28, 2011, the attending physician ordered Bactrim and Ms. ... (sic) The issue was discovered during our QA process and stopped after four days on July 6, 2011. Ms. ... was tested and found to have elevated potassium (6.6 meq/L). The elevation was treated and resolved with no adverse effects. All of the documentation has been updated and a QA/PI (quality assessment/performance improvement) action plan was initiated on July 13, 2011 and reported to the monthly PI Committee on July 20, 2011. ..."" Review of the medical record revealed the Bactrim DS was ordered on [DATE] to be given twice a day for ten days. The resident took the medication for approximately 8 days, not the four days reported. The Bactrim was discontinued on 7/6/11 after the resident's potassium reached 6.6. The facility's action plan for Orders and Allergies From Readmission Discharge Summaries was dated 7/13/11. Review of the facility's Nursing Policies and Procedures Subject: Allergy History revealed the admitting nurse was to obtain the allergy history, document, and communicate findings with the appropriate staff. Allergies were to be recorded on the plan of care, nurse's assessment form, Minimum Data Set, Medication Administration Record, [REDACTED]. An allergy label was to be attached to the front of the chart. Dietary was to be notified of food allergies. The nurse was to advise the physician of any allergies when notifying him of the admission. Any adverse reactions or suspected allergies were to be documented and reported to the physician. A resident's allergies were to be included in the discharge summary and responsible party information at discharge. An interview with the DON at 10:30 AM revealed the floor nurses did the admission paperwork. They followed two separate checklists, one for the physician and one developed by the DON in effect since Spring 2011. The condition alert was done first. Orders from the hospital were then transcribed onto the physician's orders [REDACTED]. Allergies were to be noted on the transcribed physician orders.",2014-12-01
9721,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-08-03,428,G,1,0,EL7K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and review of the monthly consulting pharmacy reports, the facility failed to ensure that the pharmacy consultant reported irregularities concerning medication sensitivities for 1 of 1 resident who was administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes indicated the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Again Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition, but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). Review of Resident #1's medical record revealed the facility was alerted by her nephrologist on 1/19/11 and again on 3/31/11 that she should not be given Bactrim. Bactrim was determined to cause hyperkalemia in the resident. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop Naproxen which had been ordered for knee and back pain 3/15/2011, avoid all Nsaids (non-steroidal anti-inflammatory agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the pharmacy consultant's monthly reports for 2/9/11, 3/14/11, 4/15/11, and 6/13/11 showed no documentation alerting the physician or facility staff of the resident's new allergy listings. Bactrim was ordered for Resident #1 on 6/28/11 causing the resident's potassium level to again rise above normal range which required repeated treatment with Kayexalate to bring it down to within normal limits. Cross refer to F-333 as it relates to Resident #1's identified allergy to the medication Bactrim and the pharmacy consultant's failure to address this during monthly review.",2014-12-01
9722,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2011-08-03,520,F,1,0,EL7K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews, observations, interviews, and review of the monthly consultant pharmacy reports, the facility failed to ensure that it's quality assessment and assurance committee identified and put appropriate corrective actions in place timely to address residents with allergy alerts so that the information was clearly communicated to staff for 3 of 7 resident records reviewed (Resident #1, #6, and #7). The findings included: Review of Resident #1's medical record revealed the facility was alerted by the resident's nephrologist on 1/19/11 and again on 3/31/11 that she should not be given Bactrim. Bactrim was determined to cause [MEDICAL CONDITION] in the resident. The facility's medical and nursing staff, and consulting pharmacist, failed to address this directive. Bactrim was ordered on [DATE], administered to the resident for 8 days causing the resident's potassium level to rise above normal range, which required repeated treatment with [MEDICATION NAME] to bring it down to within normal limits. The facility reported to the State survey and certification agency on 7/21/11 that the resident's sensitivity to Bactrim had been brought to it's Quality Assurance committee and the following corrective actions were put in place to avoid any similar problems: 1. All of Resident #1's documentation was updated to show her drug sensitivities. 2. Chart audits for all residents readmitted to the facility from the hospital in the past six months were audited, with corrections made to the records as needed. 3. Staff training on allergy alert protocols were to be done. Although the facility did identify the problem on 7/6/2011, the action plan was not developed until 7/13/2011. Resident #6 arrived at the facility on 7/26/11. His [DIAGNOSES REDACTED]. Resident #7 arrived at the facility in September 2010. Her [DIAGNOSES REDACTED]. The resident returned to the facility from a hospitalization on [DATE] and again on 7/28/11. Cross Refers to F-333 as it relates to the facility failure to follow the quality assessment and assurance in regards to Resident #1's drug allergies [REDACTED]. Resident #7, who was included in the chart audit, was allergic to [MEDICATION NAME] but her chart had not been updated. Resident #6, a new admission, was noted to be allergic to [MEDICATION NAME] but there was no source information in his medical record.",2014-12-01
9723,VALLEY FALLS TERRACE INC,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2011-05-10,164,D,0,1,5Y6011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the policy provided by the facility entitled ""Catheter Care (Indwelling Catheter)"", the facility failed to provide full visual privacy for one of one sampled residents observed for catheter care. Resident #6 was not draped appropriately during catheter care. The findings included: The facility admitted Resident #6 on 5/1/89 and readmitted her on 4/18/11 with [DIAGNOSES REDACTED]. Observation of catheter care on 5/9/11 at 2:30 PM revealed Licensed Practical Nurse (LPN) #3 unfastening the resident's brief and pulling her gown up so that LPN #2 could perform catheter care. LPN #2 and LPN #3 left the bedside to wash their hands leaving Resident #6 exposed from her waist down to her feet. The resident continued to lay exposed as LPN #2 stood by the bed while she donned gloves and LPN #3 left the room to get another glove. When LPN #3 returned to the room, LPN #2 finished performing catheter care and then LPN #3 fastened the resident's brief and fixed her sheets. During an interview on 5/9/11 at 2:40 PM, LPN #2 and LPN #3 verified they had left the resident uncovered while they went to wash their hands and while LPN #3 went out of the room to get a glove. Review of the policy provided by the facility on 5/10/11 entitled ""Catheter Care (Indwelling Catheter) revealed under ""General Resident Rights Guidelines"" to ""...Screen and drape resident for maximum privacy"".",2014-12-01
9724,VALLEY FALLS TERRACE INC,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2011-05-10,225,D,0,1,5Y6011,"On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled ""Resident Abuse Policy"", the facility failed to report alleged abuse to the appropriate agency. Review of one of one reportable incidents revealed alleged physical abuse had not been reported to DHEC (Department of Health and Environmental Control) Certification. The findings included: Review of reportable incidents of alleged abuse on 5/9/11 at 5:20 PM revealed an incident of alleged physical abuse that occurred on 4/4/11 in which a resident alleged a Certified Nursing Assistant (CNA) slapped her. According to documentation provided by the facility, the Ombudsman was notified on 4/11/11 along with DHEC Licensure. The facility could provide no documentation that DHEC Certification had been notified. During an interview on 5/10/11 at 8:25 AM , the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 could provide no documentation that DHEC Certification had been notified. During an interview on 5/10/11 at 10:20 AM, LPN #1 stated that the incident occurred on 4/4/11 and the report had been sent to Licensure and the Ombudsman on 4/11/11. She stated she was aware that there was an initial 24 hour report and a 5-day follow up report that should have been sent to Certification. Review of the policy provided by the facility on 5/10/11 entitled ""Resident Abuse Policy"" revealed under ""Reporting"" that ...""A. Alleged violations involving abuse of any kind, neglect, injuries of unknown origin, misappropriation of resident property, involuntary seclusion or corporal punishment are reported accordingly...E. The initial report must be phoned or faxed by the Director of Nursing or the Administrator or designees within 24 hours to appropriate agencies to include Ombudsman, DHEC Certification and Licensure and /or appropriate law enforcement agencies"".",2014-12-01
9725,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,157,J,1,0,NOG311,"**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 at a scope and severity level of ""J"" related to the facility's failure to notify the physician of changes in condition and failed to notify the responsible party of changes in condition. Facility staff failed to notify Resident #3's physician and responsible party of an increase in sexually inappropriate behaviors. The facility also failed to notify Resident #4 and Resident #6's physician and or responsible party that they were the victims of sexually inappropriate behavior. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 8/5 at 6:55 AM, Resident #3 was ""noted with hand between female resident's (Resident #4's) legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. "" On 8/23 at 8 AM, "" resident exposed himself to a female resident in TV area. Was redirected and taken back to room. "" On 8/24 at 5 PM, "" Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. "" There was no evidence that the Physician or the Responsible party were notified of the incidents on 8/5, 8/23 or 8/24. There was no other documentation of Resident #3's sexually inappropriate behavior. No female residents were identified in the records. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Record Review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual assaults that had occurred and there was no evidence Resident #4 had been examined by a physician related to the sexual assaults. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member had come to speak with her about the incidents. Record review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. During an interview with Resident ""A"" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident ""A"" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident ""A"" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records of Resident #3 or #4 related to the incident identified by Resident ""A"". During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant reported to her that Resident #3 was touching Resident #4 inappropriately. LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:25 PM, the Director of Nurses stated that she was not aware of the incident on 8/5 between Resident #3 and #4. She confirmed that neither the family or the physician were notified of the incident. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were "" manageable. "" He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the "" status quo was not working and there were other things we could have tried."" He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. Additional information provided by the physician and facility noted an order was written on 8/9/2011 to add the medication [MEDICATION NAME] for ""aggression"". No documentation was provided to clarify the type of ""aggression"". Review of the facility's policy on "" Physician Notification "" did not include any reference to WHEN staff should notify the physician. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9726,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,223,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on observations, record review, and interview, Substandard Quality of Care and Immediate Jeopardy at a scope and severity of ""J"" was identified related to the facility's failure to provide the necessary care and services to prevent Resident #3 from sexually abusing other residents and the facility's failure to identify and protect those residents that were alleged to be sexually abused. On 8/5/2011 Resident #4 was allegedly sexually abused by Resident #3. Resident #3 also allegedly sexually harassed Resident #6. The facility failed to put interventions in place to protect Resident #4 and Resident #6 and other residents that had the potential to be sexually abused by Resident #3. In addition, a Certified Nursing Assistant failed to report to facility staff an allegation of resident to resident sexual abuse. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of "" resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . "" Approaches included "" make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. "" The Care Plan was not updated with the resident's behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5 PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in "" day room exposing private part. "" There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, "" res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. "" On 6/30 at 11AM, "" res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. "" At 12:20 PM, "" nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. "" At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. "" On 7/1/2011 at 1:30 PM, "" Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. "" Resident #3 was admitted to Carolina Behavioral Health from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. Continued review of the Nurses Notes revealed Resident #3 was admitted back to the facility on [DATE]. On 7/12/2011 at 7 PM, Resident #3 "" hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. "" At 7:20 PM, "" GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). "" At 7:25 PM, sister notified by social worker of resident's behavior. "" On 7/23 at 3:30 PM, "" resident exposed his penis to (Certified Nursing Assistant). "" On 7/25 at 2 PM, "" Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. "" On 7/26 at 3PM, "" several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. "" On 8/5 at 6:55 AM, "" noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. "" On 8/23 at 8 AM, "" resident exposed himself to a female resident in TV area. Was redirected and taken back to room. "" On 8/24 at 5 PM, "" Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. "" Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: "" he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually send them back with no treatment. There is not always an availability in a psych setting. "" On 7/23, "" DON notified me that (Res #3) had exposed himself to a CNA. When I visited he was sleeping as normal. "" On 7/25, "" DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. "" On 7/26, Res #3 "" has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. "" On 7/27 a care plan meeting was held and social services documented the following: "" (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... "" On 8/5, "" received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, "" oh. "" I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. "" On 8/24, "" DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. "" Review of the 24 Hour Reports revealed on 7/12 Resident #3's behaviors were not included on the reports. On 7/23, Resident #3's behaviors were not on the report. On 7/25, Resident #3's exposing self and changes in orders were added. On 7/26, "" PRN [MEDICATION NAME] was used, inappropriate behavior. "" On 8/5, Resident #3's behaviors were not included on the report. On 8/9, "" inappropriate touching "" was added to the report for Resident #3. No other entries were recorded on the 24 hour reports for Resident #3 until 8/24 that indicated "" exposing himself again this evening in hallway-redirected, DON made aware. "" No consistent behavior monitoring was put in place for Resident #3. Incidents of inappropriate behavior that were documented usually did not provide enough details to determine who may be involved or what did occur. The documentation was often very limited and not found in a consistent location. Review of the Progress Notes revealed Resident #3 had a Psych Consult on 1/12/2010 and the medication [MEDICATION NAME] was added. On 1/26/2010, the Psychiatrist discontinued the [MEDICATION NAME] due to increased confusion. There was no other indication that the Psychiatrist had assessed the resident in the facility. Further review revealed no physician progress notes [REDACTED]. Review of the History and Physical dated 7/12/2011 revealed "" elderly gentleman with history of dementia having increased agitation, aggression and sexual inappropriateness. He went to Carolina Center for Behavioral Health. Initially he was very pleasant; however, after admission he became sexually inappropriate. He had several medication changes made. He was also started on [MEDICATION NAME]. Behaviors gradually improved. He stabilized and was transferred here for further care. "" Resident #3 was seen by the GNP for dry scaly skin. On 7/25, the GNP again saw Resident #3 for "" sexually aggressive behaviors. I will increase his [MEDICATION NAME] and schedule [MEDICATION NAME] and monitor his behaviors. "" No other progress notes were located. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence's were: "" 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). "" No other incident reports were found related to Resident #3's sexually inappropriate behaviors. Review of the Physician order [REDACTED].#3 had [MEDICATION NAME] 75 mg PO BID ordered and "" to report to MD in one week re: behaviors. On 6/30 the [MEDICATION NAME] was increased to 150 mg BID. Review of the Cumulative Orders from July 1, 2011 revealed Resident #3 was prescribed [MEDICATION NAME] 4.5 mg BID, [MEDICATION NAME] 10 mg BID and [MEDICATION NAME] 75 mg BID. Resident #3's readmission orders [REDACTED]. On 7/12/2011, [MEDICATION NAME] 10 mg PO every 12 hours PRN was ordered in addition to the IM [MEDICATION NAME]. On 7/25/2011 the [MEDICATION NAME] was increased to 300 mg BID and [MEDICATION NAME] was scheduled 10 mg every day and 10 mg once daily PRN, all previous [MEDICATION NAME] PRN orders were discontinued. On 7/27 a U/A was ordered and on 8/2 [MEDICATION NAME] was started for a UTI. On 8/9 [MEDICATION NAME] 25 mg and then increased to 50 mg was started for "" aggression. "" Review of Nurses Notes revealed there were no nurses notes that corresponded to the orders for a UA (Urinalysis) on 7/27/2011 and for the [MEDICATION NAME] addition on 8/9/2011 for depression. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she had witnessed Resident #3 touching female residents inappropriately. She stated that she immediately would remove the resident and redirect him. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 inappropriately touching other female residents. She stated that Resident #3 "" mostly goes after "" Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 touched her inappropriately. CNA#1 stated that she did not inform the nurse of the report of sexual abuse for Resident #6. CNA#1 then stated Resident #3 would go into other resident's rooms and lay down in their beds. During an interview with Resident ""A"" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident ""A"" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident ""A"" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident ""A"". The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #4 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual assaults. Record Review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member had come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents and no interventions had been put in place related to the incidents. During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 "" had her pants on. "" LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:25 PM, the Director of Nurses stated that she was not aware of the incident on 8/5 between Resident #3 and #4. She confirmed that neither the family or the physician were notified of the incident. The DON also confirmed there were not any incident reports related to Resident #3's sexually aggressive behavior. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were "" manageable. "" He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the "" status quo was not working and there were other things we could have tried."" He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/11 at 10:10 AM, the Medical Director stated that he was aware of Resident #3's sexually aggressive behaviors prior to his psychiatric hospitalization . He stated that he was informed today (8/30) of Resident #3's sexually inappropriate behavior since his readmission on 7/11. The Medical Director stated that he was usually made aware of Resident issues if the facility had a concern, the severity of the incident or if the resident continued to have ongoing problems. He stated that he wouldn't be notified of every occurrence but should have been notified of Resident #3's behaviors. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there "" was nothing else to do. "" She stated that the resident was on "" the list to move to the men's unit. "" When asked where the list was, the DON stated that there was not an actual list, it was "" in our heads who is next to move. "" The Administrator then stated that she couldn't "" just move someone "" and it was "" based on bed availability "" and there were no beds available. The Administrator confirmed that the ""Men's Unit"" was not a designated unit and female residents reside on the unit; she confirmed that that unit had a heavier concentration of male residents. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's In-Services revealed on June 1, 2011 an in-service was conducted that included: "" what do you do if see/hear abuse-Report to Supervisor who report to Administrator and DON. "" Also included were "" How to manage difficult residents. "" The types of Abuse were also included as well as "" timely reporting "" and "" zero tolerance! "" "" Any abuse- not for us to decide its "" just behavior, just normal. "" On 6/21/2011 an in-service was conducted, topics included "" Nursing Documentation: change in condition or unusual occurrence happens (behavior...). "" Also attached to the in-service was an email from the Corporate Educator Administrator that revealed: "" documentation in-service should cover legal aspects of documentation as well as how and when to document changes in condition and notification to responsible party. You could go over what is needed for...behavior monitoring...Social Services- would need to address any type of documentation that indicates a social need, clothing need, [MEDICAL CONDITION] medication/behavior monitoring... "" On 7/5/2011 an in-service was conducted on Abuse and Neglect. "" The 7 Types of Abuse: 7. Sexual-Inappropriate touching in private areas (genitalia, breasts etc.). "" Twenty six CNAs attended the in-service and 14 nurses attended. CNA#1 attended on 7/5/2011 and attended the 6/1/2011 in-service Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-223 as it relates to the facility's failure to provide the necessary care and services to prevent, identify and protect against sexual abuse. Cross Refer to F-226 as it relates to the facility's failure to implement the policy on sexual abuse related to the identification and protection of residents. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. Cross Refer to F-490 as it relates to the facility's failure to assure Resident #3's behaviors were monitored consistently and failed to assure effective interventions were put in place for the sexually inappropriate behaviors. The facility's Administration also failed to assure two identified residents that were victims of sexually inappropriate behavior received the necessary care and services related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9727,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,226,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on observation, record review, interview and review of the facility's Abuse Neglect Policy, Substandard Quality of Care and Immediate Jeopardy was identified at a scope and severity of ""J"" related to the facility's failure to implement the policy on sexual abuse related to the protection of residents. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. On 8/5 Resident #3 allegedly sexually abused Resident #4. Resident #6 reported an incident of sexual abuse/harassment to CNA#1. During an interview on 8/29 at 3:20 PM, LPN (Licensed Practical Nurse) #2 stated that a nursing assistant had notified her that Resident #3, independently mobile, had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she has witnessed Resident #3 touching female residents inappropriately. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 inappropriately touching other female residents. She stated that Resident #3 "" mostly goes after "" Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 had touched her inappropriately. CNA#1 stated that she did not inform the nurse of the report of sexual abuse for Resident #6. Review of the facility's policy on Abuse and Neglect revealed: "" Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. "" "" 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. "" Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-223 as it relates to the facility's failure to provide the necessary care and services to prevent, identify and protect against sexual abuse. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. Cross Refer to F-490 as it relates to the facility's failure to assure Resident #3's behaviors were monitored consistently and failed to assure effective interventions were put in place for the sexually inappropriate behaviors. The facility's Administration also failed to assure two identified residents that were victims of sexually inappropriate behavior received the necessary care and services related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9728,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,250,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, based on interviews, review of facility policy on Abuse and Neglect, and record review, the facility failed to ensure that one of one resident reviewed (Resident #3) with identified inappropriate sexual behaviors, received the necessary social service intervention to attain the highest practicable psychosocial well being and 2 of 2 residents reviewed (Resident #4 & #6) that were victims of alleged sexual abuse received assessment and followup by social services after the alleged incidents. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in "" day room exposing private part. "" There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, "" res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. "" On 6/30 at 11AM, "" res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. "" At 12:20 PM, "" nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. "" At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) Trileptal back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. "" On 7/1/2011 at 1:30 PM, "" Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. "" Resident #3 was admitted to Carolina Behavioral Health from 7/1-7/11/11. Provera 5 mg was added to Resident #3's medication regime during the admission. The resident returned to the nursing home on 7/11/2011. Further review of the nurse's notes revealed on 7/12/2011 at 7 PM, Resident #3 "" hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. "" At 7:20 PM, "" GNP (General Nurse Practitioner) notified, new orders received for Geodon 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue Geodon 10 mg IM (intramuscularly). "" At 7:25 PM, sister notified by social worker of resident's behavior. "" On 7/23 at 3:30 PM, "" resident exposed his penis to (Certified Nursing Assistant). "" On 7/25 at 2 PM, "" Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. "" On 7/26 at 3PM, "" several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN Geodon given 2 hours p (after) scheduled Geodon...Will report to oncoming nurse. "" On 8/5 at 6:55 AM, "" noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. "" On 8/23 at 8AM, "" resident exposed himself to a female resident in TV area. Was redirected and taken back to room. "" On 8/24 at 5PM, "" Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. "" During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 "" had her pants on. "" LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: "" he has a PRN order for IM Geodon but no PRN by mouth. Nurse called the NP and she gave order for PRN PO Geodon every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. "" On 7/23, "" DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. "" On 7/25, "" DON spoke with (GNP) She increased dosage of Trileptal and gave scheduled dose of Geodon. He did expose himself in the day room this day but was redirected by staff. "" On 7/26, Res #3 "" has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. "" On 7/27 a care plan meeting was held and social services documented the following: "" (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no lasting results... "" On 8/5, "" received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, "" oh. "" I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. "" On 8/24, "" DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. "" Review of the Progress Notes revealed on 7/25, the GNP saw Resident #3 for "" sexually aggressive behaviors. I will increase his Trileptal and schedule Geodon and monitor his behaviors. "" No evidence of consistent monitoring of behavior or psychiatric evaluation was provided. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: "" 1. Provider updated on incident and Geodon ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). "" No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were "" manageable. "" He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the "" status quo was not working and there were other things we could have tried. "" He stated that if he was made aware he would have changed the medications, increased the Provera, send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there "" was nothing else to do. "" She stated that the resident was on "" the list to move to the men's unit. "" When asked where the list was, the DON stated that there was not an actual list, it was "" in our heads who is next to move. "" The Administrator then stated that she couldn't "" just move someone "" and it was "" based on bed availability "" and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: "" Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. "" "" 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. "" The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual abuse. Record Review revealed no documentation of any sexual assault in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member has come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9729,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,280,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to review and revise the care plan of 1 of 1 resident reviewed (Resident #3) with identified inappropriate sexual behaviors when the behaviors began to increase and involve other residents. The facility also failed to assess and revise the care plans of 2 of 2 residents reviewed (Residents #4 & #6) that were alleged victims of sexual abuse. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of "" resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . "" Approaches included "" make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. "" The Care Plan was not updated with the resident's recent behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in "" day room exposing private part. "" There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, "" res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. "" On 6/30 at 11AM, "" res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. "" At 12:20 PM, "" nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. "" At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. "" On 7/1/2011 at 1:30 PM, "" Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. "" Resident #3 was admitted from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. On 7/12/2011 at 7 PM, Resident #3 "" hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. "" At 7:20 PM, "" GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). "" At 7:25 PM, sister notified by social worker of resident's behavior. "" On 7/23 at 3:30 PM, "" resident exposed his penis to (Certified Nursing Assistant). "" On 7/25 at 2 PM, "" Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. "" On 7/26 at 3PM, "" several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. "" On 8/5 at 6:55 AM, "" noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. "" On 8/23 at 8AM, "" resident exposed himself to a female resident in TV area. Was redirected and taken back to room. "" On 8/24 at 5PM, "" Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. "" Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD documented: "" he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. "" On 7/23, "" DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. "" On 7/25, "" DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. "" On 7/26, Res #3 "" has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. "" On 7/27 a care plan meeting was held and social services documented the following: "" (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... "" On 8/5, "" received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, "" oh. "" I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. "" On 8/24, "" DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. "" No evidence of any consistent behavior monitoring was put in place for Resident #3. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: "" 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). "" No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview with Resident ""A"" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident ""A"" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident ""A"" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident ""A"". During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were "" manageable. "" He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the "" status quo was not working and there were other things we could have tried. "" He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there "" was nothing else to do. "" She stated that the resident was on "" the list to move to the men's unit. "" When asked where the list was, the DON stated that there was not an actual list, it was "" in our heads who is next to move. "" The Administrator then stated that she couldn't "" just move someone "" and it was "" based on bed availability "" and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. Review of the Care Plan dated 12/2010 revealed Resident #4 had a problem area identified related to combative behaviors and resisting care. The Care Plan had not been updated and no new interventions had been added related to the sexual abuse. Record Review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #4. Resident #4's Attending Physician and the Responsible Party had not been notified of the sexual abuse that had occurred. There was no evidence Resident #4 had been examined by a physician related to the sexual abuse. No interventions had been put in place related to the incidents. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/29/2011 at 2:10 PM, Resident #6 stated Resident #3 was in the hallway and rubbed her arm and thigh and commented on how pretty she was and how nice her legs were. Resident #6 asked him to stop and he continued rubbing her leg. Resident #6 then removed Resident #3's hand from her body and left the area. Resident #6 stated that she reported the incident to CNA#1. Resident #6 stated that Resident #3 would also come to her doorway and expose himself to her. She stated that she would press the call light and staff would come down and move Resident #3. She stated that the staff did not do anything for her. Resident #6 stated that she felt uncomfortable and whenever she saw Resident #3 in the area she would leave and go in the other direction. Resident #6 stated that no staff member has come to speak with her about the incidents. Record review revealed no documentation of any sexual abuse in the Nurses Notes, Social Service Notes or Progress Notes. Further review revealed no behavior monitoring for Resident #6. Resident #6's Attending Physician had not been notified of the incidents. No interventions had been put in place related to the incidents. On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9730,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,319,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, based on record review, interview, review of facility policy Abuse and Neglect, and observation, the facility failed to ensure that 1 of 1 resident reviewed (Resident #3) with aggressive/sexually inappropriate behaviors was monitored consistently and had effective interventions put in place to prevent escalation of the problem and protect Resident #3 and/or other residents at the facility from harm. The findings included: The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. Review of the Care Plan dated 11/24/2010 and printed on 7/27/2011, revealed a problem area of "" resident has hx (history) of becoming aggressive leading him to strike at staff and peers. This could be related to impaired hearing and vision keeping him from understanding what is taking place. Has also been sexually inappropriate requiring psych hospitalization . "" Approaches included "" make all staff aware of the fact that resident can be aggressive and sexually inappropriate, approach resident carefully making sure you have gained his attention, check with resident to make sure he has heard and comprehended what you have said to him, work in pairs if indicated, if behaviors persist, obtain further medical intervention, Psych consult done [DATE]. Will ask for follow up related to recent behaviors, administer medications, observe closely for inappropriate sexual behavior and gently redirect and remove from situation. "" The Care Plan was not updated with the resident's behaviors and no new interventions for the sexually inappropriate behaviors were added to the Care Plan. Review on 8/29/2011 of the Nurses Notes revealed an entry dated 6/21 at 12:15 PM, Resident #3 was placed on every 30 minute checks for sexually inappropriate behaviors. Review of the 30 minute check documentation from 6/21-6/24 revealed Resident #3 did not have documentation of his whereabouts on 6/22 from 5PM to 7PM, 6/23 from 5AM-7AM, 6/23 from 11:30 PM to 7 AM on 6/24. On 6/24/2011 at 11:45 AM, Resident #3 was observed in "" day room exposing private part. "" There were no other 30 minute checks after 12 PM on 6/24/2011. Further review of the nurses notes revealed on 6/25 at 11:45 AM, "" res(ident) up in front of nurses station exposing self to staff and other res. Res took in room and explained not to expose self to staff and res clothes helped back on and res taken back to nursing station per his request. "" On 6/30 at 11AM, "" res in hallway, parked in w/c (wheelchair) next to a female resident c (with) his pants open and his penis exposed-This nurse quickly went to res and asked him to please pull up his pants, Res looked angry and did pull his pants up also asked res to zip his pants, Res did this. Made DON (Director of Nurses) and Social Services aware. "" At 12:20 PM, "" nurse observed res back in hall exposing himself to a female resident and I immediately removed this res from hall and transferred to his room. I immediately notified DON of this as well. "" At 1PM, the Attending Physician updated on (increasing) sexual behaviors and orders received to (increase) [MEDICATION NAME] back to 150 mg BID (twice daily), check U/A (urinalysis) and f/u (follow up) c Carolina Behavioral Health. "" On 7/1/2011 at 1:30 PM, "" Resident in front of nurses station touching a female resident's shoulder c pants open and penis hanging out. Separated from resident immediately and taken to room for lunch. DON notified. Resident ate lunch and then transported by transport to Carolina Behavioral Health. Sister notified and she stated she was waiting on him at the facility. "" Resident #3 was admitted from 7/1-7/11/11. [MEDICATION NAME] 5 mg was added to Resident #3's medication regime. On 7/12/2011 at 7 PM, Resident #3 "" hit this nurse on the left side of nurses' face, then hit this nurse in the face. DON notified. DON took resident to his room and talked with resident. "" At 7:20 PM, "" GNP (General Nurse Practitioner) notified, new orders received for [MEDICATION NAME] 10 mg PO PRN q 12 hours (by mouth as needed every 12 hours), continue [MEDICATION NAME] 10 mg IM (intramuscularly). "" At 7:25 PM, sister notified by social worker of resident's behavior. "" On 7/23 at 3:30 PM, "" resident exposed his penis to (Certified Nursing Assistant). "" On 7/25 at 2 PM, "" Resident exposed himself in day room. Redirected to room. Laying down on bed. Will report to oncoming nurse. "" On 7/26 at 3PM, "" several episodes of inappropriate behavior this shift, nurse re-directed x2 of approaching female residents. Exposed himself in PT and in hallway, PRN [MEDICATION NAME] given 2 hours p (after) scheduled [MEDICATION NAME] report to oncoming nurse. "" On 8/5 at 6:55 AM, "" noted with hand between female resident's legs, touching inappropriately. Resident removed from the area and instructed not to touch other residents, that behavior was inappropriate. Resident was noted touching same resident inappropriately and moved to another area but went back to lounge sitting area, will monitor closely. "" On 8/23 at 8AM, "" resident exposed himself to a female resident in TV area. Was redirected and taken back to room. "" On 8/24 at 5PM, "" Res observed exposing himself in the hallway on Station 1. This nurse asked Res to please pull his underwear up and his pants-Res complied-Assisted back to the privacy of his room-DON immediately notified. "" Review of the Social Service Progress Notes revealed on 7/12/2011 the Social Services Director (SSD) met with Resident #3 regarding him striking a staff member in the face causing a bloody nose. The SSD document: "" he has a PRN order for IM [MEDICATION NAME] but no PRN by mouth. Nurse called the NP and she gave order for PRN PO [MEDICATION NAME] every 12 hours. I called (RP) to let her know what had occurred. I asked her if she ever knew of (Res #3) being abused as a child and she said no...(the RP) felt (Resident #3's child hood residence) would have been a rough neighborhood. The nurse practitioner said if this behavior occurred again to send him out. We have tried this in the past but for emergent psychiatric care, they have to go through the ER and if he is calm when he gets there, they usually sent them back with no treatment. There is not always an availability in a psych setting. "" On 7/23, "" DON notified me that (Res #3) had exposed himself to a CNA___. When I visited he was sleeping as normal. "" On 7/25, "" DON spoke with (GNP) She increased dosage of [MEDICATION NAME] and gave scheduled dose of [MEDICATION NAME]. He did expose himself in the day room this day but was redirected by staff. "" On 7/26, Res #3 "" has continued with inappropriate behavior of exposing himself. Staff has intervened appropriately and resident has accepted redirection without aggression. I went to attempt to talk to (Res #3) regarding his behavior but he was sleeping soundly and did not (???) when I called his name. I will follow. "" On 7/27 a care plan meeting was held and social services documented the following: "" (Res #3) is unable to cognitively participate. He suffers from dementia with behavioral disturbances manifested by sexual acting out and aggressiveness as prior documentation shows. He has been followed by attending psychiatrist and has been in a psych setting recently with no [MEDICATION NAME] results... "" On 8/5, "" received word from nursing staff that (Res #3) was again exhibiting inappropriate sexual behaviors. They had already intervened appropriately asking and assisting him to his room for privacy. I visited (Res #3) in his room. When I talked with him about this behavior, he really seemed confused. I explained that exposing himself and touching people inappropriately was not acceptable behavior. I told him that this kind of behavior could be considered assault and people can be arrested for this. He responded, "" oh. "" I doubt full comprehension of this conversation. I will follow and continue to assist staff in observing for behavior. "" On 8/24, "" DON has notified me that inappropriate sexual behavior has again been noted by staff in the past two days. I had observed (Res #3) out of his room earlier today and assisted him through the day room and to the dining area which is where he was going. There were no other residents in the dining area when I left him. We keep MD updated on behavior and I will ask for follow up for psychiatrist. "" Review of the 24 Hour Reports revealed on 7/12 Resident #3's behaviors were not included on the reports. On 7/23, Resident #3's behaviors were not on the report. On 7/25, Resident #3's exposing self and changes in orders were added. On 7/26, "" PRN [MEDICATION NAME] was used, inappropriate behavior. "" On 8/5, Resident #3's behaviors were not included on the report. On 8/9, "" inappropriate touching "" was added to the report for Resident #3. No other entries were recorded on the 24 hour reports for Resident #3 until 8/24 that indicated "" exposing himself again this evening in hallway-redirected, DON made aware. "" No evidence of consistent behavior monitoring was put in place for Resident #3. Review of the Incident Report dated 7/12 revealed the interventions put in place to prevent future reoccurrence were: "" 1. Provider updated on incident and [MEDICATION NAME] ordered orally along with his IM, 2. SS and DON interviewed resident and assisted resident to his room to eat supper and 3. Plans to f/u c (Psychiatrist) or provider (Attending physician/GNP). "" No other incident reports were found related to Resident #3's sexually inappropriate behaviors. During an interview on 8/29/11 at 2 PM, Licensed Practical Nurse #1 stated that she has witnessed Resident #3 touching female residents inappropriately. She stated that she immediately would remove the resident and redirect him. She stated that Resident #3 did not single out one resident in particular that it was whatever female resident happened to be near him. During an interview on 8/29/11 at 2:05 PM, CNA#1 (Certified Nursing Assistant) stated that she has witnessed Resident #3 touching inappropriately other female residents. She stated that Resident #3 "" mostly goes after "" Resident #4. However, she stated that Resident #6 had reported to her that Resident #3 touched her inappropriately. CNA#1 stated that she did not inform the nurse of the incident between Resident #3 and #6. CNA#1 then stated Resident #3 would go into other resident's rooms and lay down in their beds. During an interview with Resident ""A"" (a resident on the Unit identified as interviewable) on 8/29/2011 at 2:15 PM, Resident ""A"" stated that she/he had witnessed Resident #3 expose himself and touch Resident #4 inappropriately in the day room. Resident ""A"" then stated that this occurred last week around mid-morning. The resident stated that she/he informed LPN #1 of the incident and LPN#1 moved Resident #3 to the other side of the day room. Upon review there were no nurses notes, 24 hours reports or any reference in the records related to the incident identified by Resident ""A"". During an interview on 8/29/2011 at 3PM, the SSD stated that she had spoken to Resident #3 regarding his behaviors and informed him that the behaviors were inappropriate and unacceptable. She then stated that Resident #3 did not know what he was doing and stated that he did not comprehend what she was saying. The SSD stated that the if the staff saw Resident #3 acting inappropriately they were to immediately remove him from the situation and redirect him. The SSD stated that no other interventions were put in place for Resident #3's behaviors. The SSD stated that she was aware of Resident #3 touching Resident #4 inappropriately. She stated that nothing was put in place for Resident #4. The SSD stated that she was not aware of any other residents, therefore nothing had been put in place for any other female residents that had been victimized. During an interview on 8/29 at 3:20 PM, LPN #2 stated that she was assigned to Resident #3 on third shift on 8/5/11. LPN#2 stated that a nursing assistant had notified her that Resident #3 had his hand down Resident #4's blouse fondling her breast. LPN#2 stated that she then moved Resident #3 to the other side of the day room. LPN#2 stated that approximately 30 minutes later, Resident #3 was reported to have his hands between Resident #4's legs touching her inappropriately. LPN#2 stated that she removed the resident from the day room and informed the resident that that behavior was inappropriate. She stated that he did come back out to the day room afterwards but did not touch any resident inappropriately again. LPN#2 stated that Resident #4 "" had her pants on. "" LPN#2 stated that she informed the DON of the incident but stated that she was not sure if she called the physician or the resident's responsible party. During an interview on 8/29/2011 at 3:40 PM, the Attending Physician stated that since Resident #3's readmission on 7/11/11 his behaviors were "" manageable. "" He stated that he was aware of only one incident that had occurred. The Attending Physician stated that he was not notified of Resident #3's increasing sexually inappropriate behaviors. He also stated that he was not notified of the incident on 8/5 and stated that he was not aware of any specific residents that Resident #3 had touched inappropriately. The Attending Physician stated that the "" status quo was not working and there were other things we could have tried. "" He stated that if he was made aware he would have changed the medications, increased the [MEDICATION NAME], send the resident out to the hospital, monitor the behaviors, activities to keep him busy and to keep him away from women. The Attending Physician confirmed that Resident #4 and #6's psychosocial needs were not addressed. He stated that Social Services should have assessed the residents, both residents should be monitored closely for behavior changes and the facility should prevent the incidents and should protect the residents. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there "" was nothing else to do. "" She stated that the resident was on "" the list to move to the men's unit. "" When asked where the list was, the DON stated that there was not an actual list, it was "" in our heads who is next to move. "" The Administrator then stated that she couldn't "" just move someone "" and it was "" based on bed availability "" and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: "" Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. "" "" 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. "" On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9731,GLORIFIED HEALTH AND REHAB OF GREENVILLE,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2011-08-30,490,J,1,0,NOG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, facility policy review, and interview, the facility administration failed to use its resources effectively and efficiently to attain the highest practicable well-being for 1 of 1 resident with identified inappropriate sexual behaviors (Resident #3) and 2 of 2 residents alleged to have been sexually abused (Resident #4 & #6). In addition, the facility Administration failed to ensure the facility Medical Director had reviewed and acknowledged acceptable all Policies followed in the facility. The findings included: Cross Refer to F-157 as it relates to the facility staff's failure to notify the physician and the responsible party of an increase in sexually inappropriate behaviors. The failure to notify the physician of two identified residents that were victims of the sexually inappropriate behavior. Cross Refer to F-226 as it relates to the facility's failure to implement the policy on sexual abuse related to the identification and protection of residents. Cross Refer to F-250 as it relates to the facility's failure to provide medically related social services for Resident #3's sexually inappropriate behavior and the facility failed to assure Resident #4 and #6 received the necessary social services following allegations of sexual abuse. Cross Refer to F-280 as it relates to the facility's failure to care plan interventions following an allegation of sexual abuse of Resident #4 and Resident #6. Resident #3's care plan was not updated and new interventions were not added related to an increase in sexually inappropriate behaviors. Cross Refer to F-319 as it relates to the facility's failure to address, monitor and implement effective interventions for Resident #3's sexually inappropriate behavior. The facility admitted Resident #3 on 7/10/2009 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 8/29/2011 at 12:30 PM, revealed him up in a wheelchair in his room with his back to the door. Resident #3's pants were unzipped and his shirt tails were loosely covering his groin area. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired in decision making abilities. No behaviors were coded as occurring during the assessment period. Resident #3 was coded as requiring one person limited assistance with transfers and was able to self propel himself in the wheelchair. The facility admitted Resident #4 on 7/13/2009 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 had short term and long term memory problems and was severely impaired with decision making abilities. The facility admitted Resident #6 on 3/18/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 had a BIMS score of 15. No behaviors were coded during the assessment period. During an interview on 8/30/2011 at 10:20 AM, the Administrator and the Director of Nurses (DON) stated that they were aware of Resident #3's sexually inappropriate behaviors. The DON stated that she was aware of some of the incidents but not all. Both stated that they were not aware of the incident on 8/5 between Resident #3 and #4. Both stated that they were not aware of any particular resident involved. The Administrator and the DON stated that the staff acted appropriately by removing the resident from the situation. The DON stated that there "" was nothing else to do. "" She stated that the resident was on "" the list to move to the men's unit. "" When asked where the list was, the DON stated that there was not an actual list, it was "" in our heads who is next to move. "" The Administrator then stated that she couldn't "" just move someone "" and it was "" based on bed availability "" and there were no beds available. Both the Administrator and the DON stated again that they were aware Resident #3 was exposing himself to other residents. The Administrator and the DON stated that there was no tool in place to monitor the behaviors specifically. However, both stated that during the morning meeting the 24 hour reports were reviewed and Resident #3's behaviors should be recorded on them. Review of the facility's policy on Abuse and Neglect revealed: "" Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. "" "" 4. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events such as...occurrences, patterns and trends that may constitute abuse. 6. Investigate different types of incidents...7. Protect residents from harm during an investigation...8. Report all alleged violations and all substantiated incidents to the State Agency and all other agencies as required and take all necessary corrective actions depending on the results of the investigation. "" During an interview on 8/30/11 at 10:10 AM, the Medical Director stated that he was aware of Resident #3's sexually aggressive behaviors prior to his psychiatric hospitalization . He stated that he was informed today (8/30) of Resident #3's sexually inappropriate behavior since his readmission on 7/11. The Medical Director stated that he was usually made aware of Resident issues if the facility had a concern, the severity of the incident or if the resident continued to have ongoing problems. He stated that he wouldn't be notified of every occurrence but should have been notified of Resident #3's behaviors. Review of the facility's Nursing Policies and Procedures and the Infection Control Manual revealed they had not been approved with signature by the Medical Director or the Director of Nursing. During an interview on 8/30/2011 at 4 PM, the Administrator confirmed the Medical Director and the DON had not approved with signature the Nursing Policies and Procedures and confirmed the Medical Director had not approved the Infection Control Manual. She stated that the Medical Director had approved the facility's "" Glow and Grow "" Manual which is the Quality Assurance Manual. However, she stated that the Medical Director's approval with signature of all policy and procedure manuals had not been completed as of the time of the survey. The Administrator confirmed the Medical Director accepted the position on April 1, 2011. Review of the Duties and Responsibilities of Medical Director located in the Medical Directors Service Agreement revealed "" 10. Review and approve standardized procedures which registered nurses may utilize in the performance of patient care services. 11. Review reports of incidents and accidents occurring on the facility's premises which may pose a potential danger for patients, visitors or employees of the facility. "" On 8/30/2011 at 10:50 AM the Administrator and the Director of Nursing was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-223, F-226, F-250, F280, F-319, and F-490 at a scope and severity of ""J"". The findings were related to the Immediate Jeopardy identified due to the facility failure to provide proper treatment and care for 2 of 2 residents involved in an allegation of sexual abuse and the failure to provide the proper care and treatment for one of one resident with sexually inappropriate behaviors. On 8/5/2011 independently mobile Resident #3, identified with a history of sexually inappropriate behaviors, was observed with his hand down cognitively impaired Resident #4's blouse fondling her breast and was redirected and moved to the other side of the dayroom, and then 30 minutes later found to have his hands between her legs. The Immediate Jeopardy was not removed upon exit from the facility on 8/30/2011 and remains ongoing.",2014-12-01
9732,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2011-08-29,431,F,0,1,G5SB11,"On the days of the survey, based on observation, interview and review of the facilities' policy and procedures, the facility failed to store all drugs and biological's in locked compartments and permit only authorized personal to have access to the keys for one (1) of two (2) treatment carts, one (1) of two (2) medication carts and two (2) large containers where medications were being stored unlocked and unsupervised at the nursing station. The findings included: Observations upon entering the facility on 8-28-2011 at 11:25 AM revealed a treatment cart unlocked and unsupervised. Biological's in the treatment cart included: Scissors, Silva Sorb Gel, Medi Honey Wound & Burn dressing, Nysttin Powder (prescription), Triple Antibiotic Ointment, Allergy Cream, Zinc Oxide, Xenaderm Ointment, Desoximetasone cream, Betadine solution, Desenex Powder, and Peroxide. Observations during this time also revealed residents in the immediate area of the treatment cart. Interview with Licensed Practical Nurse (LPN) #4 on 8-28-2011 at approximately 11:32 AM confirmed these findings and stated she was unaware that the treatment cart was unlocked. Observations on 8-28-2011 at 5:50 PM by two (2) State Surveyors revealed the bottom drawer of the medication cart on the 'Carolina Unit' open and unsecured. Review of the contents of the bottom drawer included: Mono Jet Syringes, Potassium Chloride, Pain and Fever liquid, Valporic Acid solution, Buprofen oral suspension, Eldertonic Mineral Supplement, Maalox Advanced, Milk of Magnesia (MOM), Polyetyene Glycol, and Albutrol Sulfate. Interview with the Director of Nursing (DON) on 8-28-2011 at 5:52 PM confirmed the unlocked drawer and stated the lock did not catch on the drawer. On 8/28/2011 at 3:30 PM, two large blue totes were observed stacked under the nurses desk. Upon examination the totes were noted to contain boxes of prescription medications. There were numerous medications in the two totes. There were no locks or ties to secure the totes. The totes were not locked up. There was no inventory available for the medications in the totes. During an interview with LPN #2 at 4:00 PM, she stated, ""The courier comes daily. The courier was suppose to pick them (totes) up on Friday. Review of the facility policy entitled, ""Acquisition and Receiving of Medications"", under the fourth bullet, it stated, ""Any unused medications are counted and documented and returned to the pharmacy"". Review of the facility policy entitled, ""Labeling and Storage of Medications"", under the ninth bullet of the policy it stated, ""Medications must be stored in a secure fashion at all times. Med carts must be locked when not in use or in visual control of the licensed staff who is administering."" Review of the facility policy entitled, ""Disposition of Medications"", under the third bullet it stated, ""All medications that have been discontinued by order or discharge shall be removed from med cart, counted and returned to the pharmacy....The medications will be placed in a sealed bin, stored in the locked med room until the next courier pickup. The facility did not have a medication room.",2014-12-01
9733,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2011-08-29,322,D,0,1,G5SB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, facility policy, and observations, the facility failed to provide tube flushes in a manner to prevent complications for 2 of 2 residents observed for tube flush. Resident #2 and Resident #8, did not receive the prescribed amount of water flushes nor did the nurse check for residual. The findings included: The facility admitted Resident #8 on 2/13/2004 with [DIAGNOSES REDACTED]. Review of the August 2011 Physician's Orders revealed an order to ""Flush G/T (Gastrostomy Tube) with 60 cc H2O (water) Pre and Post Med Administration. On 8/28/2011 at 12:00 Noon, Licensed Practical Nurse (LPN) #1 was observed administering a G/T flush. The nurse obtained the resident's medication and poured a cup of water (the nurse did not measure the water). The nurse injected air into the G/T to check for placement. The nurse poured 10 cc of water in to the syringe to flush the tube, gave medication, then poured remained of water from cup, that measured 60 cc by the syringe barrel. The facility admitted Resident #2 on 10/8/2001 with [DIAGNOSES REDACTED]. Review of the Physician's orders of August, 2011, had an order for tube flushes of ""Flush [DEVICE] with 60 cc (milllileters) H2O (water) PRE and POST MED (Medication) Admin (Administration). On 8/28/2011 at 4:45 PM, LPN #1 was observed to administer a tube flush to the resident. The LPN obtained the resident's medication, poured a cup of water; without measuring the amount of water. After checking placement by injection of air into the gastrostomy tube, the LPN did not check for residual. The LPN gave 10 cc of water flush before administering the medications, gave crushed medications, followed with 10 cc of water, gave liquid medications, followed with [MEDICATION NAME] mixed with water. The nurse did not check for residual before beginning the tube flush on either resident , nor did the nurse measure the amount of water given to the residents. The residents should have received 120 cc of water flush with the tube flush, 60 cc before administering the medications and 60 cc of water following the administration of the medications. There were two sized drinking cups on the medication cart. The nurse did not know how much fluid either cup held. Review of the facility policy titled, ""Gastrostomy Feedings/Flush"", stated under #11: after checking placement...""Next check for residual."" With the piston syringe still in the tubing, pull back on the piston gently to withdraw contents from the stomach...If the residual is greater than 100 cc do not give the flush or feeding unless otherwise specified by the physician. #12 stated, ...""Slowly pour the prescribed amount of water into the syringe and allow to gravity flow.""",2014-12-01
9734,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2011-08-29,332,E,0,1,G5SB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observations, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error was 6.5%. There were 3 errors out of 46 opportunities. The findings included: Error 1 and 2: On 8/28/2011 at 4:45 PM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer one Klonopin 1 mgm (milligram) tab and 6 other medications to Resident #2. During reconciliation of the medications, the resident's Physician order [REDACTED]. The eye drops were not administered. During an interview with the LPN on 8/28/2011 at 5:00 PM, the nurse stated there were no eye drops available to give the resident. The nurse went through the medication cart and did not locate any [MEDICATION NAME] eye drops for the resident. The LPN was asked what he did when the resident did not have their prescribed medication? The nurse stated he waited for the pharmacy to bring the medication. LPN # 1 was unaware if the pharmacy would bring the medication that day. The LPN was asked if the facility had a back up pharmacy, he stated, ""yes"", he would have to call the pharmacy. On 8/29/2011, during the 8 AM medication pass, the LPN was asked to review the drug count on the resident's Klonopin. The resident had two (2) cards of the drug. One card contained the 1 mgm dosage. The second card contained a 0.5 mgm dosage of the drug. Review of the drug count on the 0.5 mgm dosage was 13 tabs remaining on the card. The declining inventory sheet for the medication had the count of 13. The medication was not signed out for the 6 PM on 8/28/2011 dose of medication on the declining inventory sheet. On 8/29/11 during the AM medication pass on the Virginia Unit, the LPN was asked if the [MEDICATION NAME] Eye Drops had come in the night before. She stated that the [MEDICATION NAME] drops were kept in the refrigerator at the nurses station. The Director of Nurses, brought the bottle of [MEDICATION NAME] eye drops that were refrigerated for Resident #2. The bottle of the [MEDICATION NAME] Eye Drops was dated as opened on 7/25/2011. The medication had been available for the resident at the PM dose the evening before. Review of Resident #2's Medication Administration Record [REDACTED]. The Drug Information Handbook for Nursing, 2010, on page 1343, described the medication ([MEDICATION NAME]) as an [MEDICAL CONDITION] medication. The medication was used to treat elevated intraocular pressure in patients with open angle [MEDICAL CONDITION] or Ocular Hypertension. Error #3: During medication pass on 8/28/2011, at 5:15 PM, LPN #1 was observed to administer a PRN (as needed) medication to resident A. On reconciliation of the medications, the August Physician order [REDACTED]. The [MEDICATION NAME] medication was not given at that time.",2014-12-01
9735,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2011-03-30,225,D,0,1,UBNZ11,"On the days of the Recertification survey, based on record review, interview, and review of the facility's policy entitled ""Plan for the Prevention of Elder Abuse"" revised July, 2010, the facility failed to report an injury of unknown source to the State Survey and Certification Agency as required for one of three reportable incidents reviewed. The findings included: One of three reportable incidents reviewed revealed that an injury of unknown origin, a bruise on the left hip measuring 19 cm (centimeters) by 8 cm, was reported to the State Survey and Certification Agency on 1/14/11. Review of the incident report stated the bruise occurred on 1/14/11 at 1:00 AM, however, staff statements indicate the bruise was first observed on 1/11/11. Staff statements documented two Certified Nursing Assistants (CNA) noted the bruise on 1/11/11 and it was reported to the nurse at that time. The Confidential Quality Assessment Statement from the nurse who received the report stated the CNA had reported the incident on 1/11/11 and that she ""was not aware of any accidents or trauma that occurred."" The incident was not reported to the State Survey and Certification Agency until 1/14/11 at 4:09 PM, three days later. Review of the policy entitled ""Plan for the Prevention of Elder Abuse"" stated in the Section VII, Reporting/Response, A. ""It is the responsibility of the staff member receiving a complain of abuse or neglect, ... to inform Administration immediately. In addition, all injuries of unknown source will be reported immediately to Administration....Administrator or designee will notify the appropriate State agency as soon as practicable, but not to exceed twenty four (24) hours.....Bruises and injuries of unknown source flag potential abuse...."" On 3/29/11 at 3:40 PM, these findings were confirmed in an interview with the Director of Nursing, the Assistant Director of Nursing and the Registered Nurse Safety Director, all of whom share responsibilities in the abuse prevention program. On 3/30/11 at 10:24 AM, the Nursing Home Administrator also confirmed that she was aware of the incident and that the State Agency was not notified of the incident within 24 hours as required.",2014-12-01
9736,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,157,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record review, interviews, review of the facility's policy on Extreme Heat, and review of the facility's investigative files, the facility failed to ensure the physician was immediately notified of 1 of 1 allegation of sexual abuse and 1 of 1 sampled resident with weight loss and possible heat related illness. The family of Resident #1 voiced concerns to a staff member on 7/7/2011 that Resident #1 may have been sexually abused. The Registered Dietitian (RD) was not notified when Resident #9 experienced a significant weight loss and the physician was not notified when the Resident #9 was found outside in the heat, lethargic and experiencing symptoms of possible heat exhaustion. The findings included: Resident #1, a fifty year old female, with [DIAGNOSES REDACTED]. On 7/7/11, the resident's family members alleged to staff that Resident #1 had been sexually abused. A review of the facility Complaint/Grievance Report signed 7/7/2011 at 3 PM revealed the statement ""Family Expressed concern that they feel that Ms... has been sexually abused because she is having new onset bleeding"". Review of an Incident Report by local law enforcement documented ""...When the deputy arrived, he spoke with Ms...(Administrator). Ms... (Administrator).stated that Ms... (Resident #1) sister approached her yesterday (7/7/2011) and stated that her sister (Victim) was bleeding from her vagina. Ms...(Administrator) stated an investigation was started and the Director of Nursing was notified..."" Review of the Nurses Notes found no documentation of an allegation or investigation until 7/8/2011 at 3:20 PM when it was noted ""F/U (Follow-up) c (with) resident regarding family concerns about vaginal bleeding. Resident (#1) expressed that a male peer (resident #2) had come in to her room and touched her. Unable to express when this occurred but did identify a male resident by name. Call placed to Dr. ... & the Law enforcement division. Police came out and investigated. Instructed to send to ... for Eval (evaluation) & rape kit. Calls placed to Family & unable to be reached..."" Review of the facility records revealed the concern of suspected sexual abuse was reported to the facility on [DATE] at 3 PM and not addressed until 7/8/2011 at 3:20 PM when a facility staff member examined Resident #1. At that time Resident #2 was identified as a possible perpetrator. Resident #1's physician and Law Enforcement were not notified until 24 hours after the initial allegation of suspected abuse. The date of physician notification of the allegation was confirmed during an interview with the physician on 7/19/11 at 2:45 PM. The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurses Notes revealed on 6/4/2011 the resident's family member reported the resident was dehydrated. On 6/7 the resident was noted down the service hallway by the exit door. On 6/19 at 11:45 AM, ""Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt."" On 6/19/2011 at 5:30 PM a late entry documented ""upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..."" There was no documentation that the Attending Physician was notified of the incident. During an interview on 8/2/2011 at 12:35 PM, the Food Service Director stated that if a significant weight loss was detected then the Registered Dietitian would be notified as well as the doctor. During an interview on 8/2/2011 at 2:15 PM, the Registered Dietitian stated that she saw the resident on 6/2/2011 and confirmed that she did not address the significant weight loss. The RD stated that she was in the building on 6/12 but did not see Resident #9. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed the RD and the doctor were not notified of the loss. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. Review of the facility's policy on Extreme Heat revealed, ""the physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations. "" On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9737,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,224,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review and interviews, the facility failed to implement procedures to ensure 3 of 5 residents reviewed with tracheostomies and 1 of 1 residents reviewed with dehydration were not neglected. Resident #6 did not receive the necessary emergency care at the time she was found with [MEDICAL CONDITION] her hand. Resident's #7 and #8 identified with tracheostomies failed to have necessary [MEDICAL CONDITION] at the bedside or readily available and the staff acknowledged a lack of training related to [MEDICAL CONDITION]. The facility failed to ensure Resident #9, admitted with a [MEDICAL CONDITION] and a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #6 on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #6 was sent to the emergency roiagnom on [DATE] for ""status [REDACTED]."" Review of the Physician's orders revealed the following: ""[MEDICAL CONDITION] every 3 days and PRN (as needed), clean inner cannula once a day, suction as needed date time and initial,[MEDICAL CONDITION] every shift, and O2 2 l/[MEDICAL CONDITION] maintain sats @ 90% [MEDICAL CONDITION]."" There was no physician's order for the type and size of Resident #6's trach. There was no documentation in the nurse's notes or assessments of the type and size of Resident #6's trach. Record review revealed Resident #6 was transferred to the emergency roiagnom on [DATE] for ""trach to be replaced."" Review of the Nurse's Notes revealed on [DATE] at 1:35 AM, ""writer (LPN #1) noted resident (Resident #6) [MEDICAL CONDITION] hand, South Wing nurse called for backup kept airway open attempted to [MEDICAL CONDITION] in, unsuccessful 911 called gave report. MD called, order to send resident to hospital to replace trach. Resident alert and breathing through mouth, EMS arrived attempted to [MEDICAL CONDITION] no avail, Resident transported to (hospital)."" At 3:05 AM, ""(hospital) called to report Resident had expired."" Review of the Medication Administration for [DATE] revealed no documentation that Resident #6 was suctioned. During an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #6 on [DATE] during the night shift. She stated that she walked into the resident's room and saw the ""[MEDICAL CONDITION] out"". LPN #1 told the Certified Nursing Assistant (CNA) to call 911. LPN #1 stated that the other nurse (LPN #2) came into the room and she (LPN #1) then left the room to call the doctor. LPN #1 stated that she ""freaked out"" and ""didn't know what to do"" and ""had never been through this before."" LPN #1 stated that she had never received training or inservices regarding emergency care of tracheostomies or how to replace a decannulated trach. LPN #1 stated that there was not a [MEDICAL CONDITION] emergency supplies in Resident #6's room. Review of the facility obtained statement of LPN #2 dated [DATE] revealed, at ""1:,[DATE]:45 AM, I got called to go to the other side. I ran to the other side, when I got to the unit, the nurse yelled 'Oh my god! She's blue y'all, she's blue!' I went in the room, she was blue, her fingertips and hands were blue. We had to find out if she's a full code. She was not breathing, she did not have a pulse. There was no ambu bag. Instructed the other nurse to call 911. I tried to reinsert [MEDICAL CONDITION] came out. I extended her neck and started compressions. She started breathing. She (LPN #1) found the ambu bag. The nurse was frantic and freaking out. I told her to call (Physician). She (Resident #6) started mouth breathing. (LPN #1) was trying to hook the ambu bag to the concentrator. When (Resident #6) left she was breathing. The nurse told me she received a phone call saying she (resident #6) had expired."" ""The [MEDICAL CONDITION] there, but there was no arbitrator (sic)."" Multiple attempts were made by telephone to contact LPN #2 on [DATE] and [DATE]. During an interview on [DATE] at 1:45 PM, the Attending Physician/Medical Director stated she was notified on [DATE] that Resident #1 had decannulated. The Physician stated that Resident #6 had a history of [REDACTED]. The Physician was asked what emergency supplies should be available at a trached resident's bedside. She stated that no supplies were needed at the bedside, the supplies only needed to be available in the building. She further stated that there was no policy that spoke to having emergency supplies. The Physician was informed of the facility's policy on [MEDICAL CONDITION] Care and emergency supplies. She then stated that it ""wouldn't be a bad idea"" to have the supplies at the bedside. The facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7's room on [DATE] revealed an ambu bag hanging on the wall above the bed. LPN #4 was asked how she would respond if Resident #7 was decannulated. She stated that she would try to replace [MEDICAL CONDITION]. LPN #4 was asked to locate the emergency supplies. She confirmed that there was no obturator in the resident's room. After approximately 5 minutes of searching through the resident's drawers and bins she located [MEDICAL CONDITION] out kit. LPN #4 confirmed that she did not know what all the contents were for in the kit. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] ""[MEDICAL CONDITION] writer (LPN #3) found out that inner cannula is absent."" Review of the Physician's orders revealed an order written [REDACTED]. During an interview on [DATE] at 10:30 AM, LPN #3 confirmed Resident #8 had a size 6 trach. LPN #3 was asked where the emergency supplies for the resident were located. LPN #3 located the disposable inner cannulas in her med cart. She also located two boxes of a size 8 [MEDICAL CONDITION] out kits. One box had been opened and was missing part of the contents. LPN #3 confirmed the supplies at the bedside were not the appropriate supplies. LPN #3 then stated that Resident #8 had pulled his inner cannula out again this morning and that was the reason that there were no disposable cannulas in the resident's room. LPN #3 confirmed that Resident #8 had pulled out his inner cannula on previous occasions. Further review revealed no interventions had been initiated related to Resident #8 partially decannulation. Observation of the unit supply rooms and the central supply room on [DATE] revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on [DATE] at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Record review revealed no documentation of the type and size [MEDICAL CONDITION] for Resident #10. During an interview on [DATE] at 12:20 PM, the Nurse Consultant confirmed that there was no documentation of the type and [MEDICAL CONDITION] for Resident #10. She stated that she would not know how staff would know what emergency supplies were necessary for Resident #10. Four nurses were interviewed (LPN #3, #4, #5, #6). All four stated that they check for [MEDICAL CONDITION] at the beginning of their shifts. All four stated that each resident with [MEDICAL CONDITION] have a replacement kit at the bedside. During an interview on [DATE] at 3:15 PM, the Director of Nurses (DON) stated that nurses should check at the beginning of their shifts for the necessary emergency supplies. The DON confirmed that if the nurses were checking each shift for the necessary emergency supplies then they would have noticed the supplies were not present at the bedside. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or the necessary emergency supplies at the bedside. The DON confirmed no interventions were put in place related to Resident #8 pulling at [MEDICAL CONDITION] partial decannulations. Review of the [DATE] General Spending Ledger revealed no Size 6 Shiley Tracheostomies were ordered. Review of the Policy on [MEDICAL CONDITION] Care stated, ""... If [MEDICAL CONDITION] outer cannula is accidentally extubated, attempt to insert [MEDICAL CONDITION](same type and [MEDICAL CONDITION] obturator should always be kept at bedside for such emergencies)."" The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 was alert and had confusion at times. Further review revealed a dietary assessment dated [DATE] that indicated Resident #9 required ,[DATE] milliliters of fluid a day and required 2300 calories per day. Resident #9 was ordered [MEDICATION NAME] 1.5, 1 can every 4 hours and 150 ml water flushes every 4 hours. Resident #9's weight was noted to be stable at 175 pounds for the month of [DATE]. On [DATE] an order was written for [MEDICATION NAME] 1.5 at 110 ml/hr from 7 PM-5 AM, 8 AM-10 AM, 1 PM-3 PM and 5 PM-6 PM with water flushes every 4 hours. On [DATE], Resident #9's weight decreased to 159.2 pounds. A significant loss of 9% in approximately 2 weeks. The Registered Dietitian saw Resident #9 on [DATE] and did not note the significant weight loss. Furthermore the tube feeds were decreased to 80 ml/hr for 12 hours with 150 ml water flushes every 4 hours. The new order provided Resident #9 with 900 ml of water and 960 ml of formula (significantly less than the required amount). Resident #9's weight on [DATE] was 154.6, another 3 % loss in one week. On [DATE] Resident #9 weighed 147, a 5 % loss on one week. Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of Resident #9's physician's orders from admission through discharge included an order for [REDACTED]. Review of the Nurse's Notes from [DATE] through [DATE] revealed multiple entries that indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Review of the ADL Tracking Log for [DATE] revealed Resident #9 refused all meals. Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding. Resident #9 was noted to be able to self propel himself in the wheelchair. Resident #9 was also noted to be alert and oriented times three on admission. However, he had increasing confusion during the month of [DATE]. Review of the Neurological Flowsheet dated ,[DATE] through ,[DATE] revealed Resident #9 was confused at all times. Review of the Nurse's Notes revealed on [DATE] the resident's son reported the resident was dehydrated. Yogurt was offered and the resident declined water. His tube was flushed with 90 ml of water. The resident was noted to have confusion at times. On ,[DATE] the resident was noted down the service hallway by the exit door. On [DATE] at 7:30 PM, ""resident decided to go sit outside for awhile and removed shirt exposing self, gentle encouragement to come back into building."" On ,[DATE] at 11:45 AM, ""Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt."" On [DATE] at 5:30 PM a late entry documented ""upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic. Asked resident to come inside and he stated no. Expressed to him that he needed to come in or he would get heat exhaustion. He then agreed to come in. Assisted back to the room and turned on AC (airconditioning) unit. Placed cool towels and washcloths to help cool him. Offered fluids and he declined. Would not allow staff to provide any fluids via tube."" On [DATE] at 5:30 PM, ""summoned to North Wing by resident's family member. Noted resident sitting up in wheelchair with signs and symptoms of lethargy. O2 sat fluctuating, 911 called... "" Review of the Emergency Department's record from the Hospital dated [DATE] revealed Resident #9's admitting [DIAGNOSES REDACTED]. Acute Dehydration 2. [MEDICAL CONDITION]."" Resident #9's labs were as follows: Sodium 162 (high), Chloride 117 (high), Glucose 198 (high), BUN 48 (high). Resident #9 received one liter of IV fluids in the ER prior to admission to the hospital. During an interview on [DATE] at 2:15 PM, the Registered Dietitian stated that Resident #9 did not tolerate the bolus tube feeds because he felt too full. She also stated that he would disconnect his continuous tube feeds. The RD stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she ""didn't know what else to do."" The RD stated that she saw the resident on [DATE] and confirmed that she did not address the significant weight loss. Also, she confirmed, that the order was changed to decrease the amount of formula. She stated that the Attending Physician changed the order and she was not aware of the change until after the resident was discharged . The RD stated that she was in the building on ,[DATE] but did not see Resident #9. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed the significant weight loss of Resident #9, confirmed the RD and the doctor were not notified of the loss. She also confirmed no interventions were put in place related to the weight loss. The ADON confirmed an elopement assessment was not completed. She confirmed Resident #9 had increasing confusion. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. The ADON confirmed that Resident #9 was sent to the hospital for dehydration. Resident #9 expired on [DATE]. Review of the facility's policy on Elopement Risk Assessment revealed: ""all residents are assessed on admission by a licensed nurse for elopement risk utilizing an elopement risk assessment form. All residents are re-assessed for elopement potential by the MDS nurse/Social Service or designee periodically throughout the patients stay."" Review of the facility's policy on Extreme Heat revealed the symptoms of heat stroke/exhaustion included ""... headache, dizziness, weakness, the person may be confused and may find it difficult to coordinate body movements. Treatment should include removing person to cool environment and encouraging increased consumption of fluids. The physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations. "" On [DATE] at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented [DATE] for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on [DATE] were not addressed until [DATE] and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On [DATE] at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on [DATE], was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of [DATE] when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] and remains ongoing.",2014-12-01
9738,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,225,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record reviews, observations, interviews, and review of facility files, the facility failed to ensure that all allegations of abuse were reported immediately to the State survey and certification agency and thoroughly investigated for 1 of 1 allegation of sexual abuse (Residents #1 and #2); and failed to ensure residents were protected from further potential misappropriation of property for 1 of 1 allegation of misappropriation of resident property reported (Resident #2 and #3). The facility delayed beginning the investigation into the allegation of Resident #1's possible sexual abuse. Family members made their allegation on 7/7/2011. The facility did not show evidence of an investigation until 7/8/2011. Review of their investigation revealed the allegation was not addressed till the next day and not all staff members working on the resident's unit were interviewed for possible pertinent information. Review of the investigative materials for the allegation of misappropriation revealed that after six ladies rings and a facility central supply key were found on 6/20/2011 in Resident #2's room, the facility did not aggressively investigate to identify any resident with missing items and did not put into place any interventions until 7/8/2011 to protect residents from further potential misappropriation of property. The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident assessments of 8/25/2010 and 5/1/2011 showed the resident was severely cognitively impaired. The 5/11/2011 assessment showed a score of 3 on the resident's BIMs (Brief Interview for Mental Status). Based on the assessment information, the resident sometimes understood communication and sometimes could be understood. She required total care from the staff for activities of daily living. Review of the facility's initial 24-Hour Report, stated under Brief Description of Reportable Incident: ""Reported to facility on 7-7-11 at 3 PM Family reported concerning that they feel their loved one was sexually abused because she has had new incidence of vaginal bleeding..."" On 7/8/2011, the Director of Nurses (DON) interviewed Resident #1. Review of her statement dated 7/8/2011 revealed the resident was asked if any men came in to her room or bothered her. She responded ""(Resident #2) comes in has sex with me."" The resident denied any sexual abuse from the staff. As the DON began opening the resident's incontinent brief for a physical examination, the resident said ""That's what he does, (Resident #2), he tries to get in there."" The DON noted some vaginal bleeding but no signs of obvious trauma. Review of the Nurse's Notes showed an entry on 7/8/2011 at 12:30 PM stating no vaginal bleeding was noted, and there had been no signs of vaginal bleeding for months. A note at 3:20 PM on 7/8/11 documented the allegation of abuse: ""... Resident expressed that a male peer (resident) had come in to her room and touched her. Unable to express when this occurred but did identify a male resident by name (Resident #2). Call placed to Dr. George & the law enforcement division. Police came out and investigated. Instructed to send to ... Hospital for Eval (evaluation) & tx (treatment) & rape kit. ..."" A grievance form documenting the family's allegation, completed by the DON, showed a communicated date of 7-8-11 with the 8 overwritten by a 7. The DON signed the document and dated it 7/7/11 at 3 PM. The State survey and certification agency was notified of the alleged abuse on 7/8/2011. The facility's initial report noted the incident was reported to the facility on [DATE] with the 8 overwritten by a 7. Resident #2 was placed under 1:1 supervision on 7/8/2011. Resident #1 returned to the facility from the hospital on [DATE] at 5:06 AM. She was placed in a different room, on the opposite side of the building. On 7/8/2011, the DON conducted interviews with the resident's past and current roommates and with the alert and oriented residents on her unit. None of the alert and oriented residents on this unit complained of inappropriate touching by male residents. Resident #2, the alleged perpetrator was independently mobile with no restrictions on his movements both in and out of the facility. There was no evidence other residents in the facility off of Resident #1's unit were interviewed. Resident #1's past roommate and her current roommate had some cognitive impairment and could not provide any useful information. Staff interview notes written by the DON, some undated and some dated 7/13/2011, revealed nine caregivers were interviewed. None of the staff members reported seeing Resident #2 go into Resident #1's room. Two of the nine staff members stated the resident had had occasional episodes of vaginal bleeding or spotting in the past months. Further review of the facility's investigation revealed an unsigned and undated statement identified by the DON as hers. The statement chronicled a number of complaints from the family, including that they noted Resident #1 was ""all bruised up ... bruises on her legs resemble hand prints (right leg). She is very upset and having vaginal bleeding every so often. Resident #1 had stopped having periods. ... Her roommate states that a man comes in all the time"" The facility's investigative report failed to include or address the family's observation of bruises on the resident's legs, and that one bruise resembled a hand print on the right leg. During an interview with the Administrator and the DON on 7/19/2011, the DON stated the resident's family reported their sister told them she had been abused. The investigation did not include a statement from the nurse on duty at the time the allegation was made. LPN #7, who was on duty for the 7-3 shift on 7/7/2011, was interviewed on 7/19/2011. She stated that when she came on duty that day, the resident was up in her chair because she had been restless all night. The resident continued to be restless. She was dressed in a gown and had her lap covered with a sheet. After breakfast, the resident was in the day room on the South Wing. Some yogurt had spilled on the sheet covering her legs. The resident's family members asked what the stain was from, and a CNA (Certified Nursing Assistant) answered that she did not know but it could be blood and the resident could be on her period again. Resident #1's family became upset. The CNA reported the incident to LPN #7. LPN #7 explained to the family that she had not noticed any vaginal bleeding for the past few months, and that the resident was in the day room under supervision for safety as she was so restless. The family complained that there were bruises on the resident's legs and one looked like a hand print. They claimed there was something going on and the facility was covering it up. LPN #7, the CNA, and the ADON immediately examined the resident. There was no vaginal bleeding and no suspicious markings on the resident's inner thighs or perineal area. A bruise was present on the right outer thigh, just above the knee, on the right shin and on the right wrist where the resident often banged her hand when agitated. The thigh bruise did not resemble a hand print. The leg bruises were attributed to the resident's recent falls. (Record review showed falls on 7/1/2011 and 7/5/2011.) LPN #7 described these events as occurring after breakfast. The DON documented she received the allegation at 3 PM on 7/7/2011. There was no explanation in the investigative notes for the discrepancy in times. Resident #1 was observed on 7/19/2011 at 10:55 AM. She was seated in a reclining chair by the nurse's station. She was clean, well groomed, dressed appropriately, and odor free. The resident sat forward in the chair and moved her legs to dangle on each side of the leg rest and then back up to the chair repeatedly. Her inner and outer thighs, just above the knees, made contact with the chair as she moved. Her right hand was contracted. Statements taken from the staff and residents by the DON during the facility's investigation failed to provide identifying information such as a room number for residents or the title of a staff member. First initials and last names only were provided. The DON signed the statements, but the person identified as providing the statement did not verify the information by their signature. Review of the Daily Staffing sheets from 7/4/2011 to 7/7/2011 revealed five nurses were assigned to South Unit on those days over all three shifts. LPN #7 was one of the five nurses and there was no statement from her in the facility's investigation. Possibly one nurse provided a statement. A particular last name was on one statement, and two nurses with that same last name were noted on the schedules, but the first initial on the statement did not match either first initial of the nurses. For that time period, 14 CNAs were assigned to South Unit on all three shifts. The facility obtained 5 statements from South Unit assigned CNAs. In addition, the Medical Records LPN, a North Unit LPN, and a North Unit CNA gave a statement to the DON. All of the staff members interviewed by the DON stated they had never seen Resident #2 go into Resident #1's room and/or said Resident #1 had not made a complaint of sexual abuse to them. The facility failed to interview the remainder of the South Unit staff to determine if there might be more information available. Resident #2 was interviewed at the facility on 7/18/2011. He denied any sexual contact with Resident #1 and denied any inappropriate touching of Resident #1. Resident #2 with [DIAGNOSES REDACTED]. The resident was alert and oriented and made his own healthcare decisions. His Quarterly Minimum Data Sets (MDS) with ARD dates of 4/1/2011 and 7/1/2011, coded the resident as he requiring extensive assistance with bed mobility, transfer, and toilet use. During an interview with the Director of Nursing (DON), on 7/26/2011 at 8:00 AM, she stated the resident was independent with transfers and only required assistance with putting on his pants. The amount of assistance that he needed depended on the staff that worked with him. A Physician's Progress Note dated 7/25/2011, stated, ""...he has been very independent, able to come and go from facility at will without difficulties... he is able to transfer from bed to chair, dress himself, bathe himself and mostly continent..."" Resident #2 propelled himself about the facility and into the community with an electric wheelchair. Review of the medical record and facility files revealed the resident was a registered sex offender. He also had a history of [REDACTED]. Review of the DON's interviews with staff revealed one staff member who stated other residents had accused the resident of theft back in 2008 and 2009. Documentation in the Social Services Progress Notes revealed multiple attempts by the facility to find alternate placement for the resident over the years. Review of the Nurse's Notes dated 6/20/2011 at 5:00 PM stated, ""At 3:45 PM resident noted by charge nurse to smell of Marijuana. Reported to this nurse the Administrator and Social Services director. Call placed to the legal dept (department) and gave instructions to question resident, notify the MD and ask resident if he agreed to have the staff search his room and agreed to a drug test. He agreed to Both as he stated he has not do any drugs nor has he been around anybody who has. These three writers (Administrator, DON, and SS) began room search and after several minutes noted a Black Change type purse with 6 rings inside Similar to the ones that have been missing for several residents over the past month or So. Asked Resident #2 where these items came from and he where these items came from and he said Oh No, you're not gonna put that on me. At this point the search was stopped (by the Administrator) and call placed to the police. At this point we instructed the resident not to leave the building until the police arrives. This resident agreed and then quickly exited the building out the back door of South hall. Myself (DON) and the Administrator escorted resident back into the building and assigned a staff member to one on one."" A Nurse's Note for 6:00 PM stated, ""Police officers interviewing the resident as well as the other residents with missing items; 6:20 PM Police finished investigation and no arrests made at this time. Resident met with this writer and the Social Worker and stated that he did not want to stay here tonight because he does not trust anybody at this facility. Stated to him that if he was to leave that he should find a safe, secure place and not be in the streets. He appeared to listen but did not respond to us. He then left and went back to his room to make some phone calls. At this time physician was notified and gave order to obtain a urine drug screen. Sent male nurse to obtain the specimen as he verbalized to others that this writer 'planted the rings in his room'. Resident was unable to urinate at this time and that he will give the specimen later."" The Nurse's Notes dated 6/22/2011 indicated urine obtained on that day was mislabeled and not processed, Resident #2 declined to give another urine specimen. In an interview on 7/18/2011 with the Administrator and Director of Nursing (DON) they stated that 5 rings and a key with ""CS"" (central supply) on it was found during the search. The ""CS"" was later identified as the Central Supply key. The search was halted when the items were found and the police called. Resident #2 left the facility by the back door during the time the police were called and after the resident was asked not to leave the building. Unknown staff members reported to the police that they saw the resident hand something in 2 bags off to two men out in back of the facility. During the search of Resident #2's room by the police officers nothing further was found. During the interview with the Administrator and DON, they stated that after finding the jewelry in the resident's room, they checked with residents and/or family members who had reported missing rings in the past months with no results. There was no evidence of any other investigation. No measures were put in place to protect residents from further potential misappropriation of property. The Administrator and DON stated the key was to the facility's central supply room. It was kept behind the South Wing nurses' station. It had been missing for about one month. On 7/7/2011, Resident #3 reported to her nurse that she had not seen her rings for over a month. The Administrator was notified and interviewed the resident on 7/8/2011. Resident #3 described the missing rings and the Administrator realized the descriptions matched 4 of the 6 rings that were found in Resident #2's room. A picture of the found rings was shown to the resident and she identified her rings. When the Administrator asked if she was interested in pressing charges against the person who stole them, the resident said: ""I want to say yes."" The police were notified. Resident #3 with [DIAGNOSES REDACTED]. Review of her medical record revealed she was alert and oriented with occasional periods of confusion. When the Administrator on 7/8/2011 interviewed Resident #3, the resident asked who took her rings. Then said, ""Is it (Resident #2)?"" When the Administrator asked her why she thought it was him, Resident #3 stated, ""He is always lookin' - always lookin' around to see what we have."" The resident reported to the DON on 7/13/2011, that Resident #2 had been to see her a day or two earlier and he inquired about how much her rings cost. She explained they were gifts and she did not know the cost. Resident #3 gave Resident #2 her sister's phone number. Resident #2 was interviewed on 7/18/2011, with the Ombudsman present at his request. The resident said he did sometimes go into Resident #3's room and she would ask him to go get a soda or snack from the machines for her, which he gladly did. Resident #2 denied taking the rings or the key. He stated, ""The DON planted the items in his room, possibly."" As of 7/19/11, no further information was forthcoming from the police about the status of the case. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9739,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,226,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on review of the facility's investigative file for an allegation of sexual abuse, and based on review of the facility's policy and procedure for Abuse, Neglect, and Misappropriation of Property, the facility failed to follow it's procedure for allegations of physical/sexual assault, rape, molestation or coercion for 1 of 1 allegation of sexual abuse (Resident #1) and 1 of 1 allegation of Misappropriation of Property (Resident #3). Failure to investigate timely and thoroughly put all residents at risk for further abuse/misappropriation. In addition the facility failed to conduct pre-employment reference checks from on 14 of 24 newly hired employees as part of their screening policy. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 7/7/11, three of the resident's family members reported to the staff that they thought the resident had been sexually abused. The physician was not notified until 7/8/11 and ordered a transfer to the hospital for evaluation. The police, the State survey and certification agency, and the Ombudsman were also notified on 7/8/11. Resident #3 with [DIAGNOSES REDACTED]. Review of her medical record revealed she was alert and oriented with occasional periods of confusion. In an interview on 7/25/2011 at 4:00 PM, Licensed Practical Nurse (LPN) #7 stated, ""It was the day after her birthday (6/25/11). She, (Resident #3) said she thought her rings were missing, she had not seen them for over a month. I told her I would report it to the Administrator. The Administrator went down and talked with Ms. ___ about her rings."" Review of the Facility Five-Day Follow-Up Report dated 7/15/11 stated, ""...On 7/7/11 Resident #3 reported 4 missing rings. Upon review she described the rings in detail and it became clear to the staff that these were the rings that had been given to the police on 6/20/11 regarding an investigation with Resident #2. At this time law enforcement was called and investigators came out. Resident #3 requested to press charges..."" The facility failed to timely and thoroughly investigate the suspected theft resulting in an 18 day delay identifying an owner (Resident #3) of 4 of the rings and a delay in protection of other residents at risk of becoming a victim. Review of the facility's Abuse, Neglect, and Misappropriation of Property policy and procedures showed the following information under Component V: Reporting/Response ""1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities)."" Review of the facility's Abuse, Neglect, and Misappropriation of Property policy and procedure showed the following information under Component VI: Investigation, section 7 Guidelines for Investigation on page SS - Section II - 9: ""...C. Maintain resident's/patient's protection during the investigation. D. Notify the attending physician and resident's/patient's legally responsible party... F. Conduct/make arrangements for physical/mental examination. DO NOT CLEAN, SHOWER OR BATHE RESIDENT in allegations of physical/sexual assault, rape, molestation or coercion prior to any such examination."" During review of employee files on 7/26/11 at 11:00 AM, 14 of 24 records reviewed did not have pre-employment references from previous employers. The HR (Human Resources) Director was interviewed on 7/26/2011. She stated that references were done prior to hire, sometimes she checked the references, sometimes the Director of Nurses checked them. Two of the employee files were shown to the HR Director that did not have reference checks. The HR Director stated that she would look for them. No employer references were provided by the facility. During an interview with the Administrator on 7/26/2011, she stated it was not the facility policy to conduct employment references. Review of the policy entitled ""Employment Process"", #4 stated, ""References are checked including OIG exclusion check and abuse registry."" As part of the screening process for new employees, the facility did not attempt to obtain information from previous employers for each new hire. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9740,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,250,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record review, the facility failed to provide medically related social services to Residents #1, #2, and #3 to attain or maintain their highest level of well-being for 3 of 3 residents involved in allegations of abuse or misappropriation of property. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was severely cognitively impaired and required total care from the staff. She had a history of [REDACTED]. On 7/7/2011, members of the resident's family alleged to staff that their sister had been sexually abused. Resident #1 named the alleged perpetrator during an interview with the Director of Nurses (DON) on 7/8/11. Review of the Social Service Progress Notes showed the resident's allegation was not addressed, nor was there any follow-up by Social Services concerning the allegation and the resident's room change (that occurred 7/9/2011) until 7/12/2011. The 7/12/2011 progress note said, ""This writer was informed by Administrator to document on Resident daily re: following up on allegation which was reported on 07/08/2011. ..."" No negative behaviors were noted. One more progress note was done on 7/13/2011, and again, no negative behaviors were noted. An interview with the Administrator on 7/19/2011 revealed the Social Worker was on vacation during the time period of the alleged abuse of the resident. The Administrator, whose background is Social Work, checked on the resident and found no negative outcomes but failed to document her visits or findings. Resident #3 with [DIAGNOSES REDACTED]. Her rings had been found in Resident #2's room on 6/20/2011. Resident #3 pressed charges against Resident #2 and her case was still pending as of 7/26/2011. A witness statement was dated 7/7/2011 and documented that the Administrator was notified 7/7/2011 that Resident #3 reported missing rings. The Administrator interviewed Resident #3 on 7/8/2011 at 10 AM and documented that the resident did identify 4 of the rings that were found in the room of Resident #2. Resident #3 asked where her rings were found and the Administrator declined to give that information stating she would let the law enforcement investigators speak with her. Resident #3 asked at that time ""Is it... (Resident #2)?"" and when asked by the Administrator why she thought that, Resident #3 commented ""He is always lookin'-always lookin' around to see what we have."" Review of the Social Services Progress Notes showed no documentation of any counseling or emotional support provided to the resident related to the incident. Resident #2 with [DIAGNOSES REDACTED]. He was the alleged perpetrator in the sexual abuse allegation and in the misappropriation of resident property allegation. Review of the Social Services Progress Notes from 4/5/2011 through 6/20/2011 showed an entry date 6/9/2011 that stated, ""...Resident displays being very demanding, cursing and yelling at times re: staff related to ADL (activities of daily living) care. Resident #2 states that he has a poor appetite and has little interest and little pleasure in doing things due to back pain, during this assessment period. Resident was last seen by the Psychiatrist on 5/16/2011, and by physician on 5/8/2011 and 5/25/2011, per physicians progress notes. Resident had order written to D/C (discontinue) Tylenol #3 and give Tylox for pain... The last entry described the events of 6/20/2011 when Resident #2's room was searched by the Administrator due to the smell of a strong drug substance in his room. There was no further documentation concerning any counseling of the resident, assisting the resident in managing the new 1:1 supervision, or preparing him for possible legal action. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for the trach residents in the building and facility staff were not adequately trained to provide all aspects of care required with trach residents. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9741,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,276,D,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, the facility failed to perform a quarterly assessment during the month of April for 1 of 1 resident reviewed for quarterly assessments. Resident #3, did not have a quarterly assessment completed for April, 2011. The findings included: The facility admitted resident #3 on 7/6/2010 with [DIAGNOSES REDACTED]. A review of the resident's MDS, Minimum Data Set, revealed a 5 day assessment was completed on 3/28/2011. The assessment was not marked for a quarterly assessment. A MDS was completed for 7/19/2011 and was marked as a quarterly assessment. During an interview with the MDS Nurse on 7/26/2011 at 8:15 AM, she stated, the resident had a short hospital stay and had been picked up for Medicare A. She stated, ""She should have been a quarterly at that time. She (Resident #3) got off schedule with the readmission. She is due for an annual in July. """,2014-12-01
9742,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,278,D,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record review and interviews, the facility failed to accurately assess 1 of 2 residents reviewed for assessments. Resident #2 was assessed as requiring extensive assistance with his Activities of Daily Living (ADLs). The staff reported he was independent and only needed assistance with donning his pants. The findings included: Resident #2 lived at the facility since 10/25/2007. He was admitted with [DIAGNOSES REDACTED]. His Quarterly Minimum Data Sets (MDS) with ARD dates of 4/1/2011 and 7/1/2011, coded the resident as he requiring extensive assistance with Bed mobility, transfer, and toilet use. During an interview with the Director of Nursing (DON), on 7/26/2011 at 8:00 AM, she stated the resident was independent with transfers and only required assistance with putting on his pants. The amount of assistance that he needed depended on the staff that worked with him. A Physician's Progress Note dated 7/25/2011, stated, ""...he has been very independent, able to come and go from facility at will without difficulties... he is able to transfer from bed to chair, dress himself, bathe himself and mostly continent...""",2014-12-01
9743,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,279,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record review, the facility failed to develop a comprehensive plan of care describing the services to be provided to one resident for his protection and the protection of other residents for 1 of 1 resident with a history of being a registered sex offender ( Resident #2). The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the resident assessments of 10/13/2010 and 4/8/2011 showed the resident was cognitively intact with no communication impairment. The resident needed extensive to total assistance with transfer and dressing. Limited assistance was needed for hygiene but the resident was independent for bathing and eating. Review of the medical record showed the resident used an electric wheelchair for mobility. He came and left the facility at will. Review of the medical record revealed the resident was a registered sex offender. He was convicted in 1992 of Criminal Sexual Conduct. The facility assisted the resident to register with the county bi-annually. Review of the resident's care plan showed no problem addressing his status as a registered sex offender. There were no measures put in place to protect the community of vulnerable adults he lived with at the facility from potential harm. There also was no plan to assist the resident in protecting himself from potential harm from others who might take advantage of his history. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9744,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,280,J,1,0,KPHO13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NOT CORRECTED On the days of the follow up visit, based on observations, interviews and record reviews the deficiency was not corrected. The facility failed to ensure 1 of 2 resident's (having a [MEDICAL CONDITION]) care plans were reviewed and revised with adequate interventions to ensure the safety of Resident #8's [MEDICAL CONDITION] and failed to assure the resident was care planned with appropriate interventions related to capping [MEDICAL CONDITION] discharge teaching. The findings included: Review of the Plan of Correction with a completion date of 8/13/2011 revealed the facility was to review all resident care plans during the morning stand up meeting Monday thru Friday. The care plans were to be reviewed for accuracy and updated with any acute care concerns. The Director of Nursing was to monitor the process and report to the Quality Assurance Committee any areas of concern. The facility failed to assure all residents' care plans were accurately reviewed and revised per their plan of correction. The findings are as follows: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#8 was sent to the hospital for evaluation for [MEDICAL CONDITION] removal. A [MEDICATION NAME] was performed with the following results: ""[MEDICATION NAME] revealed subtotal occlusion of the trachea. Therefore,[MEDICAL CONDITION] could not be removed but was downsized to #4 cannuli."" Resident #8 was sent back to the VA on 9/16 related to an accidental decannulation. Further review of the physician's orders [REDACTED]. The resident was receiving speech therapy until 9/21/11 when services were discontinued. SLP was not assisting the resident in capping trials and no documentation was located related to capping. Review of the Re-Admit note dated 9/22 but the encounter date was 9/17 documented: ""sent out to VAH to be evaluated for possible removal of [MEDICAL CONDITION]. Underwent [MEDICATION NAME] and pt's (patients)[MEDICAL CONDITION] decreased to #4 from #6. Pt returns for continued teaching on care of his trach..."" Record review on 10/3/2011 revealed a Nurse's Note dated 8/23/2011 at 7:45 PM that documented: ""Summoned to room and resident put call light on upon, upon entering room sitting on side of bed holding cannula. Resident stated ""I coughed and it came out""...New inner cannula inserted without difficulty."" On 9/16/2011 at 10:20 AM, ""this writer was summoned in the room by (Certified Nursing Assistant). Upon entering resident sitting on the side of the bed with the [MEDICAL CONDITION] and inner cannula in the left hand. Right side was loosed (sic). ""Resident said: ""when I sat, it fell out.""[MEDICAL CONDITION] was insert (sic) by this writer without difficulty...Resident placed on 1:1 observation."" At 10:35 AM, (Attending Physician) was notified and orders obtained to send to the hospital. The resident returned on 9/17 at 2 AM with two #4 [MEDICAL CONDITION] kits. The 1:1 observations were not continued and no other interventions were put in place related to [MEDICAL CONDITION]. On 9/21, discharge teaching began for Resident #8's care of his [MEDICAL CONDITION]. The nurses notes documented that the resident was able to perform his [MEDICAL CONDITION] successfully. On 9/28/2011 at 2:36 AM, ""(Certified Nursing Assistant) reported [MEDICAL CONDITION]. On arrival to room, resident sitting on the side of the bed c (with)[MEDICAL CONDITION] and in lock position, stated he was coughing earlier."" There was no documentation located related to the capping of the trach. Review of the Care Plan dated 8/1 and reviewed on 9/21 revealed a problem area of ""resident has hx (history) of dislodging [MEDICAL CONDITION], unclear if it was intentional, resident denies, stated he was fidgeting [MEDICAL CONDITION] it became dislodged."" Approaches included ""encourage resident to not dislodge trach, explain importance of [MEDICAL CONDITION] to resident, ensure [MEDICAL CONDITION] remains at head of resident's bed, inservice staff on [MEDICAL CONDITION] and encourage CNAs to report [MEDICAL CONDITION]."" 1:1 observations was listed on the care plan, however it had been crossed off. The care plan had not been updated with the dislodgements on 8/23, 9/16 or 9/28. No other interventions were put in place related to the dislodgements. The care plan was not updated to include any interventions related to weaning, capping or the use of a speaking valve. The care plan was not updated related to any [MEDICAL CONDITION] teaching. During an interview on 10/3/2011 at 4:37 PM, the Administrator and the Director of Nursing stated that Resident #8's 1:1 monitoring was discontinued on 8/22/2011. The DON stated that there were no other interventions put in place related to the decannulations. She stated that the resident was not intentionally pulling the [MEDICAL CONDITION] out and it was not a behavior concern. She stated that the resident was sent to the hospital on 9/16 related to the decannulation. The DON stated that the resident decannulated at the hospital. The DON stated that the VA sent Resident #8 back to the facility and [MEDICAL CONDITION] safe. Both the DON and the Administrator confirmed that when the resident returned to the facility, no interventions were initiated related to the resident's decannulations. During an interview on 10/13/2011 at 5:20 PM, Resident #8 was asked if he had problems with [MEDICAL CONDITION] out. He stated ""yes."" The resident reported all three incidents of [MEDICAL CONDITION]. Resident #8 then stated ""last Tuesday it came out."" Resident #8 stated that he sat up in bed and was coughing and [MEDICAL CONDITION] out. Resident #8 was asked specifically what came out and he stated his trach. Resident #8 was asked again if the entire device came out or only the inner part. Resident #8 stated again that the whole then came out and ""shot across the room."" Resident #8 then stated that he ""put it back in."" Resident #8 then stated that he reported the incident to the nurse. Resident #8 was asked about his hospitalization . He stated that while he was there he received a ""cap."" He stated that ""someone"" told him to cap [MEDICAL CONDITION] night while he was sleeping. Resident #8 stated that he tried to cap [MEDICAL CONDITION] he woke up in the middle of the night and couldn't breath. Resident #8 again stated that he reported this to the nurse. Resident #8 was asked if he was still capping [MEDICAL CONDITION] he stated ""No, the nurses lost it."" During an interview on 10/3/2011 at 5:25 PM, Licensed Practical Nurse (LPN) #3 stated that Resident #8 returned from the VA Hospital with a cap and he was capping his trach. LPN #3 stated that there were no orders for the capping and that none were needed. LPN #3 also stated that the resident lost the cap. During an interview on 10/3/2011 at 5:30 PM, Speech Language Pathologist #1 stated that she was aware Resident #8 was capping his trach. She stated that she was not assisting the resident with the capping trials. SLP #1 stated that there were no orders and no monitoring was in place related to Resident #8's capping. During the Exit Conference on 10/3/2011 at 6:30 PM, the DON, the Administrator and the Nurse Consultant all confirmed there were no orders for a cap. All also confirmed that a new cap had been ordered for Resident #8. The Nurse Consultant stated that the cap was being replaced because the resident had returned from the hospital with one and a new cap was going to be placed in his emergency kit. The DON was asked what interventions had been initiated by the facility to protect the resident's airway. The DON could not provide any interventions that were implemented.",2014-12-01
9745,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,281,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and expanded survey based on record reviews, interviews, observations, the South Carolina Nursing Standard of Practice SECTION [DATE], the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section [DATE], the Nursing Code of Ethics Provision 4.3, and the South Carolina LLR Advisory Opinion #37 the facility failed to ensure that 4 of 5 residents reviewed with tracheostomies and 1 of 1 resident reviewed for dehydration received services that meet professional standards of quality. The facility failed to provide necessary emergency care on [DATE] when Resident #6 was found holding [MEDICAL CONDITION] her hand; Residents #7 and #8 were observed without the necessary emergency supplies at their bedside or supplies were not readily available; Resident #10 was not adequately care planned regarding [MEDICAL CONDITION] care. Resident #9 not adequately assessed regarding enteral (tube fed) and oral intake of fluids/nutrition became dehydrated resulting in hospitalization on [DATE]. The findings included: The facility admitted Resident #6 on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#6's trach. There was no documentation in the nurse's notes or assessments of the type and size of [MEDICAL CONDITION] for Resident #6's. Review of the Nurse's Notes revealed on [DATE] at 1:35 AM, ""writer (LPN #1) noted resident [MEDICAL CONDITION] hand, South Wing nurse called for backup kept airway open attempted to [MEDICAL CONDITION] in, unsuccessful 911 called gave report. MD called, order to send resident to hospital to replace trach. Resident alert and breathing through mouth, EMS arrived attempted to [MEDICAL CONDITION] no avail, Resident transported to (hospital). "" At 3:05 AM, ""(hospital) called to report Resident had expired. "" Review of the Medication Administration for [DATE] revealed no documentation that Resident #6 was suctioned. During an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) #1 stated that she was assigned to Resident #6 on [DATE] during the night shift. She stated that she walked into the resident's room and saw the ""[MEDICAL CONDITION] out."" LPN #1 stated that she ""freaked out "" and ""didn't know what to do"" and ""had never been through this before."" LPN #1 stated that she had never received training or inservices regarding emergency care of tracheostomies or how to replace a decannulated trach. LPN #1 stated that there was not a [MEDICAL CONDITION] emergency supplies in Resident #6's room. Review of the facility obtained statement of LPN #2 dated [DATE] revealed, at ""1:,[DATE]:45 AM, I got called to go to the other side. I ran to the other side, when I got to the unit, the nurse yelled, 'Oh my god! She's blue y'all, she's blue!' I went in the room, she was blue, her fingertips and hands were blue. We had to find out if she's a full code. She was not breathing, she did not have a pulse. There was no ambu bag... The nurse was frantic and freaking out."" Multiple attempts were made to contact LPN #2 on [DATE] and [DATE]. The facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7's room revealed an ambu bag hanging on the wall above the bed. LPN #4 was asked how she would respond if Resident #7 was decannulated. She stated that she would try to replace [MEDICAL CONDITION]. LPN #4 was asked to locate the emergency supplies. She confirmed that there was no obturator in the resident's room. After approximately 5 minutes of searching through the resident's drawers and bins she located [MEDICAL CONDITION] out kit. LPN #4 confirmed that she did not know what all the contents were for in the kit. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:30 AM, LPN #3 confirmed Resident #8 had a size 6 trach. LPN #3 was asked where the emergency supplies for the resident were located. LPN #3 located the disposable inner cannulas in her med cart. She also located two boxes of a size 8 [MEDICAL CONDITION] out kits. One box had been opened and missing part of the contents. LPN #3 confirmed the supplies at the bedside were not the appropriate supplies. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Record review revealed the Interim Plan of Care did not address the resident's respiratory status, [MEDICAL CONDITION] or history of [MEDICAL CONDITION] hemorrhage. Further record review revealed no documentation of what type and size [MEDICAL CONDITION] ordered for Resident #10. During an interview on [DATE] at 12:20 PM, the Nurse Consultant confirmed the Interim Care Plan did not address the resident's needs. She confirmed that the resident'[MEDICAL CONDITIONS] history was not included and should have been. She also confirmed there was no documentation of what type and [MEDICAL CONDITION] #10 had. She stated that she would not know how staff would know what emergency supplies were necessary for Resident #10. Four nurses interviewed (LPN #3, #4, #5, #6) stated that they checked for [MEDICAL CONDITION] daily, at the beginning of their shifts. All four stated that each resident with [MEDICAL CONDITION] have a replacement kit at the bedside. During an interview on [DATE] at 3:15 PM, the Director of Nurses (DON) stated that nurses should check at the beginning of their shifts for the necessary emergency supplies. The DON confirmed that if the nurses were checking for the necessary emergency supplies then they would have noticed the supplies were not present at the bedside. Review of the policy on [MEDICAL CONDITION] Care stated, ""... If [MEDICAL CONDITION] outer cannula is accidentally extubated, attempt to insert [MEDICAL CONDITION](same type and [MEDICAL CONDITION] obturator should always be kept at bedside for such emergencies). "" The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurse's Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further review revealed on [DATE] the resident's family member reported the resident was dehydrated. On ,[DATE] the resident was noted down the service hallway by the exit door. On ,[DATE] at 11:45 AM, ""Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt. On [DATE] at 5:30 PM a late entry documented ""upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..."" Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding or exit seeking behavior. There were no interventions put in place to address the resident's weight loss or refusal of meals/hydration. Record review revealed no Elopement Assessment was completed during the resident's admission to the facility. During an interview on [DATE] at 2:15 PM, the Registered Dietitian (RD) stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she ""didn't know what else to do."" The RD stated that she saw the resident on [DATE] and confirmed that she did not address the significant weight loss. The RD stated that she was in the building on ,[DATE] but did not see Resident #9. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. The RD confirmed that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed an elopement assessment was not completed. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. Review of the South Carolina Nursing Standard of Practice SECTION [DATE]. (23) stated, ""... grounds for disciplinary action: assigned unqualified persons to perform nursing care functions, tasks, or responsibilities or failed to effectively supervise persons to whom nursing functions are delegated or assigned. "" Review of the South Carolina Nurse Practice Act Laws and Policies, Chapter 33 Section [DATE](62) stated, ""... 'Unprofessional conduct' means acts or behavior that fail to meet the minimally acceptable standard expected of similarly situated professionals including, but not limited to, conduct that may be harmful to the health, safety, and welfare of the public, conduct that may reflect negatively on one's fitness to practice nursing, or conduct that may violate any provision of the code of ethics adopted by the board or a specialty."" Review of the Nursing Code of Ethics Provision 4.3 stated, ""... nurses accept or reject specific roles based upon their education, knowledge, competence and extent of experience."" Review of South Carolina LLR Advisory Opinion #37 stated, ""... The Board of Nursing for South Carolina acknowledges that it is within the role and scope of practice of a RN (registered nurse) and LPN to temporarily remove, reposition or reinsert [MEDICAL CONDITION] in children and adults with well established stomas in the home or school setting providing the environment is supportive to emergency medical care. This responsibility is an expanded role for the RN and LPN. Appropriate written policies and procedures should be developed which specify required special education and training. This special education and training should include documented safety practices and other didactic material as well as clinical skill competency components. The agency policies and procedures should address how the agency will assure a physician or Advanced Practice Registered Nurse (APRN) authorizes removal, repositioning or reinsertion of [MEDICAL CONDITION]. This can be defined in the written policies, procedures, and protocols. Annual updates/reviews need to be documented."" On [DATE] at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented [DATE] for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on [DATE] were not addressed until [DATE] and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On [DATE] at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on [DATE], was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of [DATE] when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on [DATE] and remains ongoing.",2014-12-01
9746,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,309,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on record review, interviews, and review of facility files, the facility failed to ensure residents received necessary care and services of prompt assessment, interventions, monitoring, and continued assessment for 1 of 1 resident who was the alleged victim of sexual assault (Resident #1). The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident assessments of 8/25/2010 and 5/1/2011 showed the resident was severely cognitively impaired and she required total assistance from the staff for all her activities of daily living. On 7/7/2011, family members alleged that the resident was being sexually abused due to a new onset of vaginal bleeding. Review of the medical record showed no evidence the family made this complaint. The physician was not notified. An interview with LPN #7 on 7/19/2011 revealed she assessed the resident immediately after the family made their allegation, but her findings were not documented. The facility began an investigation on 7/8/11 after the resident named a male resident as the alleged perpetrator during an interview with the Director of Nurses (DON). The physician was notified and the resident was sent to the hospital for a rape kit on the afternoon of 7/8/11. She returned to the facility on [DATE] at 5:06 AM. No pelvic exam had been done or evidence recovered. Review of the medical record showed no physician's examination of the resident. An interview with the Medical Director on 7/19/11 revealed she did an external examination of the resident on 7/9/11 but was called away on an emergency before documenting in her progress notes. Review of the Nurse's Notes showed an entry on 7/9/11 at 6:50 PM saying the resident was in bed and adjusting to her new environment (her room was changed). It did not show any assessment of the resident related to vaginal bleeding, any developing physical signs of trauma, or signs of emotional distress. There were no further Nurse's Notes until 7/13/11. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9747,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,319,G,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review the facility failed to ensure that appropriated psychosocial services were provided for 1 of 5 residents reviewed with tracheostomies. Resident #8 had no behavior monitoring/supervision or interventions in place to address his know behavior of pulling at [MEDICAL CONDITION] attempting to decannulate. One of 1 resident reviewed with dehydration. Resident #9's with known wandering and exit seeking behaviors; and resisting nourishment had not interventions in place to address these behaviors. Resident #9 admitted to the hospital with [REDACTED]. The findings included: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 7/23/2011 ""[MEDICAL CONDITION] writer (LPN #3)found out that inner cannula is absent. "" During an interview on 8/1/2011 at 10:30 AM, LPN #3 stated that Resident #8 had pulled his inner cannula out again this morning. LPN #3 confirmed that Resident #8 had pulled out his inner cannula on previous occasions. Record review revealed no behavior monitoring or supervision for Resident #8. Also, there were no interventions in place to prevent Resident #8 from pulling at [MEDICAL CONDITION] attempting to decannulate. The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurse's Notes revealed multiple entries that indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further review revealed on 6/4/2011 the resident's family member reported the resident was dehydrated. On 6/7/2011 the resident was noted down the service hallway by the exit door. On 6/19/2011 at 11:45 AM, ""Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt."" On 6/19/2011 at 5:30 PM a late entry documented, ""upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic... Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him..."" Review of the ADL Tracking Log for June 2011 revealed Resident #9 refused all meals. Resident #9 was noted to self propel himself in the wheelchair. Resident #9 was also noted to be alert and oriented times three on admission. However, he had increasing confusion during the month of June 2011. Review of the Neurological Flowsheet dated 6/17 through 6/20/2011 revealed Resident #9 was confused at all times. Further record review revealed no behavior monitoring or interventions in place related to the resident's behavior of disconnecting his tube feeding or his increased confusion with exit seeking behavior. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed Resident #9 had increasing confusion. The ADON also confirmed that no interventions were put in place related to Resident #9's known wandering and exit seeking. The ADON confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration.",2014-12-01
9748,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,325,G,1,0,KPHO11,"**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 the facility failed to assure 1 of 1 residents maintained acceptable parameters of nutrition and body weight. Resident #9 sustained a 19% weight loss in less than 4 weeks. The findings included: The facility admitted Resident #9 on 4/28/2011 with [DIAGNOSES REDACTED]. Record review revealed a dietary assessment dated [DATE] that indicated Resident #9 required 2300-2400 milliliters of fluid a day and required 2300 calories per day. Resident #9 was ordered [MEDICATION NAME] 1.5, 1 can every 4 hours and 150 ml water flushes every 4 hours. Resident #9's weight was noted to be stable at 175 pounds for the month of May 2011. On 5/24/2011 an order was written for [MEDICATION NAME] 1.5 at 110 ml/hr from 7PM-5AM, 8AM-10 AM, 1PM-3PM and 5PM-6PM with water flushes every 4 hours. On 6/1/2011, Resident #9's weight decreased to 159.2 pounds. A significant loss of 9% in approximately 2 weeks. The Registered Dietitian saw Resident #9 on 6/2/2011 and did not note the significant weight loss. Furthermore the tube feeds were decreased to 80 ml/hr for 12 hours with 150 ml water flushes every 4 hours. The new order provided Resident #9 with 900 ml of water and 960 ml of formula (significantly less than the required amount). Resident #9's weight on 6/9/2011 was 154.6, another 3 % loss in one week. On 6/13/2011 Resident #9 weighed 147, a 5 % loss on one week. Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the physician's orders [REDACTED]. Review of the Nurse's Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Review of the ADL Tracking Log for June 2011 revealed Resident #9 refused all meals. Further record review revealed no documentation of intake and output for Resident #9. No behavior monitoring or interventions were put in place related to the resident's behavior of disconnecting his tube feeding. During an interview on 8/2/2011 at 2:15 PM, the Registered Dietitian stated that Resident #9 did not tolerate the bolus tube feeds because he felt too full. She also stated that he would disconnect his continuous tube feeds. The RD stated that she was trying to find a way to provide Resident #9 his required nutrition but stated that she ""didn't know what else to do."" The RD stated that she saw the resident on 6/2/2011 and confirmed that she did not address the significant weight loss. Also, she confirmed, that the order was changed to decrease the amount of formula. She stated that the Attending Physician changed the order and she was not aware of the change until after the resident was discharged . The RD stated that she was in the building on 6/12 but did not see Resident #4. She stated that the facility staff did not inform her of the continued significant weight loss. The RD stated that she did not contact the Attending Physician for further interventions and confirmed that no interventions were put in place to address the resident's significant weight loss. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) confirmed the significant weight loss of Resident #9, confirmed the RD and the doctor were not notified of the loss. She also confirmed no interventions were put in place related to the weight loss.",2014-12-01
9749,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,327,G,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on record review, interview and review of the facility's policy on Extreme Heat, the facility failed to assure one of one residents reviewed for hydration received adequate fluid intake to prevent dehydration. Resident #9 not adequately assessed regarding enteral and oral intake of fluids/nourishment became dehydrated resulting in hospitalization on [DATE]. The findings included: The facility admitted Resident #9 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #9 sustained a 19% weight loss in less than 4 weeks. Review of the Nurses Notes revealed multiple entries indicated Resident #9 would disconnect his tube feeds and saturate the bed with formula. Further record review revealed no documentation of intake and output for Resident #9. Review of the Nurse's Notes revealed on [DATE] the resident's family member reported the resident was dehydrated. Yogurt was offered and the resident declined water. His tube was flushed with 90 ml of water. The resident was noted with confusion at times. On [DATE] at 7:30 PM, ""resident decided to go sit outside for awhile and removed shirt exposing self, gentle encouragement to come back into building."" On ,[DATE] at 11:45 AM, ""Res alert and oriented x 2 with confusion noted. Resident's son found resident in hall near front entrance without pants on and with a brief and shirt."" On [DATE] at 5:30 PM a late entry documented ""upon entry to the building noted resident sitting halfway undressed on the front porch. Was hot and slightly lethargic. Asked resident to come inside and he stated no. Expressed to him that he needed to come in or he would get heat exhaustion. He then agreed to come in. Assisted back to the room and turned on AC unit. Placed cool towels and washcloths to help cool him. Offered fluids and he declined. Would not allow staff to provide any fluids via tube. "" On [DATE] at 5:30 PM, ""summoned to North Wing by resident's family member. Noted resident sitting up in wheelchair with signs and symptoms of lethargy. O2 sat fluctuating, 911 called..."" Review of the Emergency Department's record from the Hospital dated [DATE] revealed Resident #9's [DIAGNOSES REDACTED]. Acute Dehydration 2. [MEDICAL CONDITION]. "" Resident #9's labs were as follows: Sodium 162 (high), Chloride 117 (high), Glucose 198 (high), BUN 48 (high). Resident #9 received one liter of IV fluids in the ER. During an interview on [DATE] at 2:15 PM, the Registered Dietitian stated that Resident #9 was not provided adequate hydration. During an interview on [DATE] at 3 PM, the Assistant Director of Nurses (ADON) confirmed that Resident #9 was outside for an undetermined amount of time and was not provided adequate hydration. The ADON confirmed there was no documentation that the physician was notified of the resident going outside and subsequent heat exhaustion. The ADON confirmed that Resident #9 was sent to the hospital for dehydration. Resident #9 expired on [DATE]. Review of the facility's policy on Extreme Heat revealed the symptoms of heat stroke/exhaustion included ""headache, dizziness, weakness, the person may be confused and may find it difficult to coordinate body movements. Treatment should include removing person to cool environment and encouraging increased consumption of fluids. The physician should be notified promptly to obtain specific directions for care. Depending on the time and exposure this event may require a self report to the state agency per regulations.""",2014-12-01
9750,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,328,J,1,0,KPHO13,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NOT CORRECTED On the days of the follow up visit based on record review, observation and interview the deficiency was not corrected. The facility failed to assure one of two residents sampled with tracheostomies received the necessary care and services related to the tracheostomies. Resident #8, who had a history of [REDACTED]. The facility also failed to assure Resident #8 had orders and the appropriate monitoring in place related to the capping of his [MEDICAL CONDITION]. The findings included: The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. Resident #8 was alert and oriented x3 per the Nurses Notes, Progress Notes, Social Notes and the BIMS Score of 15 on the Minimum Data Set (MDS). Resident #8 was placed on 1:1 monitoring for dislodgement of his [MEDICAL CONDITION] beginning 8/1/2011. The 1:1 monitoring was discontinued on 8/22/2011. The Psychiatrist evaluated Resident #8 on 8/1 with no recommendations. He was evaluated again on 8/18 and on 8/22 with no recommendations. Resident #8 was evaluated by the Attending Physician on 8/23/11 with no reference to the dislodgement on 8/23. The physician documented ""referral to VAH about consideration [MEDICAL CONDITION]-pending."" Review of the Re-Admit note dated 9/22 but the encounter date was 9/17 documented: ""sent out to VAH to be evaluated for possible removal of [MEDICAL CONDITION]. Underwent [MEDICATION NAME] and pt's (patients)[MEDICAL CONDITION] decreased to #4 from #6. Pt returns for continued teaching on care of his trach..."" Review of the physician's orders [REDACTED].#8 was sent to the hospital for evaluation for [MEDICAL CONDITION] removal. A [MEDICATION NAME] was performed with the following results: ""[MEDICATION NAME] revealed subtotal occlusion of the trachea. Therefore,[MEDICAL CONDITION] could not be removed but was downsized to #4 cannuli."" An order was written on 9/15/11 that changed the resident'[MEDICAL CONDITION] from a #6 to a #4. Resident #8 was sent back to the VA on 9/16 related to decannulation. Further review of the physician's orders [REDACTED]. The resident was receiving speech therapy until 9/21/11 when services were discontinued. SLP was not assisting the resident in capping trials and no documentation was located related to capping. Record review on 10/3/2011 revealed a Nurse's Note dated 8/23/2011 at 7:45 PM that documented: ""Summoned to room and resident put call light on upon, upon entering room sitting on side of bed holding cannula. Resident stated ""I coughed and it came out""...New inner cannula inserted without difficulty."" There was no evidence the physician or the responsible party was notified related to the incident. On 9/16/2011 at 10:20 AM, ""this writer was summoned in the room by (Certified Nursing Assistant). Upon entering resident sitting on the side of the bed with the [MEDICAL CONDITION] and inner cannula in the left hand. Right side was loosed (sic). ""Resident said: ""when I sat, it fell out.""[MEDICAL CONDITION] was insert (sic) by this writer without difficulty...Resident placed on 1:1 observation."" At 10:35 AM, (Attending Physician) was notified and orders obtained to send to the hospital. The resident returned on 9/17 at 2 AM with two #4 [MEDICAL CONDITION] kits. The 1:1 observations were not continued and no other interventions were put in place related to [MEDICAL CONDITION]. On 9/21, discharge teaching began for Resident #8's care of his [MEDICAL CONDITION]. The nurses notes documented that the resident was able to perform his [MEDICAL CONDITION] successfully. On 9/28/2011 at 2:36 AM, ""(Certified Nursing Assistant) reported [MEDICAL CONDITION]. On arrival to room, resident sitting on the side of the bed c (with)[MEDICAL CONDITION] and in lock position, stated he was coughing earlier."" There was no documentation that the physician or the responsible party was notified of the incident. There was no documentation located related to the capping of the trach. Review of the VA Hospital Discharge Summary dated 9/15 and signed 9/16 revealed no indication for any decannulation/capping trials. The Discharge Summary reported the [MEDICATION NAME] that indicate the [MEDICAL CONDITION] could not be removed due to an occlusion of the trachea. No orders were received related to capping of the trach. Review of the Care Plan dated 8/1 and reviewed on 9/21 revealed no interventions were put in place related to the dislodgements. The care plan was not updated to include any interventions related to weaning, capping or the use of a speaking valve. The care plan was not updated related to any [MEDICAL CONDITION] teaching. Review of the Medication Administration Record [REDACTED]. Observation of Resident #8's emergency kit on 10/3/2011 at 4:00 PM revealed the above items as well as a speaking valve. During an interview on 10/3/2011 at 4:37 PM, the Administrator and the Director of Nursing stated that Resident #8's 1:1 monitoring was discontinued on 8/22/2011. They both were aware of Resident #8's decannulation on 9/16, however neither were aware of the dislodgements on 8/23 or 9/28 initially. The DON stated that there were no other interventions put in place. She stated that the resident was not intentionally pulling the [MEDICAL CONDITION] out and it was not a behavior concern. She stated that the resident was sent to the hospital on 9/16 related to the decannulation. The DON stated that the resident decannulated at the hospital. She stated that multiple tests and consults were made. The DON stated that the VA sent Resident #8 back to the facility and [MEDICAL CONDITION] safe. Both the DON and the Administrator confirmed that when the resident returned to the facility, no interventions were initiated related to the resident's decannulations. The DON then reviewed the nurses notes and stated that she did recall the 9/28 incident and had discussed the incident in the morning meeting. She stated that she spoke with the nurse and the nurse indicated that the incident did not occur. The DON stated that she did not have any documentation that the incident was discussed in the morning meeting and did not have any documentation/evidence of her investigation. During an interview on 10/13/2011 at 5:20 PM, Resident #8 was asked if he had problems with [MEDICAL CONDITION] out. He stated ""yes."" The resident reported all three incidents of [MEDICAL CONDITION]. Resident #8 then stated ""last Tuesday it came out."" Resident #8 stated that he sat up in bed and was coughing and [MEDICAL CONDITION] out. Resident #8 was asked specifically what came out and he stated his trach. Resident #8 was asked again if the entire device came out or only the inner part. Resident #8 stated again that the whole then came out and ""shot across the room."" Resident #8 then stated that he ""put it back in."" Resident #8 then stated that he reported the incident to the nurse. Resident #8 was asked about his hospitalization . He stated that while he was there he received a ""cap."" He stated that ""someone"" told him to cap [MEDICAL CONDITION] night while he was sleeping. Resident #8 stated that he tried to cap [MEDICAL CONDITION] he woke up in the middle of the night and couldn't breath. Resident #8 again stated that he reported this to the nurse. Resident #8 was asked if he was still capping [MEDICAL CONDITION] he stated ""No, the nurses lost it."" During an interview on 10/3/2011 at 5:25 PM, Licensed Practical Nurse (LPN) #3 stated that Resident #8 returned from the VA Hospital with a cap and he was capping his trach. LPN #3 stated that there were no orders for the capping and that none were needed. LPN #3 also stated that the resident lost the cap. During an interview on 10/3/2011 at 5:30 PM, Speech Language Pathologist #1 stated that she was aware Resident #8 was capping his trach. She stated that she was not assisting the resident with the capping trials. SLP #1 stated that there were no orders and no monitoring was in place related to Resident #8's capping. The Director of Nurses was asked if there was a policy related [MEDICAL CONDITION] and/or capping. No policy was produced. The policy on Tracheostomies was reviewed. Review of the Purchase Order dated 9/26/2011 revealed a ""Speaking Valve"" was ordered for Resident #8. The Administrator, the DON and the Supply Clerk stated that the ""cap"" was on back order and had not arrived. During the Exit Conference on 10/3/2011 at 6:30 PM, the DON, the Administrator and the Nurse Consultant all confirmed there were no orders for a cap. All also confirmed that a new cap had been ordered for Resident #8. The Nurse Consultant stated that the cap was being replaced because the resident had returned from the hospital with one and a new cap was going to be placed in his emergency kit. The Nurse Consultant confirmed that a cap was not an emergency supply device. The DON again stated that the resident's decannulation/dislodgements were not a behavior concern. The DON was asked what interventions had been initiated by the facility to protect the resident's airway. The DON could not provide any interventions that were implemented.",2014-12-01
9751,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,490,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended survey the facility's Administration failed to put interventions in place to protect Resident #1 whose family alleged sexual abuse occurred on 7/7/2011 and Resident #3 whose rings were found in Resident #2's room on 6/20/2011. The facility failed to follow accepted procedures for the investigation of incidents involving alleged sexual abuse and misappropriation of property. The facility failed to identify timely the owner (s) of 6 rings found in Resident #2's room during a search on 6/20/2011; failed to provide medical social support to Resident's #1, #2, and #3; and failed to educate all facility staff regarding the allegations and the interventions necessary to protect all residents at risk of becoming victims. The facility's administration failed to ensure residents with tracheostomies (Resident's #6, #7, #8, #10) had the necessary emergency supplies at the bedside and failed to ensure staff members were adequately trained to handle emergency situations related to residents with tracheostomies. The findings included: Resident #1, a [AGE] year old female with [DIAGNOSES REDACTED]. Family members made their allegation on 7/7/2011. The facility delayed beginning the investigation into the allegation of Resident #1's possible sexual abuse until 7/8/2011. During an interview with the Administrator and the DON on 7/19/2011, the DON stated the resident's family reported their sister told them she had been abused. The investigation did not include a statement from the nurse on duty at the time the allegation was made. Resident #1 was not examined at the facility or the physician notified until 7/8/2011 and the resident was sent to the emergency roiagnom on that day. Resident #2 with [DIAGNOSES REDACTED]. The resident was alert and oriented. He propelled himself about the facility and into the community with an electric wheelchair. Review of the medical record and facility files revealed the resident was a registered sex offender. No care plan was in place to address the residents known behavior. Resident #3 with [DIAGNOSES REDACTED]. Review of the investigative materials for the allegation of misappropriation revealed that after six ladies rings and a facility central supply key were found on 6/20/2011 in Resident #2's room, the facility did not put into place any interventions until 7/8/2011 to protect residents from further potential misappropriation of property. In an interview on 7/18/11 with the Administrator and Director of Nursing (DON) the Administrator and DON stated that 5 rings and a key with ""CS"" (central supply) on it was found during the search. The search was halted when the items were found and the police called. The resident was left alone during the call to the police and was seen leaving the facility with items from his room. The search of Resident #2's room was not completed until the police conducted a search and after the resident had been seen leaving the building. During the interview with the Administrator and DON, they stated that after finding the jewelry in the resident's room, they checked with residents and/or family members who had reported missing rings in the past months with no results. There was no evidence of any other investigation and no interventions put in place until a resident came forward 2 weeks later to report missing rings. No measures were put in place to protect residents from further potential misappropriation of property. The facility admitted Resident #6 on 12/10/2009 and readmitted on [DATE], with [DIAGNOSES REDACTED]. Record review on 8/1/2011 revealed Resident #6 was sent to the emergency roiagnom on [DATE] following decannulation. The facility staff neglected to provide necessary emergency care to Resident #6, a [MEDICAL CONDITION] resident, when the resident decannulated. The facility admitted Resident #7 on 8/3/2010 with [DIAGNOSES REDACTED]. The facility admitted Resident #8 on 7/1/2011 with [DIAGNOSES REDACTED]. The facility admitted Resident #10 on 7/6/2011 with [DIAGNOSES REDACTED]. Resident #10 was discharged to the hospital on [DATE] related to acute respiratory distress. Observation of Resident #7 and #8's room revealed Resident #8 did not have a 6 Shiley at the bedside. Resident #7 did not have the emergency supplies readily available. Resident #10 was not adequately care planned regarding [MEDICAL CONDITION] care. During an observation of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. Review of the July 2011 General Spending Ledger revealed no Size 6 Shiley tracheostomies were ordered. During an interview on 8/1/2011 at 3:15 PM, the Director of Nurses (DON) confirmed that she was aware of LPN #1's statement of ""freaking out"" and the lack of knowledge regarding emergency management of tracheostomies when Resident #6 was found with [MEDICAL CONDITION] her hand. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or the need for emergency supplies at the bedside. During an interview on 8/2/2011 at 9:45 AM, the Administrator stated that both the DON and the Nurse Consultant working at the facility during the time the incident was investigated were aware the [MEDICAL CONDITION] were not available in the facility. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) stated that she reported to the Nurse Consultant that the necessary emergency supplies were not at the resident's bedside. The ADON stated that she was told the nurse consultant would ""take care of it."" She also stated that all supplies were ordered through central supply. However, the central supply aid has been on suspension for 3 weeks. The ADON stated that she was not sure who was responsible for the procurement of the supplies. Cross Refers to F-224, F-225, and F-226 as it relates to the failure of the facility Administration to ensure residents are free from Neglect, Abuse, and Misappropriation, any alleged incidents are investigated timely, and interventions are in place to ensure residents are protected during an investigation. In addition failure of the facility to ensure emergency supplies are available as needed for resident care and staff is sufficiently trained to provide care for all residents in the building. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9752,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,501,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended survey based on interviews, observations, review of the facility's policy [MEDICAL CONDITION] Care, and record reviews, the facility Medical Director failed to ensure the facility's policies and procedures were implemented. Residents with tracheostomies did not have the necessary emergency supplies at the bedside, nor were the necessary emergency supplies ordered and in the facility's supply rooms. The findings included: Observation of Resident #7 and #8's room revealed Resident #8 did not have the appropriate [MEDICAL CONDITION] supplies at the bedside. Resident #7 did not have the emergency supplies readily available. During an observation of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. During an interview on 8/1/2011 at 1:45 PM, the Attending Physician/Medical Director was asked what emergency supplies should be available at a trached resident's bedside. The Medical Director stated that no supplies were needed at the bedside, the supplies only needed to be available in the building. She further stated that there was no policy that spoke to having emergency supplies. The Physician was informed of the facility's policy on [MEDICAL CONDITION] Care and emergency supplies. She then stated that it ""wouldn't be a bad idea "" to have the supplies at the bedside. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9753,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2011-08-02,520,J,1,0,KPHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended survey based on observations, record review and interviews the facility failed to identify a concern and develop a plan of action for residents with tracheostomies. Residents #6, #7 and #8 failed to have the necessary and appropriate supplies at the bedside. (2 of 2 residents with tracheostomies reviewed and 1 of 3 closed records of residents with tracheostomies.) The findings included: Observation of Resident #7 and #8's room revealed Resident #8 did not have the appropriate supplies at the bedside. Resident #7 failed to have the necessary emergency supplies readily available. Observation during the survey of the unit supply rooms and the central supply room revealed no size 6 Shiley [MEDICAL CONDITION]. During an interview on 8/1/2011 at 12:00 PM, the Nurse Consultant and the Director of Nurses confirmed there were no size 6 [MEDICAL CONDITION] house and confirmed the necessary emergency supplies were not at the residents' bedsides. Review of the July 2011 General Spending Ledger revealed no Size 6 Shiley tracheostomies were ordered. During an interview on 8/1/2011 at 3:15 PM, the Director of Nurses (DON) confirmed she was aware of LPN #1's statement related to Resident #6, found with [MEDICAL CONDITION] her hand, of ""freaking out"" and the lack of knowledge regarding emergency management of tracheostomies. The DON also stated that there were no inservices conducted related to emergency management of tracheostomies,[MEDICAL CONDITION] outs or emergency supplies at the bedside. During an interview on 8/2/2011 at 9:45 AM, the Nurse Consultant stated that both the DON and the Nurse Consultant that was present during investigation of the incident with Resident #6 were aware the [MEDICAL CONDITION] were not in the facility. The Nurse Consultant stated that an ACLS (Advanced Cardiac Life Support) nurse had arrived at the facility on 8/2/2011 to perform the inservices to the nurses regarding the emergency management of trachs and replacing a decannulated trach. During an observation on 8/2/2011 at 11 AM, the ACLS Nurse was observed providing one to one training. The training only [MEDICAL CONDITION]. The training did not include replacing a decannulated trach, emergency management or competency checks. During an interview on 8/2/2011 at 3 PM, the Assistant Director of Nurses (ADON) stated that she reported to the Nurse Consultant that there were not the necessary emergency supplies at the resident's bedside. The ADON stated that she was told the nurse consultant would ""take care of it."" She also stated that all supplies were ordered through central supply. However, the central supply aid has been on suspension for 3 weeks. The ADON stated that she was not sure who was responsible for the procurement of the supplies. On 7/25/2011 at 6:15 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157, F-225, F-226, F-250, F-279, F-309, and F-490 at a scope and severity of ""J"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 6/20/2011 when property not belonging to Resident #2 was found in his room, law enforcement became involved, and an investigation was started that was found to be incomplete and not done timely leaving residents potentially vulnerable and at risk until interventions were implemented 7/8/2011 for their protection. Additional allegations of sexual abuse of Resident #1 by Resident #2 made on 7/7/2011 were not addressed until 7/8/2011 and again an incomplete and delayed investigation was conducted and interventions that were implemented to protect the residents did not address care and/or social needs of Residents involved in the allegations. (Residents #1, #2, and #3) On 8/1/2011 at 2:30 PM the Administrator and a Corporate Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at the additional areas of F-224, F-280, F-281, F-328, F-501, and F-520 at a scope and severity of ""J"". The citation at F-490, cited on 7/25/2011, was also included in this Immediate Jeopardy and the scope and severity was elevated to a ""K"". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 7/21/2011 when Resident #6 decannulated and the necessary emergency care was not provided to the resident and the facility became aware that emergency supplies were not available for [MEDICAL CONDITION] in the building and facility staff were not adequately trained to provide all aspects of care required [MEDICAL CONDITION]. The Immediate Jeopardy was not removed upon exit from the facility on 8/2/2011 and remains ongoing.",2014-12-01
9754,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,241,E,0,1,TYIJ11,"On the days of the survey, based on random observations of both the lunch and evening meal and interview, the facility failed to promote care for residents in a manner that enhanced their dignity and respect related to dining for 2 of the 3 Units observed and a random observation made of Resident A. The findings included: During random meal (lunch) observation on 2/14/11 at approximately 12:40 PM on Unit 300 2 dining tables were noted with 1 resident seated per table, 3 dining tables were noted with 2 residents per table and 1 dining table with 4 residents seated. Per the dining schedule, residents on the 300 Unit were to be served by 12:30 PM. The first food cart arrived at 1 PM. During the meal delivery, the facility staff was observed taking the food trays off the food cart and taking them to a counter in the back of the dining room to prep them. They then proceeded to take the trays to the residents. The facility staff did not serve all the residents seated at the same table prior to serving other residents. The table with the 4 residents seated was noted to have 3 residents served and eating while one resident was not served and eating. After 15 minutes the resident not served or eating seated at the table with the two residents that were eating was removed from the dining room and seated in the hallway near the door while the residents that remained ate their meals. Around 1:20 PM at second cart was delivered to the unit and the resident who was placed in the hallway was returned to the dining room. From 1 PM to 1:25 PM two male residents, seated at a table near the window, were not served while the other residents nearby were served and eating. During random meal (dinner) observation on 2/14/11 at approximately 6:33 PM a second food cart was delivered to the dining room. The two male residents were seated at a table but not served while the other residents were eating. Staff was noted going back and forth to the food cart to locate the dinner trays for the residents. There were two tables with one resident served and eating while another resident at the table was not served nor eating. At 6:45 PM a staff member was observed giving a resident the wrong food tray. At 6:50 PM a staff member was observed with a food tray and was trying to locate a resident. The nurse informed the staff member that the resident was already discharged from the facility. During group interview on 2/15/11 at 1:45 PM 6 of 6 residents presented in group stated their meals were usually late. Review of the Resident Council Minutes from 11/10 to 01/11 revealed the residents expressed concerns regarding the lateness of the breakfast meal on Sundays because it interfered with them not being able to attend church services on time. Meal observation on 12/14/11 at 12:30 PM revealed 7 tables with two or more residents seated at each table. One or 2 residents were served at each table, with at least 1 resident at each table waiting up to 15 minutes for their meals. Meal observation on 2/14/11 at 12:46 PM revealed that Resident A was brought into the dining room by the hospice nurse for lunch. One tray cart was blocking table access. A Certified Nursing Assistant (CNA) told the hospice nurse to remove the resident from the dining area at that time. At 1:15 PM, the resident was observed being served her meal in her room by a CNA. Per interview with the hospice nurse at 1:20 PM, the only reason the resident was removed from the dining area was due to the tray cart blocking the table where the resident was supposed to be fed. Review of the facility's list of residents that required feeding by staff at meals, provided by the administrator, revealed that Resident A was a total dependent feeder who ate in the dining room. Meal observation on 12/14/11 at 6:00 PM revealed three tables with only 1 resident served at each table and 2 residents at each table waiting on meals. One table had two residents both served their meals at 6:05 PM. One resident at the same table was observed with a lid from one of the other resident's trays using her finger to wipe the water from inside the lid and then placing the finger in her mouth. The same resident proceeded to eat off of another resident's plate, eating half of the resident's meal before the resident was provided with her own meal at 6:20 PM. One resident was heard and observed dropping her utensil on the floor while two CNAs were present. The two CNAs did not make any attempt to retrieve the utensil or to provide a clean utensil for the resident. Another resident from a different table wheeled herself over to the table to pick up the utensil off the floor and handed the utensil back to the resident. The resident then proceeded to finish eating her meal with the utensil that had fallen on the floor. At 6:32 PM, a CNA was observed feeding Resident A while another resident seated at the same table repeatedly reached across the table for Resident A's tray of food. At this time, all the residents in the dining room had been served their meals except for this one resident who still waiting to be fed by staff. After the CNA was finished feeding Resident A, she provided the final tray to the only resident that had not been served. At 6:45 PM the CNA began feeding her. Both residents that were fed by the CNA had pureed diets. The CNA was observed on two separate occasions mixing the pureed foods together and feeding the resident without asking the resident(s) if this was their preference.",2014-12-01
9755,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,425,E,0,1,TYIJ11,"On the days of the survey, based on observations, interview, and the Drug Facts and Comparisons book (updated monthly), the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in the 300 Unit medication room. The findings included: On 2/14/11 at 3:06 PM, observation of the 300 Unit medication room revealed the following: -one 100 Rugby B Complex Dietary Supplement (Softgel Capsules), expired 8/10. -one 5 milliliter (ml) vial (50 tests) Tubersol, Tuberculin Purified Protein Derivative (PPD),opened with a puncture date of 1/10/11. The Drug Facts and Comparisons book, page 2001, states (in reference to Tuberculin Purified Protein Derivative): ""Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency."" During an interview on 2/14/11 at 3:36 PM, Licensed Practical Nurse (LPN) #1 stated that she was not sure who checked the medication room for expired medications but she checks the medication refrigerator twice a day. The medication nurses do spot checks. The Pharmacy checks the medication room when they observe medication pass but she (LPN #1) was not sure of their schedule.",2014-12-01
9756,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,502,D,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interviews, the facility failed to provide physician ordered laboratory services for a resident with signs and symptoms of an incision infection (Resident #23) and failed to follow a procedure to ensure that expired laboratory testing supplies were removed from storage with other laboratory testing supplies, available for resident use, in 1 of 3 medication rooms. The findings included: On [DATE] at 1:48 PM, observation of the 100 Unit medication room revealed 3 [MEDICATION NAME] EDTA (Na2) laboratory test tubes (blue top), expired ,[DATE]. The 3 expired tubes were in a clear plastic zip-lock bag with 24 other laboratory testing tubes which were still in date. During an interview on [DATE] at 2:22 PM, Registered Nurse (RN) #1 stated that the Medication Nurse on medication cart #2 checked the medication room every morning for expired products. During an interview on [DATE] at 2:34 PM, the facility's Central Supply person stated that the facility contracts with a laboratory service to do laboratory testing and that the laboratory workers have their own supplies and are responsible for their supplies. The facility admitted Resident #23 on [DATE] following a Femoral-Popliteal Bypass. On [DATE] at 3:20 PM, review of [DATE] Nurse's Notes revealed an entry at 1 PM: ""While completing tx (treatment) to l(ef)t leg noted to lower incision redness (sic) c (with) swelling around area c white yellowish creamy substance coming from incision..."" The physician was notified and an order obtained to ""Culture L(ef)t (lower) leg incision for drainage. Start Bactrim DS (Double Strength) PO (by mouth) qd (daily) X 7 days."" Further review of the record revealed no results of the wound culture. Registered Nurse #1 reviewed the medical record on [DATE] at 9:30 AM and also could not locate the lab results. He accessed the lab via computer and stated no lab results were available. The Unit Manager was advised and was unable to produce the results. Nurse's Notes were reviewed with the Unit Manager. An entry dated [DATE] at 6 AM stated: ""Talked with lab person + they don't carry culture kits with them. Will send a culture kit on Mon(day) Jan(uary) 31."" No further entries were noted related to obtaining the culture as ordered.",2014-12-01
9757,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,281,E,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of Saunders Nursing Drug Handbook 2008, staff nurses failed to follow acceptable standards of practice by failing to document and/or rotate injection sites for two of four sampled residents on insulin and one of two sampled residents on injectable anticoagulant therapy. Insulin injection sites were not rotated for Residents #5 and #7. No injection sites were recorded for [MEDICATION NAME] for Resident #5. The findings included: The facility admitted Resident #5 on 12-7-10 with [DIAGNOSES REDACTED]. Record review on 2-14-11 at 2:30 PM revealed that the resident received [MEDICATION NAME] from 1-3-11 through 2-13-11. Review of the 1-11 and 2-11 Medication Administration Records (MAR) revealed that the only site of subcutaneous injection recorded for the insulin for the 42 day period was ""abd"" (abdomen). Further review of physician's orders [REDACTED]. During an interview on 2-14-11 at 4:20 PM, the Unit Manager reviewed the MARs and verified that injection sites were not recorded for the [MEDICATION NAME] and that, based on the documentation, sites were not rotated for the administration of insulin. The facility readmitted Resident #7 on 1-18-11 with a [DIAGNOSES REDACTED]. Review of the 1-11 and 2-11 Medication Administration Records (MAR) revealed that the only site of subcutaneous injection recorded for the insulin from 1-27-11 through 2-13-11 (18 days) was ""abd"" (abdomen). During an interview on 2-15-11 at 9 AM, the Unit Manager reviewed the MARs and verified that, based on the documentation, injection sites were not rotated for the administration of insulin. Review of Saunders Nursing Drug Handbook 2008, page 620, revealed the following regarding subcutaneous injection of insulin: ""Rotation of injection sites is essential; maintain careful record."" Regarding [MEDICATION NAME] injections, page 570 noted to ""Rotate injection sites.""",2014-12-01
9758,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,282,D,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to follow the plan of care for 1 of 14 sampled residents reviewed. Resident #13 did not receive assistance with meals as needed. The findings included: During initial dining room observation on 2/14/11 at 12:30 PM in the 200 hall dining room, Resident #13 was observed with two other residents seated at a table in a geri-chair. Resident #13's tray was set up in front of her and a Certified Nursing Assistant (CNA) provided the resident with one bite of food. The CNA proceeded to leave the resident and continue to pass trays. The resident was observed feeding herself a few bites of food and then stopped eating. No staff assisted the resident with her meal after the initial bite. The resident stayed at the table throughout the meal with no assistance until she was removed from the dining room. Per review of the CNA meal intake sheet, the resident consumed 25% of the meal. During a second meal observation on 2/14/11 at 6:00 PM in the 200 hall dining room, Resident #13 was observed sitting at a table by herself in the corner of the dining room. Staff provided tray set up for the resident. The resident proceeded to eat 2 to 3 bites of food and then pushed away from the table. After 15 minutes of sitting at the table alone, the resident began mixing her foods together. Staff did not assist the resident with eating at any time during the meal. Review of the resident's most recent 60 day Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as requiring extensive physical assistance of one person for eating. Per review of the resident's care plan initiated on 12/7/10 the resident was at risk for nutritional deficit, skin breakdown, and weight loss related to Alzheimer's, Hypertension, [MEDICAL CONDITION]. Interventions included: ""encourage and assist as needed to consume all foods and/or supplements and fluids offered at and between meals."" On the facility's list of residents that required feeding by staff at meals dated 2/15/11, Resident #13 was listed as a resident who was fed by the staff in the dining room. Interview with CNA #1 on 2/15/11 at 10:45 AM, revealed the resident usually fed herself but she stated that she had observed the resident only eating 2 bites and then not eating anymore unless the staff fed the resident. She stated that when fed by staff, the resident would typically consume all her meal.",2014-12-01
9759,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,309,E,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide necessary care and services for two of fourteen sampled residents reviewed. The facility failed to check the circulation of Resident #5's casted left lower extremity as ordered. The facility also failed to ensure that Resident #5's cervical immobilization collar was in place and the resident's skin integrity checked every shift as ordered. Neuro checks were not done as ordered for Resident #7 who was being monitored for increased intracranial pressure related to treatment for [REDACTED]. The findings included: The facility admitted Resident #5 on 12-7-10 with [DIAGNOSES REDACTED]. Record review on 2-14-11 at 3:20 PM revealed 12-7-10 physician's orders [REDACTED]. Check Q shift for skin integrity around and under brace."" The collar was discontinued on 1-5-11. Review of 1-11 Documentation Records (Treatment Administration Records) revealed no initials to indicate that the physician's orders [REDACTED]. The 2-11 Documentation Record provided by the Unit Manager made no reference to assessment of the left lower extremity. The cast was not removed until 2-14-11. During an interview on 2-14-11 at 2 PM, the Unit Manager reviewed the Documentation Records and verified the above information. She was unable to explain why the treatments had not been done. The facility readmitted Resident #7 on 1-18-11 with [DIAGNOSES REDACTED]. Record review on 2-14-11 at 5:30 PM revealed an admission physician's orders [REDACTED]."" Review of 1-11 and 2-11 Documentation Records revealed initials to indicate that the checks had been performed, but review of the Neurological Evaluation Flow Sheets in the record revealed that the results had not been documented every shift as required (1-22-11: 11-7, 7-3; 1-24-11: 7-3, 3-11; 1-25-11: 7-3, 3-11, 11-7; 1-26-11: 11-7). There were no flow sheets found for 2-11. During an interview on 2-14-11 at 4:30 PM, the Unit Manager stated that the results of the neuro checks were supposed to be documented on the Neurological Evaluation Flow Sheets. She verified the incomplete documentation for 1-11 and stated she would check with Medical Records to see if the 2-11 Neurological Evaluation Flow Sheets had been thinned. On 2-15-11 at 9:30 AM, the Unit Manager stated that she had been unable to locate the documents and that the neuro checks had not been done as ordered since 2-1-11. She stated that the need for continued checks should have been clarified when the resident saw his neurologist on 2-1-11.",2014-12-01
9760,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,312,D,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide necessary Activities of Daily Living (ADL) care and services to maintain good nutrition for 1 of 2 sampled residents requiring dining assistance. Resident #13 with limited feeding ability was not provided assistance with eating and sustained a significant weight loss. The findings included: During initial dining room observation on 2/14/11 at 12:30 PM in the 200 hall dining room, Resident #13 was observed with two other residents seated at a table in her geri-chair. Resident #13's tray was setup in front of her and a Certified Nursing Assistant (CNA) provided the resident with one bite of food. The CNA proceeded to leave the resident and continue to pass trays. The resident was observed feeding herself a few bites of food and then stopped eating. No staff assisted the resident with her meal after the initial bite. The resident stayed at the table throughout the meal with no assistance until resident was removed from the dining room. Per review of the CNA meal intake sheet the resident only consumed 25% of the meal. During a second meal observation on 2/14/11 at 6:00 PM in the 200 hall dining room, Resident #13 was observed sitting at a table by herself in the corner of the dining room. Staff provided tray set up for the resident. The resident proceeded to eat 2 to 3 bites of food and then pushed away from the table. After 15 minutes of sitting at the table alone, the resident began mixing her foods together. Staff did not assist the resident with eating at any time during the meal. Per review of the resident's most recent 60 day Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as requiring extensive physical assistance of one person for eating. Per review of the resident's care plan initiated on 12/7/10, the resident was at risk for nutritional deficit, skin breakdown, and weight loss related to Alzheimer's, Hypertension, [MEDICAL CONDITION]. Interventions included: ""encourage and assist as needed to consume all foods and/or supplements and fluids offered at and between meals."" The resident was also care planned for ADL self care deficit related to Alzheimer's, incontinence, and immobility intiated on 11/17/10. Interventions included: ""assist with...eating as needed."" Per review of the facility's list of residents that required feeding by staff at meals dated 2/15/11, Resident #13 was listed as a resident that was fed by the staff. Per review of the resident's monthly weights it was noted that the resident had a 6.8% weight loss between 1/6/11 (weight was 160#) and 2/2/11 (weight was 149.8#). The significant weight loss was not addressed until 2/16/11 at the conclusion of the survey. Per review of the Registered Dietitian's (RD) note dated 2/8/11, the resident was not assessed regarding the weight loss. Per interview on 2/15/11 at 10:45 AM, CNA #1 stated that the resident usually fed herself, but that she had observed the resident only eating 2 bites and then not eating anymore unless the staff fed her. She stated that when fed by staff, the resident would typically consume all of her meal. Per interview with the Unit Manager (Registered Nurse (RN) #3) on 2/16/11 at 9:55 AM, the resident was not fed by staff but would be helped if needed. RN #3 stated that she only noticed that the resident had weight loss when she was copying the weight log to provide to the surveyor and would have the resident re-weighed immediately. Per interview with the RD on 2/16/11 at 11:30 AM, the weight meeting for the facility was held at the end of the month. She stated that when she assessed the resident on 2/8/11, it was to address the resident's protein regimen, not her weight. The RD stated that she received the weights for the residents by the 5th day of the month. The RD also verified that the resident was fed by staff.",2014-12-01
9761,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,333,E,0,1,TYIJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of Saunders Nursing Drug Handbook 2008, the facility failed to ensure that one of twenty-one residents reviewed for medication assessment remained free of significant medication errors. physician's orders [REDACTED].#7 who was being treated for [REDACTED]. The findings included: The facility readmitted Resident #7 on 1-18-11. Review of physician's orders [REDACTED]. Review of laboratory results revealed that on 2-7-11, the [MEDICATION NAME] trough level was 20.02ug (High) with a Reference Range of 5.00-10.00ug. The report noted that the physician was notified. An order was noted on the lab report to ""Decrease [MEDICATION NAME] to 1250 mg daily"". On 2-10-11, the [MEDICATION NAME] trough level was 27.49 (High) and an order was received on 2-14-11 to decrease the [MEDICATION NAME] to 750mg every 12 hours for 1 week. Review of the Documentation (Medication Administration) Records with the Unit Manager on 2-14-11 at 6 PM revealed that the 2-7-11 order had not been transcribed and implemented. Review of Saunders Nursing Drug Handbook 2008 pages 1203-1204 revealed that toxic trough levels of 15 or greater can result in nephrotoxicity and/or ototoxicity.",2014-12-01
9762,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,364,F,0,1,TYIJ11,"On the days of the survey, based on observation and interview, the facility failed to provide food that was prepared by methods that conserved nutritive value, flavor, and appearance. The facility also failed to provide food that was palatable and attractive. Brown uncovered sliced apples were served throughout the facility. The findings included: During the initial tour of the kitchen with the Dietary Manager on 2/14/11 at 10:45 AM, two trays filled with individual bowls of sliced apples were observed uncovered in the walk in cooler. At the time of the observation the apples were noted to be brown. Meal observation on 2/14/11 at 12:30 PM revealed that browning sliced apples in individual serving bowls were observed uncovered on the trays and served to residents throughout the facility. During observation of the lunch meal tray service on the 100 Hall on 2-14-11, a resident asked the surveyor, ""Would you eat that?"" She indicated that the sliced apples on her tray were ""black"" and that she was unable to eat them.",2014-12-01
9763,HEARTLAND HEALTH CARE CENTER - GREENVILLE WEST,425294,600 SULPHER SPRINGS ROAD,GREENVILLE,SC,29611,2011-02-16,371,F,0,1,TYIJ11,"On the days of the survey, based on observation, interview, and review of facility policies entitled ""Food Service Guidelines Glove Usage"" (4/7/06) and ""Food Service Guidelines Handwashing"" (4/6/06), the facility failed to store, prepare, distribute, and serve food under sanitary conditions pertaining to labeling/dating, handwashing/glove use, cleanliness of equipment, and the condition of the equipment. The findings included: On 2/14/11 at 10:45 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM), two trays filled with individual bowls of sliced apples were observed uncovered, unlabeled, and undated in the walk in cooler. Ice build up was observed on the pipes and on boxed food items under the fans in the walk in freezer. On 2/14/11 at 5:15 PM during a random observation in the kitchen, one dietary staff member dropped a clean serving spoon and spatula on the floor of the kitchen. The staff member picked up the utensils, placed them on the counter next to the coffee machine, and continued to put clean dishes away without washing her hands. On 2/15/11 at 9:05 AM during a tour of the kitchen with the CDM, it was observed that the can opener was dirty and not in use. The slicer had chips along the blade that the dietary manager acknowledged were present. The walk in freezer still contained ice on the pipes and ice on two boxes of food under the fans. The ice scoop container on the wall did not cover the ice scoop completely, leaving the scooper part exposed. On 2/15/11 at 11:30 a.m. during trayline service, a dietary aide was observed placing both hands inside her apron against her uniform and then proceeded to grab plates of food and place them on trays. The dietary aide was observed doing this four times during trayline and did not sanitize her hands. The cook during trayline removed her gloves and replaced with new gloves four times during meal service, but did not wash her hands at any time between glove changes. A pan of cooked pork was observed above the steam table throughout the meal service. The temperature of the meat was not taken before serving and the meat was not placed in the steam table at any time during meal service. Review of the dietary policy entitled ""Food Service Guidelines Glove Usage"" (4/7/06) revealed that ""hands are washed before putting on gloves and when changing into a fresh pair of gloves"". Review of the dietary policy entitled ""Food Service Guidelines Handwashing"" (4/6/06) revealed hands should be washed after ""handling soiled utensils or dishes"" and when ""engaging in any activities that contaminate the hands"".",2014-12-01
9764,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,323,E,0,1,G9M911,"On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment was free of accident hazards. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with linoleum that was in disrepair: Room 13 - Linoleum was observed with adhesive not holding along the seam. The seam was uneven with elevated areas noted on both sides of the seam. Room 14 - Linoleum seam buckled in the middle with elevated areas on both sides of the seam Room 17 - Linoleum seam uneven and elevated in 2 areas (about 8 inches each in length) Room 22,- Linoleum seam on the right side of the room near Bed B was observed with adhesive not holding, resulting in elevated areas. Room 5 - Linoleum seam by bed C was observed with the adhesive not holding resulting in elevated areas along the seam. When a chair was slid across the seam of the linoleum, the leg of the chair caught on the seam. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director stated that he would re-glue the elevated areas of the linoleum and fill in any gaps along the seams with putty or other filler material, allow that to dry and then buff or sand down any uneven areas.",2014-12-01
9765,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,332,E,0,1,G9M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interview and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication errors rates of 5% or greater. The medication error rate was 8.7%. There were 4 errors out of 46 opportunities for error. The findings included: Error #1: On 10/11/10 at 4:25 PM, during observation of medication pass. Licensed Practical Nurse (LPN) #1 was observed to administer one [MEDICATION NAME] 500 milligram (mg) tablet and 4 other medications to Resident A, followed with water. Review of the current physician's orders [REDACTED]. Resident A's meal tray arrived at 5:54 PM. Error #2: On 10/12/10 at 8:10 AM, during observation of medication pass, LPN #2 was observed to administer two puffs of [MEDICATION NAME] Aerosol Inhalation to Resident B. LPN #2 handed the [MEDICATION NAME] Inhaler to the resident without instructing the resident to wait one minute between inhalations. Resident B self administered 2 inhalations with no wait between puffs. The Drug Facts and Comparisons book (updated monthly), page 669b, states (in reference to administration technique for aerosol inhalers): ""Allow greater than or equal to 1 minute between inhalations (puffs)."". Error #3: On 10/12/10 at 8:40 AM, during observation of medication pass, LPN #3 was observed to administer 1 puff of [MEDICATION NAME] HFA 110 to Resident C without shaking the canister before administration. The Drug Facts and Comparisons book (updated monthly), page 672a, states (in reference to preparation for administration of [MEDICATION NAME] HFA): ""Shake well before using."". Error #4: On 10/12/10 at 8:42 AM, during observation of medication pass, LPN #3 was observed to administer one drop of Omnipred Ophthalmic Suspension to the right eye of Resident C without shaking the bottle before administration. The Drug Facts and Comparisons book (updated monthly), page 1725 states (under General Considerations in Topical Ophthalmic Drug Therapy, in reference to suspensions): ""Resuspend suspensions (notably many ocular steroids) by shaking to provide an accurate dose of the drug."". During an interview on 10/12/10 at 8:48 AM, LPN #3 stated that she was aware that both medications ([MEDICATION NAME] HFA 110 and Omnipred Ophthalmic Suspension) needed to be shaken. LPN #3 stated that she was so used to giving these two medications that she thought that she had shaken then.",2014-12-01
9766,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,460,E,0,1,G9M911,"On the days of the survey, based on observations and interview, the facility failed to provide ceiling suspended curtains, which extended around the bed to provide total visual privacy for each resident. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with curtains that did not extend around the bed to provide total visual privacy. -Room 23, curtain at foot of the bed was too short leaving an open gap -Room 9, bed D with front curtain about one foot too short -Room 12, bed A with front curtain about 8 to 10 inches too short -Room 13, bed C with side curtain too short -Room 19, bed B with curtain at foot of the bed which was hindered from covering the foot of the bed by the sprinkler pipe which was also suspended from the ceiling and touching the metal pipe holding the suspended curtain. The clips holding the curtain could not pass between the 2 pipes. -Room 22 bed A with front curtain which was about 2 feet short -Room 23 bed C with curtain at the foot of the bed too short. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director revealed that the short curtains had been replaced with longer curtains or additional curtains had been added in the affected rooms and that the sprinkler pipe in room 19 at the foot of bed B had been raised enough to allow the curtain to move along the pipe without being hindered.",2014-12-01
9767,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,425,D,0,1,G9M911,"On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired medications and expired resident care products were removed from storage with other medications and resident care products, available for resident use, in 1 of 2 medication rooms. The findings included: On 10/12/10 at 2:53 PM, observation of the Back Hall Medication Room revealed the following: -two 5 Gram packets of Fougera Vitamin A + Vitamin D Ointment, expired 8/10 -three packs PDI Antiseptic/Germicide Swabsticks (3's), expired 3/10 -one Kendall Kangaroo All Silicone Gastrostomy Tube with Y-Port, expired 9/10 During an interview on 10/12/10 at 3:38 PM, Licensed Practical Nurse (LPN) #4 revealed that the Medication Nurses check the medication room for expired insulin and check the emergency drug kits. Pharmacy comes once a month to check medications. LPN #4 did not know who was responsible for checking supplies and stated that she did not know why Vitamin A and D Ointment and Antiseptic Germicide Swabsticks were in the medication room.",2014-12-01
9768,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,159,F,0,1,G9M911,"On the days of the survey based on record reviews and interviews, the facility failed to hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. Two (2) of 5 resident trust accounts did not have proper authorization to manage the resident funds, 5 of 5 resident trust accounts were not managed according to accepted accounting principles and the facility failed to provide accurate accounting practices with the petty cash fund. The findings included: On 10/13/10 at 10:15 AM a review of 5 random Resident Trust Fund accounts and an interview with the Business Office Manager was conducted. The sample consisted of Residents # 3, #11, #14, and Resident D and E. Residents #3 and Resident D did not have an authorization in the records to allow the facility to manage their funds. The only authorization found in Resident #3 and Resident D's records related to The Resident Fund Management Service direct depositing the residents' Social Security check and the forms were signed by the Business Office Manager. There was no resident or Responsible Party signature on the form which did not constitute authorization to manage the residents' funds. During an interview with the current Business Office Manager on 10/13/10 at 10:15 AM, she informed the surveyor that they had changed their accounting system last Spring and now had a contract with Resident Fund Management Service in Virginia. It was her understanding that she or the previous Business Office Manager could sign the Resident Fund Management Service Authorization and Agreement to handle Resident Funds and that the resident or responsible party did not need to sign the form. Upon further review of the selected Resident Trust Fund sample on 10/13/10 at 2:30 PM it was revealed that Resident D had disbursements from his account for multiple Beauty/Barber services: 5/25/10-$13.00, 6/17/10-$10.00, 7/13/10-$10.00, 8/12/10-$10.00, and 9/28/10-$10.00. There were no resident signatures or witness signatures found in the file for the services. The only documentation provided was a list of residents for the dates of the service with no authorizing signatures on the list and no verification that the service was provided. Resident D also had disbursements for room and board : 7/2/10-$1047.00, 8/03/10-$1047.00, 8/1/10-$1583.69, 09/03/10-$1047.00, and 10/01/10-$1047.00. There was no authorization on record for the disbursements for room and board for this resident. Resident E's account revealed disbursements from her account for multiple Beauty/Barber services: 7/19/10-$25.00, 08/06/10-$13.00, 08/27/10-$25.00, and 9/30/10-$13.00. There were no resident signatures or witness signatures found in the file for the services. The documentation provided was a list of residents for the dates of the service with no authorizing signatures on the list and no verification that the service was provided. Resident #3's account revealed a Beauty/Barber disbursement on 7/14/10 for $13.00 and there was no resident signature or witness signatures found in the file for the service. The documentation provided was a list of residents for the date of service with no authorizing signature on the list and no verification that the service was provided. Resident #11's account revealed that on 5/7/10 a disbursement of $18.26 for Personal Needs Item was made and there was no resident signature, no witness signatures, or a receipt for the item or identification of the item. On 5/21/10 a disbursement of $5.00 for Personal Needs Item was made with a $5.00 standard receipt with white and pink copy attached available in the record. The receipt was signed with an X with no witness signatures, identification of item purchased, and the Business Office Manager confirmed in an interview on 10/13/10 at 1:30 PM that she had not provided the resident with a copy of the receipt. On 6/4/10 a disbursement of $50.00 for Personal Needs Item was made and a receipt from the Dollar General on 6/3/10 was provided for $18.26. A note on the receipt stated ""difference of $31.54 given to resident 6/4/10"": the note was not signed. There was no resident signature and no witness signatures for the withdrawal of the $50.00. On 6/25/10 a disbursement of $60.00 for Personal Needs Items was made and a receipt from Lady Foot Locker dated 7/17/10 was provided for $53.49(shoes) and showed tendered change as $6.51. There was no documentation that the change was returned to the resident account or given to the resident. On 7/28/10 a disbursement of $50.00 for Personal Needs Item was made and a receipt from Walmart dated 7/27/10 for $36.38 and a receipt from Dollar Tree dated 7/27/10 for $5.35 were provided. The total for the receipts was $42.73 and there was no record of the remaining $7.27 being returned to the resident account or given to the resident. There was no resident signature and no witness signatures to authorize the withdrawal. On 10/12/10 a disbursement was made for Clothing in the amount of $6.82 and there was a Walmart receipt provided which included purchases for 3 other residents and there was no documentation that the total, including taxes, was equally divided between the 4 residents. There was no signature/signatures to authorize the withdrawal. Review of Resident #14's account revealed a disbursement on 4/6/10 for Clothing in the amount of $25.57 and a receipt from Southern Comfort for $25.57 with no date provided. There was no authorizing signature/signatures for the disbursement. Multiple disbursements for Beauty/Barber Services were made to the resident account: 5/25/10-$13.00, 6/17/10-$10.00, 7/13/10-$10.00, and 8/12/10-$10.00. There was no authorizing signature or signatures for the withdrawals and the only documentation provided was a list of residents for the dates of service with no authorizing signature. During an interview with the Business Office Manager on 10/13/10 at 1:30 PM, she stated that she did not provide receipts to the residents when disbursing money because they usually just dropped them on the floor. She was unaware that the resident must sign for the the withdrawals and if not able to sign there needed to be 2 witness signatures, which could not include her signature. She was unaware that the individual taking the money for resident purchases must be authorized to do so. During the interview, the Business Office Manager was asked about the Petty Cash Fund. She stated that the Human Resources Manager put $50.00 from the facility's monies each Friday on the nurses' cart for the resident's use. She stated that the nurses are supposed to have residents sign for the amount they withdraw, but this usually doesn't happen. According to the Business Office Manager, she tallied up what was spent and reimbursed the facility for that amount on Monday. She did not have a ledger or accounting system for the Petty Cash withdrawals.",2014-12-01
9769,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,318,E,0,1,G9M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to provide appropriate intervention for identified contractures for one of three sampled residents reviewed with contractures. The facility failed to provide intervention to improve or maintain Resident # 6's range of motion in his upper extremities and failed to adequately assess if the resident had a decline in range of motion. The findings included: The facility admitted Resident # 6 on 4/8/04 with a [DIAGNOSES REDACTED]. On 10/10/10 at approximately 11:00 AM, during initial tour of the facility, Resident # 6 was observed with contractures of the right arm and hand and bilateral contractures of legs and feet. On 10/10/10 review of the resident's clinical record revealed on the MDSs (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 7/8/10, 9/22/10 and 10/5/10, that the facility had coded the resident as having the following limits related to range of motion: arm: one sided limitation with full loss of voluntary movement hand: one sided limitation with full loss of voluntary movement leg: limitation of both sides with full loss of voluntary movement foot: limitation of both sides with full loss of voluntary movement Review of the RAPS (Resident Assessment Protocol) dated 10/5/10 revealed that the resident had right sided [MEDICAL CONDITION] which was the resident's dominate side. Further review of the document on the ADL (Activities of Daily Living) Supplement, revealed that the facility stated that the resident was dependent except for feeding. Review of the Physician's cumulative orders dated 10/1/10 revealed a physician's orders [REDACTED]. Interview with the facility Rehabilitation Manager on 10/13/10 at 10:16 AM, revealed that the facility practice was to inform the nurses on the unit what services should be provided and that the Restorative CNAs are shown what should be done prior to beginning Restorative services. When questioned what had been the recommended plan for Resident # 6, she stated that she did not know and both she and Restorative CNA # 1 were unable to find the Restorative Plan of Care"" form for the resident. Reviewed with the Rehabilitation Manager the rehabilitation screen dated 6/30/10 post fall which stated that the resident was receiving restorative services to both the upper and lower extremities. Review of the Restorative Care Flow Records for June, July, August and September. Restorative CNA # 1 stated that she stretches the resident's leg with the contracture when questioned what care she provides to the resident. The Rehabilitation Manager stated that the nurse of the unit supervises the Restorative CNAs. When questioned who evaluates the effectiveness of services, the Rehabilitation Manager stated that Restorative CNAs should report if they notice any decrease in the range of motion. A discussion followed related to Resident # 6's documented contractures of the right hand/fingers and decreased range of motion. When asked why services were not being provided to the resident to maintain or prevent further decline to the upper extremities, the Rehabilitation Manager stated she did not know. When questioned if anyone assessed the degree of contracture or the degree of range of motion, the Rehabilitation Manager stated that this was not done. When questioned how would you be able to evaluate the effectiveness of the services or if the resident had a decline if the facility was not assessing for the degree of contracture/limited range of motion of his lower extremities and no answer was given. When questioned how the Restorative CNAs would be able to assess the resident's upper extremities if no services were being provided and no answer was given. When asked if the resident had been evaluated for any splints or hand rolls, the Rehabilitation Manager stated that she did not know and was unable to provide any documentation that the resident had been assessed for this type of intervention. The above findings were shared with the DON (Director of Nurses) and the facility Nurse Consultant on 10/13/10 at approximately 3:00 PM.",2014-12-01
9770,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2010-10-13,278,D,0,1,G9M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to ensure the accuracy of assessments on two of ten sampled residents reviewed for accuracy of assessment. The facility failed to accurately assess Resident # 7 related to wandering behaviors. In addition, the facility failed to accurately reflect Resident # 6's combativeness during care on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening. The findings included: The facility admitted Resident # 7 on 8/18/10 with diagnoses of [MEDICAL CONDITION]. On 10/10/10 review of the resident's clinical record revealed documentation on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 8/27/10 that the resident was coded as alert and oriented. In addition, the facility coded that the resident had not displayed any wandering behaviors. Review of the admission resident profile dated 8/18/10 revealed that the nurse had documented under the section for elopement risk, that the resident was not ambulatory, not resistant to being placed in a long-term care facility and had no history of elopement. The nurse documented that the resident displayed no indications or [DIAGNOSES REDACTED]. Review of the ""Elopement Assessment Risk Tool"" revealed that the resident had been assessed as a ""5"". Per the form, a score of 0-6 indicated being at low risk for elopement, 7-13 was considered moderate risk and 14 and above was considered a high risk for potential elopement and would warrant the need for extra supervision. No interventions were documented as needed to decrease the risk. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of the admission assessment completed by the Nurse Practitioner dated 8/18/10 revealed that she had documented that the resident was alert and oriented. Further review of the physician progress notes [REDACTED]. Review of the Nurses' notes dated 8/18/10 to current date revealed no documentation of behaviors or wandering behavior. Review of the resident's care plan revealed no care plan related to wandering or behaviors. On 10/12/10 at approximately 10:00 AM, LPN (Licensed Practical Nurse) # 3, was asked why the resident had a wanderguard. She stated that she was not sure but thought he had been seen ""Checking the doors"". LPN # 3 stated that she did not know who made the decision for wanderguard placement. The Administrator was asked what was the facility's policy related to wanderguards, he stated that wanderguards were placed on all residents on admission, and if after seven days, the resident did not need one, it would be removed. When questioned if this was done for residents who were alert and oriented and he stated yes. The Administrator was asked if a resident was alert and oriented, would he be allowed to leave the facility if he wanted to? He stated no, the resident might wander into the road. There was no determination noted that the resident was not competent. Interview with LPN # 4 at approximately 3:00 PM, revealed that the facility practice was to place wanderguard on all new admissions for the first seven days. Questioned why Resident # 7 had a wanderguard and she stated that he had been ""checking the doors."" In reviewing the resident's chart with LPN # 4, she confirmed that the resident had not been assessed as being a moderate or high risk for elopement and that there was no documentation of wandering behaviors. When questioned if a resident was alert and oriented - would he/she be free to leave the facility if he wanted to, she stated no. In addition, she stated that the RP (Responsible Party) would have to agree. On 10/13/10 during an interview with the facility Nurse Consultant, she confirmed that the resident's assessments did not reflect the need for a wanderguard. She confirmed that there was documentation in the chart related to wandering or behaviors. On 10/13/10 interview with the MDS Coordinator revealed that she was unaware of the resident having a wanderguard or the resident displaying wandering behavior. She stated that she obtains her information from the chart and the facility staff. The facility admitted Resident # 6 on 4/8/04 with a diagnoses of Late Effect [MEDICAL CONDITION] of the right side and Muscle Disuse Atrophy. On 10/10/10 review of the resident's clinical record revealed that the resident had displayed combative behavior while receiving restorative services during the months of June, July, August and September. Further review of the resident's chart revealed on the MDSs (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 7/8/10, 9/22/10 and 10/5/10, that the facility had coded the resident as having no behaviors. Further review of the resident's clinical revealed that the facility had not care planned the combative behaviors. On 10/13/10 interview with Restorative CNA (Certified Nursing Assistant) # 1 revealed that she provided restorative services to the resident. She stated that the resident frequently tries to kick and hit the restorative CNAs during the provision of restorative services. On 10/13/10 interview with the MDS Coordinator revealed that she was unaware of the resident being combative during care. She stated that she obtains her information from the chart and the facility staff.",2014-12-01
9771,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-08-25,226,H,1,0,OCF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the abbreviated survey, based on record review, review of the facility policy for Detection and Prevention of Resident Abuse and Neglect and staff interview, the facility failed to implement their policies that prohibit neglect and abuse of residents. Residents #5, #6 and #7 tested positive for illegal and/or prescription drugs, the facility was unable to provide evidence of an investigation related to positive drug screens for three of three residents sampled during the survey. The findings included: Cross Refer to F224 as it relates to the facilities failure to implement their policy for Detection and Prevention of Resident Abuse and Neglect related to Resident #5 with [DIAGNOSES REDACTED]. Resident #6 with [DIAGNOSES REDACTED]. Resident #7 with [DIAGNOSES REDACTED]. Review of the facility's policy for Detection and Prevention of Resident Abuse and Neglect defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Page 3 item 5 ""Investigation and Reporting Practices: A. Any person observing or hearing a complaint of mistreatment, neglect, abuse... should immediately report it to Administration, the Director of Nursing, the Social Service Director..."" ... C. The Administrator or designee will immediately notify the state Complaint Investigation and Referral Unit and the resident's legal representative and/or responsible family member of the incident... The Administrator or designee will direct the investigation. E. The Administrator or designee will make an initial investigation of the allegation... to determine: Whether abuse or neglect have occurred; The status of the resident; The causative factors that precipitated the abuse or neglect; Immediate interventions needed to prevent further injury and/or harm... F. ...The facility investigation will include the following information: An initial description and evaluation of the incident; The names of all involved persons; An evaluation of and interview with the victim; An interview with the alleged perpetrator; Interviews with witnesses; A clinical history (if needed); and A physical examination (if needed); A psychosocial evaluation (if needed); Photographic evidence of any injuries (with written permission); and Findings and conclusions of the investigation. G. The written report of the complete investigation will be submitted to the State Agency within five (5) working days of the incident... 6. Protection Practices: A. The facility believes that protection is a critical factor in the detection and prevention of abuse and neglect. The facility will protect the rights of residents who are victims of abuse or neglect. Such protection may include any of the following: Room or room-mate change; Staffing changes; Psychosocial or psychological evaluation; Follow-up counseling; More frequent monitoring; and Revision or addition to the resident's interdisciplinary care plan...""",2014-12-01
9772,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-08-25,241,E,1,0,OCF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the abbreviated survey, based on observations and staff interviews, the facility failed to provide care in a way to ensure a resident's dignity for 3 of 3 resident's observed to receive incontinence care, on the front hall and for 4 of 4 residents observed to be checked for incontinence episodes on the back hall. Residents #1, #2, and Resident #3 were observed receiving incontinence care. The privacy curtain was not pulled around the residents during care. Random observations of 4 residents checked for incontinence did not have their privacy curtain pulled. The findings included: The facility admitted resident #2 on 11/18/08 with [DIAGNOSES REDACTED]. On 8/15/11 at 6:10 AM, Licensed Practical Nurse, (LPN) #1 was observed to perform incontinence care. The resident was in a four bedroom. During the incontinence care a CNA (Certified Nursing Assistant brought another resident into the room. The other resident was sitting at the end of bed B. Resident #2 was in bed D. The resident ' s perineum was exposed. The LPN did not pull the curtain around the resident to provide privacy while she performed the incontinence care. The facility admitted resident #3 on 2/1/2010 with [DIAGNOSES REDACTED]. On 8/15/2011 at 6:20 AM, CNA #1 was observed to perform incontinence care. The resident was in a 4-bed room. Two other residents were in the room at the time of the incontinence care. The resident was exposed while receiving the incontinence care. The CNA did not pull the curtain around the resident, to provide privacy while she provided the incontinence care. The facility admitted resident #1 on 2/12/2009 with [DIAGNOSES REDACTED]. On 8/15/2011 at 6:30 AM, CNA #1 was observed to perform incontinence care. The resident was in a four-bed room. The CNA pulled the privacy curtain around the lower corner of the foot of the bed, but did not pull the curtain around the resident to provide privacy during the incontinence care. The resident in the D bed was lying on her left side, facing resident #1's bed. The resident was exposed during the incontinent care. On 8/15/2011, at 7:00 AM, CNA #2 was observed to check residents on the back hall for incontinence. She entered room [ROOM NUMBER] and checked the residents in bed B and C. She pulled back the covers and exposed their brief. She did not pull the curtain around the residents when she checked them for incontinence. CNA #2 then went to room [ROOM NUMBER]; she did not pull the curtain around the resident when she checked him for incontinence. She then proceeded to room [ROOM NUMBER] and checked a resident for incontinence. The resident's brief was exposed. She did not pull the privacy curtain around any of the residents when she checked them for incontinence. In each case the bed covers were pulled off the residents and their lower bodies were exposed. On 8/15/2011, at 12:05 PM, CNA #3 was interviewed regarding incontinence care. She stated during Peri/incontinence care, ""I let them know I am the CNA. I pull the curtain and explain the care that I am to do."" On 8/15/2011 at 12:25 PM, CNA #4 was interviewed. She stated to pull the curtain when incontinence care was provided. On 8/15/2011 at 12:35 PM, CNA #5 was interviewed. She stated, ""close the curtain"", when providing incontinent care. The procedure for perineal care was reviewed. Under the section ""Process"", the first part stated, ""... screen for privacy.""",2014-12-01
9773,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-08-25,315,D,1,0,OCF612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Follow-Up Survey, the facility failed to provide appropriate incontinence care for 1 of 3 residents observed for incontinence care. During incontinence care Resident #2 was wiped from back to front, each side of her groin and up between her labia. The findings included: The facility admitted resident #2 on 11/18/08 with [DIAGNOSES REDACTED]. On 10/24/2011 at 10:20 AM, CNA#1 was observed to perform incontinence care. CNA #1 washed her hands and donned gloves. She removed the resident's brief. The CNA obtained personal disposable wipes. She wiped the resident from her inner groin up wards. The CNA wiped from back to front each side of her groin and up between her labia. The resident was cleaned back to front, contaminating her perineum. Review of the Peri-Care Competency provided by the facility stated, ""Separate the Labia with one hand. With the other hand (using clean wipe with each swipe) wash from front to back the far side of the labia, then the closer side of the labia and finally wipe down the center."" During an interview with CNA #1, she confirmed she wiped upwards instead of downward.",2014-12-01
9774,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-08-25,441,D,1,0,OCF611,"On the days of the abbreviated survey, based on observation and interview, the facility failed to maintain infection control practices to provide care in a sanitary manner. CNA #2 checked four residents for incontinence and did not wash her hands between residents. The findings included: On 8/15/2011, at 7:00 AM, CNA #2 was observed to check residents on the back hall for incontinence. She entered resident A and resident B's room. She checked resident A for incontinence. She pulled back the covers and exposed their brief. She placed her hand on the resident's brief above the groin. She replaced the bedcover then went to resident B and repeated, pulled back the bed covers and placed her hand on the resident's brief above the groin area. She repeated the process for resident C and resident D. She did not wash her hands between residents. On 8/15/2011 at 2:30 PM, the Director of Nurses confirmed the CNA should have washed her hands between each resident contact.",2014-12-01
9775,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2011-08-25,224,H,1,0,OCF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the abbreviated survey, based on record review and staff interviews, the facility failed to provide the necessary services to avoid physical harm of 3 of 3 residents that tested positive for illicit drugs/prescription drugs not prescribed for the resident; and all residents in the facility. Residents #5, #6, and #7 tested positive for illicit drugs and/or prescription drugs not ordered for them. The facility did not conduct a thorough investigation to determine how the residents obtained the drugs and interventions put in place failed to keep the residents drug free as evidenced by continued positive testing and inappropriate behaviors. The findings included: The facility readmitted Resident #5 with [DIAGNOSES REDACTED]. Review of the medical record revealed a drug screen report dated 3/15/2011 that showed Resident #5 was positive for PCP (Phencyclidine). A review of the MD (Medical Doctor)/NP (Nurse Practitioner) Progress notes dated 3/15/2011 revealed the physician noted, ""...tested + (positive) for PCP today!!!..."" During an interview with the Medical Director on 8/23/2011, he stated the resident had a history of [REDACTED]. When asked why he ordered the drug screen on the resident, the Medical Director stated the resident was having abnormal behavior. On 8/23/2011, the Administrator and the Social Services Director provided a letter that was dated March 24, 2011. The resident, the Administrator, and the Social Services Director on 3/24/2011 signed the letter. A family member of Resident #5 on 3/28/2011 signed the letter. The letter stated the facility met with the resident to discuss his positive results for PCP on March 15, 2011. The letter stated, ""... To ensure the safety of the resident and staff the following must be adhered to effective immediately: Resident will have random drug screens. Resident must have ALL visits supervised. Resident is not allowed to leave with any family members or any visitors... By signing this statement I acknowledging understanding, agreement and acceptance of the interventions to be in place for resident"". Resident #5 signed the agreement on 03/28/2011. The Social Service Director (SSD) was interviewed on 8/23/2011 at 11:30 AM. When asked what had happened to initiate the drug screening, the SSD stated the resident had a history when he was originally admitted to the facility. "" Because of the number of falls he had since readmission (02/04/2011) and based on past history we decided to do a drug test. On 3/15/11 he tested positive for PCP and we decided that all of his visits had to be supervised. We met with the dad and the resident and went over the interventions."" She stated the resident could not give any information as to where the drugs came from. ""He said he had no idea. His visits were supervised and he didn't go out."" Social Services Progress Notes dated 4/7/2011, stated, ""...R (Resident #5) interviewed today by ___(Police Officer) in an effort to assess who may be providing PCP to resident which resulted in a positive drug screen on 3/15/2011. R denied using any type of illegal substance and of anyone providing illegal substances to him at SNF (skilled nursing facility) or outside of SNF. No information obtained from resident..."" Review of the medical record revealed Resident #5 continued to test positive for PCP 5/2/11, 5/3/11, and 5/14/2011, after the interventions were put in place. Resident #5 had a fall from his wheelchair on 5/17/2011 sustaining a laceration, at the time he was noted to be confused and paranoid with agitation. On 5/3/2011 the MD documented ""Advised pt (patient) that he must not use drugs!! Pt. denies drug use Pt. says he will not accept anything open from anybody."" The MD/NP Progress notes of May 17, 2011, stated, multiple lacerations on head-gash over right eye-steri strips-drug screen + this week again for PCP"". The SSD Progress Note of 5/17/2011 (after positive drug test for PCP on 5/14/2011) stated, ""R (resident) fell on smoking porch, fell out of wheelchair hit face. Observed to have laceration over right eye. R refused to go to hospital when EMS (Emergency Medical System) arrived for medical assessment. R confused/paranoid as evidenced by reports his roommate had people watching him and people talking about him..."" The Progress note dated 5/19/2011, stated, ""SSD informed of R being physically aggressive in back smoking porch as evidenced by hitting other R also agitated as evidenced by rolling out of control in wheelchair throughout SNF (skilled nursing facility) refusing to stay in bed or wheelchair. R brought inside from smoking porch. SSD contacted ___ (drug treatment facility) for possible admission... no beds are currently available for evaluation."" SSD stated case with ___ (Interim Administrator) discussed evaluation by ___ (Psychiatric Hospital) for possible admission for behavior. The hospital Discharge Summary dated 5/27/2011, stated, ""...admitted to ___(Psychiatric Unit) from the emergency room after his violent and aggressive behaviors towards the residents and staff at ___Nursing Home. He would run into the walls in the hallway and run into other residents, swing his fists as residents and staff and talk to himself, experiencing visual hallucinations. He would yell off and on, hit his face and had right eye laceration because of this, extremely paranoid, would report that people were on the porch. He had also been experiencing [MEDICAL CONDITION] which were not under control."" The facility admitted Resident #6 with [DIAGNOSES REDACTED]. At the time of the visit the resident had been discharged from the facility. Review of the resident's closed medical record revealed positive drug screens. On 3/19/2011, the resident tested positive for Meth ([MEDICATION NAME]), a prescription medication not ordered for the resident. The MD/NP Progress Notes dated March 22, 2011, stated, ""Multiple falls, UDS (Urine Drug Screen) + [MEDICATION NAME]. Spoke with pt who adamantly denies taking unprescribed medications. Reports a trip to ___, stating, 'I don't know how I got there.'"" Under (A/P) (Approach/Plan), the physician documented, ""+ Drug Screen for [MEDICATION NAME]-per nurses."" A Urine Drug Screen of 4/11/11 was positive for [MEDICATION NAME]. The MD/NP Progress Note dated 4/12/11 stated, ""S/P (status [REDACTED]. Under the (A/P) section it was documented, ""When ask pt how are you today pt says 'I am high'. Urine drug screen + for meth ([MEDICATION NAME])."" A drug screen dated 4/18/2011 was positive for [MEDICATION NAME]. The MD/NP Progress note dated 4/19/2011, stated, ""+ Drug Screen again, slurred speech just about to fall out of wheelchair ... "" A drug screen dated 4/26/2011 was positive for [MEDICATION NAME]. The MD/NP Progress Note dated 4/26/2011 stated, ""Altered behavior with + drug screens... pt continues to test + for drugs - last Monday + [MEDICATION NAME] - before this + [MEDICATION NAME] Pt cont to fall. Pt needs to be discharged ..."" A drug screen was collected on 5/3/2011, it was positive for [MEDICATION NAME]. The MD/NP Progress Note stated, ""Told pt, must quit doing drugs!! Pt. asking for something for neck but so out of it won't tell where he's getting drugs from."" A drug screen dated 6/7/2011 and 6/21/2011 was positive for [MEDICATION NAME]. The MD/NP Progress Note had documented, ""+ drug screen today for meth ([MEDICATION NAME]) warned pt this can kill him..."" A drug screen was performed on 6/28/2011, the resident was positive for PCP, and [MEDICATION NAME]. A MD/NP Progress note dated 7/5/2011 stated, ""Drug Abuse, + PCP + meth ([MEDICATION NAME]). Drug Abuse in Facility. Pt is not appropriate for facility + PCP + meth- warned pt multiple times he is going to die if he does not stop with drugs..."" During an interview with the Clinical Nurse Specialist on 8/15/2011 at 2:45 PM, she stated, ""The past Administrator called out the police and the dogs. They didn't find anything. He (Resident #6) never left the building. He had visitors, but they never signed the sign in sheet. There was an investigation. There is a file here somewhere..."" The investigation was not provided by the facility. The facility did not have the police report and called the Sheriff's Office for a copy of the police report. The report was faxed to the facility on [DATE]. During an interview with the SSD on 8/23/2011 at 11:55 AM, she stated, ""___ (Resident #6) did not have any visitors that I am aware of. He went to ___ (Drug Counseling Center) He went to the appointment, would not cooperate. They said no need for him to come back. The police interviewed him the same day they interviewed ___ (resident #5) on April 7th. He tested positive for [MEDICATION NAME]. Review of Resident #6's care plan dated 6/28/2011 identified as a problem area the ""Potential for fall/injury related to hx of recent fall. Hx of [MEDICAL CONDITION] disorder..."" The care plan was updated on 3/8/2011 ""Fall without injury"", 3/14/2011 ""Fall without injury"", 3/18/2011 ""Fall sent to ER for eval. (evaluation)"", 3/19/11 ""Fall, Neuro checks performed, sent to ER. tested + for Meth"". The 3/19/11 emergency room visit was the first time the resident drug test was positive. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a drug screen on 1/17/2011 that was positive for Cannabinoid (the active compounds in Marijuana) and Benzodiazepine (a prescription drug). Review of the resident ' s medications revealed no order for Benzodiazepine medications. A drug screen was performed on 7/8/2011 with positive results for Benzodiazepines. The MD wrote a note on the 7/08/2011 lab report, ""Not on benzo"". The resident's nurse's notes dated 1/16/2011 at 8:30 PM stated, ""Res witnessed per staff Resident smacking another resident in the mouth + (and) making a verbal threat stating 'I just hit this time next time I will beat your ass'. Resident being sent to ___ (hospital) for psych eval..."" The hospital Emergency Department (ED) Final report result date of 1/17/2011 stated, ""The patient presents with THIS MAN IS SENT HERE FROM THE FACILITY WHERE HE LIVES BECAUSE STAFF THERE WITNESSED HIM STRIKING ANOTHER RESIDENT. PT DENIES ANY OF THIS AND TELLS SUCH A CONVINCING STORY THAT HE CALLED THE NSG HOME TO CONFIRM HISTORY. HE DENIES ANY PHYSICAL COMPLAINTS. NO HALLUCINATIONS OR DELUSIONS. HE SAYS HE IS NOT MAD AT ANYONE AND THAT THE OTHER RESIDENT MADE UP THE WHOLD (sic) STORY BUT STAFF AT NSG HOME WITNESSED THE ATTACK BY PT."" The resident's urine drug screen performed during the ED visit on 1/17/2011 was positive for Cannabinoid and Benzodiazepine. The impression and Plan stated, ""Agitation with Aggressive Behavior"". Social Progress Notes dated 1/17/2011, stated, ""SSD informed in AM meeting of Resident being sent out on 1/16/2011 due to physical aggressiveness toward a female resident as evidenced by hitting her in the mouth and making verbal threats..."" There was no documentation that the resident had a positive drug test while at the hospital. Three residents tested positive for illicit and/or prescription drugs not prescribed by their physician. Two of the residents in March 2011. The facility stated an investigation that was not available at the time of the survey, was conducted regarding the positive drug screens. The facility did not have the police report and called the Sheriff's Office for a copy of the police report. On 8/23/2011 the surveyor requested a faxed copy of the 4/15/2011 police report that stated, ""...A complaint of narcotics at the facility ...Spoke with complainant the Administrator over the facility. Complainant advised that he believes narcotics are being brought into the facility and requested that a ""Drug Dog"" be brought in. ...Coordinated the K-9 being utilized. No further action taken at this time."" The report did not say if the K-9 had been into the facility or the results of the investigation. On 8/23/11 at 12:15 PM during an interview the Administrator stated, ""I was here in March... I didn't question the staff or have the staff drug tested ."" A previous Administrator called the police in to check for narcotics. At 12:30 PM, the Administrator stated he talked with the Corporate Compliance Officer and it was decided the employees would not be drug tested . ""It was discussed quite a bit but did not get statements.""",2014-12-01
9776,TUOMEY REG MED CTR SUBACUTE SC,425346,129 N WASHINGTON ST,SUMTER,SC,29150,2011-10-05,371,E,0,1,9S8C11,"On the the days of the Recertification Survey, based on observation, interview and record review, the facility failed to follow proper food handling practices to prevent foodborne illnesses. A facility cook did not demonstrate the proper procedure for calibrating a thermometer. The finding include: On 10/4/11 at 11:07 AM, during temperature testing from the steam table, Cook #1 was observed calibrating the thermometer. Cook #1 placed the thermometer into a cup of ice water for several seconds then removed the thermometer and calibrated it to 32 degrees in room air. The cook was not aware that the thermometer had to stay in the water to calibrate. The cook and the Food Service Director (FSD), a Licensed Dietician, confirmed that the cook removed the thermometer from the water to calibrate. Upon interview, the cook stated ""I always do it that way."" The Food Service Director stated that thermometers are usually calibrated once a day or if the thermometer is dropped. Record review of in-services revealed that Cook #1 attended an in-services on 1/19/11 and 5/10/11 that included calibrating thermometers. In addition, the FSD provided a copy of a Certificate of Completion for an Employee Food Safety Training for Cook #1. During an interview on 10/5/11 at 8:50 AM, the FSD stated the facility had no policy and procedure for calibrating a thermometer and confirmed that the facility should have a policy for when to calibrate and a procedure for how to calibrate a thermometer..",2014-12-01
9777,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2011-08-08,225,D,1,0,IFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to report an injury of unknown origin to the State Certification Agency and failed to provide evidence of a thorough investigation for one of one residents with an injury of unknown origin. The facility also failed to put new interventions in place to prevent further occurrence. Resident #1 sustained a laceration to the left lower leg that required 11 sutures. The findings included: The facility admitted Resident #1 on 9/15/2004 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS (Minimum Data Set) dated 4/26/2011 revealed Resident #1 was coded as having short and long term memory problems with severely impaired decision making abilities. Review of the current Care Plan revealed a problem area of ""skin integrity, high risk for impairment as related to: limited mobility, incontinence and the use of incontinence products, h/o (history of) anorexia, h/o cachexia, h/o skin breakdown. Skin is thin/friable and tears/bruises easily..."" The Care Plan was updated on 7/18/11 with ""Resident received laceration to L(eft) mid calf and sent to ER and received sutures, started on ABI (antibiotics)."" No interventions were added to the care plan to prevent further occurrence. Review of the CNA (certified nurse aide) Care Plan revealed Resident #1 transferred with a ""standing pivot, assist of 1""; was to ""lie down for nap after lunch "" and was on a ""every 2 hour toileting schedule during the day."" Review of the Nurse's Notes revealed on 7/18/2011 at 3 PM, ""Called to resident's room by CNA (certified nurse aide) where resident was noted to have laceration on L (left) lower leg approx(imately) 5 inches long and 2 inches deep. CNA and other staff unaware how laceration obtained. Moderate amount of bloody drainage noted. MD/NP (medical doctor/nurse practitioner) in to see laceration. Orders received to send resident to ER (emergency room ) for evaluation. Resident's (family member) aware and transported pt (patient) to ER herself with wc (wheelchair)."" At 7:10 PM, ""return from hospital with 11 sutures to L (lower) leg."" Further review of the Nurse's Notes revealed Resident #1 was non verbal but had facial grimaces and ""makes noises."" Resident #1 was noted to be on a pain management program. Review of the Progress Notes revealed on 7/18/2011 the Nurse Practitioner assessed Resident #1's laceration and documented the following: Resident #1 was ""noted to have some bleeding on her left leg. Very long laceration to her left lower extremity and there is depth where you can see some of the adipose tissue underneath. The steristrips are not really appropriate. There is also a large amount of bleeding to it... send to ER for laceration repair."" Observation of Resident #1 on 8/11/2011 revealed a thin, elderly individual sitting slightly slumped in a specialty wheelchair. Resident #1 was observed to have a suture line on the left lower extremity that was well approximated. Scabbing was observed on the lower portion of the wound. No drainage or inflammation was observed to the wound or peri wound area. The wound was noted to have no jagged edges or tearing of the skin. There was no bruising or evidence of a healing bruise to the peri wound area. Observation of Resident #1's room, bathroom and wheelchair revealed no sharp exposed objects. Further review of the record revealed Resident #1's weight on 7/13/2011 was 83.7 pounds. Review of the Reportable Incidents revealed Resident #1's laceration was not reported to the State Certification Agency. Review of the Investigation Summary revealed the ""Director of Nursing interviewed all staff on the unit and determined the skin tear occurred at breakfast when a resident, who was sitting beside (Resident #1), chair was lowered and bumped (Resident #1's) leg. (Resident #1) was wearing black pants and there was no active bleeding through her clothes. The Certified Nurse Aide, (CNA #1) assigned to (Resident #1), transferred the resident for her afternoon nap around 1:45 PM. At that time she removed her shoes and did not notice the skin tear. Preventative actions include in-services on safety awareness when repositioning chairs and transferring residents."" Review of the Employee Witness Statements revealed CNA #1's statement dated 7/18/2011 documented the following: ""I was (Resident #1's) nursing assistant on the above date. I gave her a shower in the morning around 7:05 AM and noted no skin problems, tears or other things. Before and after her shower she was toileted. The nurse came in and did a treatment to her feet and the nurse said she would put her shoes and socks on and take her to the dining room. I saw (Resident #1) doing activities with (Activities Coordinator #1) around 10:30 AM. I fed resident her lunch around 12:30 PM. She was sitting at the dining table with other residents until I finished picking up lunch trays. Resident was in a wheelchair. No footrests were on. Resident had been removed from the table and I saw her propelling herself in the wheelchair down the hall. I went and got her and carried her to her room. I transferred her to the bed around 1:45 PM for her afternoon nap. I transferred her from her wheelchair to the bed. I removed her shoes. Her socks were on. During the transfer the bed was even with the chair. She is assist of one. I checked her to see if she was dry and she was. I did not pull her slacks all the way down..."" During an interview on 8/11/2011 at 12:30 PM, CNA #1 stated that she was assigned to Resident #1 on 7/18/2011. CNA #1 confirmed that she did not know how or when the injury occurred. CNA #1 stated that the first she was aware of the wound was when CNA #2 informed the nurse of the blood on the sheet. CNA #1 stated that she could not remember what the wound looked like or if there was any bleeding. Review of the Employee Witness Statements revealed CNA #2's statement dated 7/19/2011 that documented the following: ""I remember seeing some blood on the fitted sheet (not sure of amount but it was small. I noticed blood on the top sheet. The blood was a circle around 4-5 cm around. I saw her pants leg was up and that is when I saw the cut. It was on her left lower leg. I went and got the nurse."" During an interview on 8/11/2011 at 1 PM, CNA #2 stated that around 2:30 PM, she was walking past Resident #1's door and saw blood on the top sheet. She stated that she immediately went and got the nurse. CNA #2 stated that she did not pull up the resident's pant leg and that the there was not a rip or a tear in the resident's pants. Review of the Employee Witness Statement revealed, Registered Nurse (RN) #1's statement dated 7/18/2011 documented the following: ""called to room by (CNA #2) around 2:50 PM. I saw blood on the sheet around half dollar in size. I pulled the top sheet back and noticed blood. When I started to pull the pant leg up the pants were slightly adhered to her leg. I gently pulled the pant leg up and noticed a moderate amount of blood. I cleaned the leg with normal saline and noticed the laceration to her left lower leg. (The NP and MD) came into room and assessed resident's laceration. The send (sic) ""let's send her to the ER and call her daughter."""" During an interview on 8/11/2011 at 10:30 AM, RN #1 stated that CNA #2 reported the blood to her. RN #1 stated that she went to the resident's room and pulled back the sheet and lifted up the pant leg. She stated that the pant leg was adhered to the leg. RN #1 stated that the wound edges were clean and approximately 5 inches long and 2 inches deep. RN #1 stated that there was a moderate amount of bleeding with blood noted on her pants, socks and sheets. RN #1 confirmed that she did not know how or when the laceration occurred. Further review of the Employee Witness Statements revealed no staff member had knowledge of how the laceration occurred or when the laceration occurred. Review of the DON's statement dated 7/19/2011 revealed the following: ""Resident #1 was sitting at the breakfast table on the am of July 18, 2011 around 7:30 AM. Resident #2 (Sampled Resident #3) was sitting beside her. When resident was seated at the breakfast table the footrest were lowered on her chair and caused a laceration to resident #1 leg. Resident #1 did not cry out in pain. She was wearing black slacks at the time of the incident and there was no active bleeding through her clothes. Laceration to leg was noted around 2:45 PM by nursing assistant who went in to check on her. Noted blood on sheet by nursing assistant and she notified the nurse. MD saw leg an (sic) stated to notify the daughter. Daughter came in and we agreed to sent (sic) her to the ER for evaluation. Resident required 11 sutures and antibiotics."" During an interview on 8/11/2011 at 9:45 AM, the Director of Nurses stated that there was no additional investigation material. She reiterated again that there were no additional employee statements or further documentation related to the investigation. The DON stated that Resident #3's wheelchair caused the laceration to Resident #1's left lower leg. The DON stated that the wheelchair had been removed from the facility, however, she stated that there was no blood or tissue found on the wheelchair and confirmed that Resident #1's pant leg was not ripped. The DON stated that the laceration was a ""slice"" and had no jagged edges or bruising. The DON stated that she came to the conclusion that the injury occurred 7 hours prior to the discovery of the wound because she ""backtracked"" the resident's events that day. The DON stated that she ""role played"" the resident's injury with the wheelchair. The DON also confirmed that she did not have evidence of her role playing and could not account for the entire 7 hours. The DON stated that no staff member witnessed the injury and the resident could not account for the injury. During an interview on 8/11/2011 at 10:45 AM, the Rehab Manager stated the alleged wheelchair had been removed from the facility. She also stated that she saw the wheelchair before it was removed. The Rehab Manager stated that there were no broken or sharp edges and no blood or tissue was noted on the wheelchair. The Rehab Manager stated that a similar chair was in the facility. Observation of the similar chair with the Rehab Manager and the DON revealed a reclining type of chair with a foot plate. The foot plate was connected to the chair via hollow metal tubes. The metal connecters were observed to have 4 metal corners that were rounded. No sharp edges were noted. The Rehab Manager confirmed the corners were [MEDICATION NAME] and had no sharp edges. The DON confirmed again that there was no bruising or tearing of Resident #1's skin and that the wound was sliced and ""opened back"" like a fillet. Both the Rehab Manager and the DON stated that the observed wheelchair was same type and condition of the chair that allegedly caused the laceration to Resident #1. The DON confirmed that the incident was not reported to the State Certification Agency within the required time frames. During a follow up interview on 8/11/2011 at 2 PM, the DON confirmed that no interventions were put in place for Resident #1 to prevent further injury. Review of the in-services revealed on 7/19/2011 an in-service was conducted on Unit 2. Topics included ""Passive Abuse, Notify Supervisor or Therapy with any jagged or sharp edges or items on wheelchairs. Remove foot rest when transferring, Transfer resident according to what is care planned."" Twenty one staff members attended the in-service. CNA #1, CNA #2 and RN #1 attended the inservice. Another in-service was conducted on 7/21/2011, the content included: Types of Chairs, Foot Pedals, How to Operate Chairs, Torn Arm Rests and Correct Chairs."" Fifty one staff members attended. CNA #1, CNA #2 and RN #1 did not attend.",2014-12-01
9778,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2011-08-08,226,D,1,0,IFPU11,"On the day of the complaint inspection based on observation, record review, interview and review of the facility's Abuse Neglect Policy, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. Resident #1 sustained a laceration to the left lower leg that required 11 sutures. The facility failed to report the incident to the State Certification Agency, failed to provide evidence of a thorough investigation and failed to implement interventions that prevented further occurrence for one of one residents reviewed with an injury. The findings included: Resident #1 sustained a laceration to the left lower leg on 7/18/2011 that required 11 sutures. Review of the facility's policy on ""Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property revealed the following: ""Injuries of Unknown Source: an injury should be classified as an injury of unknown source when both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the patient and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one point in time or the incidence of injuries over time."" Further review revealed ""6. Reporting...All alleged violations and all substantiated incidents will be reported immediately to the Administrator or his/her designated representative and to other officials in accordance with State and Federal Law including to the Stated Survey and Certification Agency."" ""Internal Investigation Policy: The results of all investigations will be completed within 5 working days of the incident. Depending on the result of the investigation, all necessary corrective actions will be taken. An accurate summary reporting of all investigations conducted by the center will be maintained as a working document of the QI Committee. Cross Refers to F-225 as it relates to the facility's failure to report, thoroughly investigate and implement interventions to prevent reoccurrence for Resident #1's laceration to the left lower leg.",2014-12-01
9779,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,441,F,0,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the facility policy entitled ""Linen Services"" and ""Handwashing"" from Safety and Environmental Control, the facility failed to provide a sanitary environment to help prevent the transmission of disease and infection pertaining to the handling of soiled linen. The cervical collar worn by Resident # 2 was observed soiled on the days of the survey. The findings included: On 10/11/2011 at 10:50 AM, observation of the laundry room was conducted with Housekeeper #1. The room was set up with the washer and dryer next to each other and no barrier separating the soiled from the clean area. A fan was running near the dryer facing the soiled laundry area. Housekeeper #1 was observed removing soiled linens from a barrel. She removed each piece of linen individually from the barrel and placed the linen on the lid of the barrel on the floor. Some linen was observed on the floor next to the lid. The fan was observed pointing in the direction of the soiled linen as the housekeeper pulled soiled linen out of the barrel. The staff member removed towels from the barrel and placed them into the washer. She then picked up the soiled linen off of the floor and placed it back into the barrel. Housekeeper #1 removed her gloves after starting the washing machine and then exited the laundry room without washing her hands. On 10/11/2011 at 2:04 PM, an interview with the Housekeeping Supervisor was conducted. She stated that the soiled linen should be taken directly out of the barrel and placed into the washing machine. Per review of the facility policy and procedure entitled ""Linen Services"" it states ""to reduce the possibility of infection transmission, soiled linen should be handled with minimum agitation and heavily soiled items placed in plastic bags before discarding in the hamper"". Per review of the facility policy entitled ""Handwashing"" from Safety and Environmental Control which states ""when to wash hands... before and after the use of sterile gloves"". The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation on 10/10/2011 revealed Resident #2 sitting in her wheelchair alone in her room. Her cervical collar was noted in place around her neck coming up around her jaw close to her mouth with a brown stain on it. During a phone interview on 10/11/2011 at 9:30 AM, a family member stated that the resident has always been concerned with her looks and that the collar she wore was a concern because it was soiled. She stated she talked to the facility about it and they told her they would have to order one. She stated she had mentioned this many times and facility staff told her to speak with therapy about it. When she talked to therapy, they said that it wasn't free. When the family member spoke with the surveyor, she stated she would go out and buy one if they would tell her where to go. Observation on 10/11/2011 at 10:28 AM revealed Resident #2 in bed wearing the Cervical Collar with a brown stain along the the bottom of the collar touching her cheek and chin. According to the Certified Occupational Therapy Assistant (COTA) who was present and working with the resident, the stain was probably coffee. She said ""This is dried coffee"". The COTA stated she didn't know if the collar could be removed to be cleaned. During an interview on 10/11/2011 at 10:33 AM, the Certified Nursing Assistant (CNA) taking care of the resident that day stated she didn't know how to clean the collar or who was responsible for cleaning it. She stated she had noticed it was ""a little dirty"". During an interview on 10/11/2011 at 10:35 AM, the Director of Nursing (DON) and Registered Nurse (RN) #1 stated they were not aware of a family member asking about a replacement collar since the resident's collar had been soiled. According to the DON, they tried to clean the collar with soap and water when the resident would allow them to take it off of her. She stated if it got too bad, they would let therapy change it out. During an interview on 10/11/2011 at 10:38 AM, the Occupational Therapist stated the resident probably had one collar that came with her from the hospital. She was not aware of a family member asking about a replacement but stated she would find out and contact a company so a replacement collar could be ordered for the resident. During an interview on 10/11/2011 at 10:45 AM, Licensed Practical Nurse (LPN) # 1 stated the resident was not supposed to be without her Cervical Collar at all. She stated she noticed it was dirty yesterday, but didn't know who was responsible for cleaning it. She thought the CNA's might be responsible for cleaning it, but stated the CNA's would have to remove the collar to clean it. Review of the policy provided by the facility on 10/11/2011 entitled ""Cervical Collar"" revealed under Washing to ""1. Change the pads/foam collar once a day or as needed, while the collar off for skin care. Rinse and allow the pads/foam collar to air dry completely so that they can be used for the next time...""",2014-12-01
9780,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,371,F,0,1,8MQE11,"On the days of survey, based on observation, the facility failed to store, prepare, distribute, and serve food under sanitary conditions pertaining to labeling/dating, cleanliness of equipment, condition of the equipment, and condition of the food. The findings include: On 10/10/11 at 10:15AM, during the initial tour of the kitchen with the Dietary Manager, a sanitizer bucket was on the prep table next to the cutting board. On 10/11/11 at 9:20AM, during tour of the kitchen with the Dietary Manager, ice build up was observed on boxes of food in the walk-in freezer and ice was hanging from the back of the freezer. There was dust on the fan guard in the freezer area. A soiled rag was observed on a box of food in the walk-in refrigerator. Two (2) spoiled cabbages and two (2) spoiled bags of grapes were observed in the refrigerator. A container of cranberry sauce dated 10/5/11 was observed in the walk-in refrigerator. Five (5) knobs on the steam table were heavily soiled. . Grease build up above the oven on the hood was observed. The sanitizer bucket remained on the shelf next to the food prep area. On 10/11/11 at 12:00PM, during trayline service, a Certified Nursing Assistant (CNA) was observed placing two (2) bowls of mechanical meat together to obtain food temperature of 120 degrees. Per the Certified Dietary Manager (CDM), microwave meat should be at 165 degrees. The CNA then mixed three (3) bowls of mechanical meats together, microwaved the portion, to obtain a food temperature of 170 degrees. The meat was then overcooked and placed back into the three (3) bowls, without the proper serving size per portion.",2014-12-01
9781,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,425,D,0,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled ""Medication Shortages/Unavailable Drugs"", the facility failed to ensure the medication Coreg was available for administration to Resident #7, one of eight residents reviewed for medication administration. The facility also failed to remove (2) opened and undated vials of Purified Protein Derivative (PPD) from the current stock available for administration in the Medication Room refrigerator. The findings include: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on 10/11/2011 at approximately 8:30 AM revealed Admission Physician order [REDACTED]. Continued review of physician's orders [REDACTED]. Review of Daily Skilled Nurse's Note(s) revealed an entry dated 9/18/2011 at 1:30 AM which stated ""Pharmacy called R/T (related to) allergies [REDACTED]. MD (Physician) will be called in AM"". Review of the Documentation Record for September 2011 on 10/11/2011 revealed the nurse's initials for the medication Coreg had been circled indicating the medication had not been given for 12 doses from the evening of 9/17/2011 until 9/30/2011. There were also 3 blanks for that time period where the nurse did not initial for the medication at all. On the back of the Documentation Record were 3 notations that referenced the Coreg. One dated 9/17/2011 at 10:00 AM stated ""Coreg----Clarification faxed to pharmacy r/t (no) true allergy"". A second dated 9/25/2011 at 8:00 AM stated ""Coreg-not in see above 9/17/2011"". The third was dated 9/29/2011 which stated ""Faxed stat order for Coreg 12.5. Did not send"". The Documentation Record revealed that the medication had been initialed as having been given starting 9/19/2011 with the evening dose and also showed that while at times the medication was circled for the morning dose, the evening dose had been initialed as having been given. Review of Nurses Notes for September 2011 and the backs of the Documentation Record did not indicate why the Nurses initials had been circled except as noted above for 3 doses. The Director of Nursing verified the circles and blanks on the Documentation Record on 10/11/2011 at 8:45 AM. She stated that the Pharmacy had initially sent only (15) 1/2 tablets of the Coreg and that she had to sign that she would pay for the medication. She stated the Pharmacy would not accept the order from the nurse. The DON was asked to provide any invoices for the medication and any communication between the Pharmacy and the facility related to the Coreg or allergies [REDACTED]. When asked if Coreg was available in the stat/emergency box, the DON stated it used to be. Observation on 10/11/2011 at 12:40 PM of the stat box in the medication room revealed it contained Coreg 3.125 mg tablets #6. Review on 10/11/2011 at 9:45 AM of the Pharmacy Invoice for medications supplied to the facility revealed Resident #7's Coreg was shipped on 9/29/2011 and delivered 9/30/2011 at 12:18 AM. During a phone interview on 10/11/2011 at 1:07 PM the Pharmacy Manager asked what the issue was and said he would call the corporate office to get permission to release the information. He called back and stated he was unable to speak with the surveyor about the issue with Resident #7 due to privacy regulations. He stated if he received a signed written request for information along with a business card he could obtain the information and then speak with the surveyor. Review of the policy provided by the facility dated 12/1/2007 entitled ""Medication Shortages/Unavailable Drugs revealed under ""If a medication shortage is discovered during normal Pharmacy hours: ... A licensed Facility nurse should call the Pharmacy to determine the status of the order... If the next available delivery causes delay or a missed dose in the resident's medication schedule, the Facility nurse should obtain the medication from the emergency stock supply to administer the dose... If a medication is not available in the emergency stock supply, Facility staff should notify the Pharmacy and arrange for an emergency delivery... If a medication shortage is discovered after normal Pharmacy hours: ... If the medication is not available in the emergency stock supply, the Facility nurse should call the Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include ... Emergency delivery... Use of an emergency (back-up) Third Party Pharmacy. If an emergency delivery is unavailable, the Facility nurse should contact the attending physician to obtain orders or directions..."" Observation of the Medication Room refrigerator on 10/11/2011 at 12:40 PM revealed (2) vials of 10 test PPD (Tubersol) that had been opened and were undated mixed in with the regular stock medications available for administration. This was verified by Registered Nurse #2. Review on 10/11/2011 of the policy provided by the facility entitled ""Medication Storage"" revealed ""...Vials will be stored per manufacturers recommendations and upon opening of the vial it will be dated with date opened and expiration date"".",2014-12-01
9782,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,314,D,0,1,Z9P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observation, interview and record review, the facility failed to provide appropriate wound care for one of one sampled residents reviewed for wound care. Resident # 1's wound care was not provided per the physician's orders [REDACTED]. The findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Drug the initial tour the resident was identified as being on transmission based precautions related to a drug resistant infection (MRSA). Personal Protective Equipment was observed outside the resident's room . On 9/27/11 at 11:30 AM, wound care was observed for Resident # 1. Licensed Practical Nurse # 3 was observed to cleanse the resident's wound with wound cleanser, cover with Vaseline gauze and wrap the area with gauze. Following the observation, review of the physician orders [REDACTED].. Interview with the Physician, at 2 PM on 9/27/11, revealed that he would expect a treatment order to be followed as written. He stated the product used was ""similar"" but was not the same. During the treatment observation, Licensed Practical Nurse # 3 also provided wound care to an area on the resident's right leg. Review of the facility wound care records did not include this area in the weekly assessment documentation. During an interview with the nurse who completed the tracking information,(Registered Nurse # 4) she stated that the facility did not measure areas for which there was no treatment ordered. When asked how she would then know if an area was improving or declining, she stated she understood. Cross refer to F 281 as it relates to professional standards and performance of wound care without a physician order. Cross refer to F 441 as it relates to Infection Control during the performance of wound care.",2014-12-01
9783,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,156,C,0,1,Z9P611,"On the day of the Initial Survey, based on observation and interview, the facility failed to post the names, addresses, and telephone numbers of State client advocacy groups. The findings included: Observations on 9/27/11 at approximately 9:15am and again at 3:20 pm revealed no posting of names, addresses, and telephone numbers for the Bureau of Certification, State Licensure, or Protection and Advocacy. Interview with the facility Administrator at 3:20pm confirmed the information was not posted in the facility.",2014-12-01
9784,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,371,E,0,1,Z9P611,"On the day of the Initial survey, based on observation and interview, the facility failed to store, prepare, and distribute food under sanitary conditions as evidenced by a scoop stored in an ice chest, dust accumulation on fans, food not labeled and dated, and trash cans without lids. The findings included: Observations on 9/27/11 at approximately 9:15am revealed in the main kitchen, lids off 2 trash cans in the area of the dishmachine, 3 floor fans with an accumulation of dust on the grills, and a pink substance on the inside lid of the ice machine. Observations on 9/27/11 at approximately 11:50am in the Health Care kitchen revealed a small fan with an accumulation of dust. Observations and interview with the Dietary Manager on 9/27/11 at approximately 3:05pm confirmed the above findings. When asked if the ice machine was on the cleaning schedule, the dietary manager indicated that it was not on a routine cleaning schedule but it was on a routine maintenance schedule. During the initial tour of the facility on 9/27/11, a plate of assorted cheesecake desserts was stored in a small refrigerator at the end of the hall. The platter was not labelled nor dated. When the Dietary Manager was questioned, he stated there was nothing in the refrigerator and the refrigerator was not in use. However, when this surveyor relayed the concern, he stated the item was leftover from a recent open house. During observation of the noon meal on 9/27/11, a blue and white ice chest was observed in the corner of the main dining room with the scoop stored inside. The finding was verified by the Dietary Manager and removed for cleaning.",2014-12-01
9785,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,441,F,0,1,Z9P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observation, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. During the observation of wound care for a resident on transmission based precautions, Nursing staff failed to appropriately don personal protective equipment (PPE) and contaminated self and clean supplies. The main Biohazard Room contained Biohazard waste and also contained clean unopened supplies. Laundry staff was observed not wearing appropriate PPE. The facility was not noting the expiration date of wipes used to clean medical supplies. The findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Drug the initial tour the resident was identified as being on transmission based precautions related to a drug resistant infection (MRSA). Personal Protective Equipment was observed outside the resident's room . On 9/27/11 during observation of wound care for a resident on transmission based precautions, two nurses failed to properly done personal protective equipment. Both nurses donned a disposable gown but failed to tie the gown. As a result, the gowns were observed to slide off from their shoulders during the observation. During the treatment observation, Licensed Practical Nurse # 1, while waiting for the other nurse, was observed to tidy the over the bed table where supplies were placed to be used for the treatment. The LPN was wearing gloves which had been contaminated by her holding the resident's leg. She was observed stacking unopened packages of dressing supplies which were to be used for the next dressing change. When the observation was shared with the LPN, she confirmed she had done so and returned to the room to discard the supplies. Additionally, LPN # 1 carried scissors into the medication room to clean them. When she was finished, she removed her gloves, wiped her face/nose before washing her hands. LPN # 3 was accompanied to the facility's main storage room for Biohazard waste on 9/27/11. The room was located near the maintenance area. When opening the door, the path to the disposal box was partially blocked by boxes of unopened medical supplies. It was necessary to reach over the boxes to drop the waste into the box which was opened without a lid. When questioned as to what was in the boxes, the surveyor was referred to the Maintenance Director. A subsequent interview with the Maintenance Director revealed that the boxes contained unopened, unused sharps containers. The supplies had been obtained but administration had decided not use the supplies. The supplies were then stored in the Biohazard room. Cross refer to F 314 as it relates to wound care. Resident # 1 was diagnosed and treated with antibiotics for a right lower lung infiltrate on 9/23/11. However, the resident's infection was not included on the infection control log (provided by the facility) as confirmed by the Director of Nursing who was responsible for maintaining the log. Observations on 9/27/11 at approximately 10:45am revealed the Housekeeping Supervisor was folding clean linen in the laundry area. When asked, at that time, what was the procedure for sorting and washing soiled/dirty laundry the housekeeping supervisor stated that the staff don gloves and sort the laundry then wash it. When asked if the staff put on gowns while sorting laundry, the supervisor stated only when they know the laundry is soiled otherwise, no. Observation of the Nurse Medication Room on 9/27/11 at 12:05 PM revealed 3 containers of PSS Select Disinfecting/Cleaning Wipes, used to disinfect Glucometers. Two of the containers were unopened, but 1 container had been opened. There was no open date nor expiration date marked on the containers. This was confirmed by RN # 4 (Registered Nurse.) The Medical Record Secretary contacted the company and found out that the containers have a Shelf Life (in original sealed containers) for 5 years stored at 0 C and 3 years stored at 15 C. When containers are opened they will expire in 2 years. There were no dates on the containers to document when the containers had been received nor when the container had been open. Therefore, the facility had no way to tract when the wipes would expire.",2014-12-01
9786,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,496,E,0,1,Z9P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on personnel folder checks, facility policy, and interview, the facility failed to obtain nurse aide registry verification that the individuals met competency evaluation requirements for 6 employees prior to hire. The facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e))2)(A) of the Act before allowing an individual to serve as a nurse aide. (6 of 17 CNA records reviewed.) The findings included: On 9/27/11, 17 Certified Nursing Assistant's personnel folders were reviewed for documentation that the Nurse Aide Registry Verification checks had been done prior to the facility's application for Medicare Certification on 8/11/11. Of the 17 folders reviewed, 6 employees ( A,B,C,D,E, and F) did not have the documentation to show Registry checks had been done. Facility Polity under Background Screening Investigation also stated under #2. Any individual applying for a position as a Certified Nursing Assistant , the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, or mistreatment of [REDACTED]. The Registry checks were done for the 6 employees on 9/27/11 by the facility staff, after confirming the checks had not been previously done.",2014-12-01
9787,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,280,D,0,1,Z9P611,"**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 the care plan for Resident # 1 to reflect contact precautions and to address the spouse's involvement in wound care. (1 of 4 sampled resident's reviewed for revision of care plans.) The findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Drug the initial tour the resident was identified as being on transmission based precautions related to a drug resistant infection (MRSA). Personal Protective Equipment was observed outside the resident's room . On 9/27/11 at 1:10 PM, review of the resident's care plan revealed no documentation that the resident was on transmission based precautions of any type. Continued review of the medical record revealed documentation that on two occasions the resident's spouse was observed by nursing staff to be in the process of performing wound care. On 9/6/11 nursing notes documented: ""...this nurse observed residents wife changing dressing on leg and foot, wife stated she was residents caregiver before his move and had changed his dressing many times."" On 9/25/11 nursing documented: ""This nurse entered residents room to change wound dressing rt. (right) heel, Wife was changing dressing. Explained to her that I had come to perform treatment. Wife stated 'I like to do it myself sometimes so I can see how it's looking.' She was applying masking tape to the dressing and stated ' I have found that it holds better than any other tape.' When asked if wound was dry, she replied it looked good today."" The care plan did not address the spouse's involvement in wound care or the need for family education/teaching related to wound care . On 9/27/11, the findings were verified by Registered Nurse # 1 who identified herself as being responsible for care plans.",2014-12-01
9788,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,281,D,0,1,Z9P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and record review, the facility failed to provide services that met professional standards of quality. A facility staff nurse provided wound care for Resident # 1 without a physician's order and did not document the wound care as being provided after its completion. (One of one treatments observed for professional standards of care.) The findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Drug the initial tour the resident was identified as being on transmission based precautions related to a drug resistant infection. On 9/27/11 at 11:30 AM, Licensed Practical Nurse # 3 was observed as wound care was provided for Resident # 1. The nurse provided care to the resident's right heel. When the treatment was completed, she then provided the same treatment to an open area on the resident's right lateral lower leg. (Cleaned with wound cleanser, applied Vaseline gauze, wrapped with gauze bandage.) Upon completion of the observation, record review revealed there was no physician's order for the treatment to leg. Review of the treatment record revealed the nurse had not signed that she had completed a treatment to the leg in addition to the heel. Interview with the nurse confirmed that there was no physician ordered treatment for [REDACTED]. The nurse verified that the treatment had been done without an order and it had not been signed off on the treatment sheet as done. Cross refer to F 314 as it relates to wound care.",2014-12-01
9789,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,328,D,0,1,Z9P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observation and interview, the facility failed to assure the oxygen concentrator filters for Resident # 2 were clean. (1 of 1 sampled residents receiving oxygen.) The findings included: The facility last admitted Resident # 2 on 8/17/11 with [DIAGNOSES REDACTED]. During initial tour of the facility, the resident was observed in bed receiving oxygen via a oxygen concentrator. The concentrator had two filters, both of which were heavily covered with a grey/white substance. Repeated observations during the noon meal and again at 3:34 PM revealed the filters remained soiled as confirmed by Licensed Practical # 1. Licensed Practical # 1 stated the filters were supposed to be cleaned by the night shift on a weekly basis.",2014-12-01
9790,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,356,D,0,1,Z9P611,"On the days of the survey, based on observation and interview, the facility failed to post facility staffing per regulatory requirement. Upon entrance to the facility there was no posting present. Previous postings failed to contain sufficient information. The findings included: On 9/27/11 during the initial tour, there was no evidence of the daily staff posted as required. Interview with Licensed Practical Nurse # 1 revealed the posting should have been completed by the medical records clerk. In a susequent interview with the medical record clerk, she verified that the posting for the day had not been done. She indicated it also had not been done for the previous day because she was not at work. Further review revealed that when the posting was completed it did not meet regulatory requirement. There was no documentation of the census per shift and the census improperly included residents on both units. It did not clearly document the total number and the actual hours worked by the licensed and unlicensed nursing (Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants) staff directly responsible for resident care per shift:",2014-12-01
9663,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-09-20,225,D,1,0,Q9U711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interviews, the facility failed to report immediately 1 of 1 allegation of abuse, to the appropriate person and/or state agencies. Resident #1 alleged abuse to her family on 8/28/2011 and the family report the allegation to the staff on the afternoon of 8/28/2011. Licensed Practical Nurse #1 and Certified Nurse Aide #1 were aware of the allegation on 8/28/2011 and the administrator was not made aware of the allegation until 8/30/2011. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Resident #1 was coded as requiring extensive assistance with transfers and dressing, and total assistance was required with personal hygiene and bathing. She was coded as always incontinent of bowel and bladder, requiring total assistance with toilet use. Resident #1, sampled as a result of a facility reported incident that allegedly occurred on 8/29/2011. Review of the facility's investigation, on 9/20/2011 revealed an undated ""Patient/Resident Incident/Accident Investigation Worksheet"" regarding the incident. The worksheet indicated the incident occurred on 8/29/2011, during the 11-7 shift. Under the type of incident/accident, it stated, ""Resident c/o (complained of) abuse."" It also stated, ""Per Regulation, this is a State Reportable Incident. Date State Notified: 8/31/2011."" Under the section titled ""Notifications and Treatments Physician Notified"" was checked with the date of 8/31/2011. Under the section ""Describe Exactly What Happened"", it was written, ""Resident c/o someone raping her during the night"". The Initial 24-hour report sent to the State Agency was dated 8/31/2011. The Date/Time of Reportable Incident was documented, ""8/29/11, 11-7 shift"". Under ""Brief Description of Reportable Incident"" was a handwritten statement that Resident #1 told her family that she was awakened during night and was startled by staff checking her for incontinence. The statement went on to say that the resident told family, of the attempted rape. The report stated that the incident was received by nursing on 8/30/2011. In a facility obtained typed statement dated 8/31/11 CNA #1 stated, ""On August 27th and 28th I was assigned to Resident #1 from 7 p. m. to 7 a. m. She allowed me to put her to bed and perform personal care on her without any problem or complaints. I was also able to perform personal care on her throughout the night without any complaints or resistance from her until about 0530. I had woke her and explained that I was going to change her brief and as I was almost complete with her care she began screaming and hitting me telling me to leave her alone. I then explained to her that I was not here to harm her and was only there to change her and I completed personal care on her. She did not say anything to me about rape in any way."" In an interview with the surveyor on 9/20/2011 at 10:30 AM., CNA #1 stated that incontinence care was being provided to the resident around 5:30 AM on Sunday morning (8/28/2011). On the last round of the shift the resident started yelling, ""Get out of here"". The CNA stated the resident started swinging. The CNA stated it was Saturday night (8/27/2011/Sunday morning (8/28/2011), on the 7:00 PM to 7:00 AM shift. Licensed Practical Nurse (LPN) #1 informed me on Sunday afternoon (8/28/11) when I came back in to work that the family came in and reported the incident. Review of the schedule and assignments for 8/27 and 8/28/2011 revealed accused CNA #1 worked from 7 PM to 7 AM on Saturday 8/27/2011/Sunday 8/28/2011. On Sunday (8/28/11) CNA #1 returned to work the 3:00 PM to 11:00 PM shift. CNA #1 was not assigned to Resident #1 on Sunday, the 3:00 PM to 11:00 PM shift. In an unsigned facility typed statement dated 9/2/2011, attributed to Licensed Practical Nurse (LPN) #1 she was reported to say that CNA #1 reported to her that Resident #1 had been yelling and swinging. She stated that CNA #1 requested not to work with Resident #1. In an interview with the surveyor on 9/20/2011, 11:30 AM LPN #1 stated the family asked her the following Sunday afternoon, (8/28/2011) if anything had occurred the night before. The LPN stated the family didn't want CNA #1 working with Resident #1 because the resident told the family that CNA #1 tried to rape her. LPN #1 stated during the interview that she went to CNA #1 on Sunday afternoon after she spoke to Resident #1 family and asked if anything had occurred with Resident #1; CNA #1 confirmed Resident #1 was upset and yelling at around 5:30 AM on Sunday morning. The Director of Nurses (DON) was interviewed on 9/20/11 at 10:00 AM. The DON stated that she was made aware of the incident on Tuesday, 8/30/11. The DON was asked by the surveyor when the incident had happened, since the report stated 8/29/2011 and the statements obtained from the investigation stated 8/28/2011. She stated, ""The dating was difficult because it occurred on the 11-7 shift, so it was late at night or early morning."" The DON stated that the family had spoken to the Social Worker and reported the incident. They were not making a complaint. The alleged incident occurred around 5:30 AM on the morning of 8/28/2011. The Administration was not notified of the alleged abuse until 8/30/2011, two days after the allegation was made. The State Agencies were not notified of the incident until 8/31/2011. Facility staff (LPN #1 and CAN #1) was aware the resident made the allegation on 8/28/2011. The staff did not immediately report the incident to their supervisor or Administrator.",2015-01-01
9664,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-09-20,226,D,1,0,Q9U711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, interviews, and review of the facility policy Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property. The facility failed to implement their policy to immediately report and protect residents from harm during an investigation (Resident #1). The findings included: Cross Refers to F225 The facility admitted Resident #1 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. The MDS coded the resident as having moderately impaired cognition skills. Resident #1 required extensive assistance with transfers and dressing, and total assistance with personal hygiene and bathing. She was coded as always incontinent of bowel and bladder and required total assistance with toilet use. Resident #1, sampled as a result of a facility reported incident that allegedly occurred on 8/29/2011. Review of the facility's investigation, on 9/20/2011 revealed an undated ""Patient/Resident Incident/Accident Investigation Worksheet"" regarding the incident. The worksheet indicated the incident occurred on 8/29/2011, during the 11-7 shift. Under the type of incident/accident, it stated, ""Resident c/o (complained of) abuse."" It also stated, ""Per Regulation, this is a State Reportable Incident. Date State Notified: 8/31/2011."" Under the section titled ""Notifications and Treatments Physician Notified"" was checked with the date of 8/31/2011. Under the section ""Describe Exactly What Happened"", it was written, ""Resident c/o someone raping her during the night"". The Initial 24-hour report sent to the State Agency was dated 8/31/2011. The Date/Time of Reportable Incident was documented, ""8/29/11, 11-7 shift"". Under ""Brief Description of Reportable Incident"" was a handwritten statement that Resident #1 told her family that she was awakened during night and was startled by staff checking her for incontinence. The statement went on to say that the resident told her family, of the attempted rap. The report stated that the incident was received by nursing on 8/30/2011. In interviews with the surveyor on 9/20/2011 Licensed Practical Nurse #1 and Certified Nurse Aide (CNA) #1 confirmed the alleged incident occurred Sunday morning, 8/28/2011. LPN #1 stated the family asked her on Sunday afternoon, (8/28/2011) if anything had occurred the night before. The LPN stated the family didn't want CNA #1 working with Resident #1 because the resident told the family that CNA #1 tried to rape her. LPN #1 stated she asked CNA #1 on Sunday afternoon after she spoke to Resident #1's family if anything had occurred with Resident #1; CNA #1 confirmed Resident #1 was upset and yelling at around 5:30 AM on Sunday morning. On Sunday afternoon after speaking with LPN #1, CNA #1 asked to not be assigned to care for Resident #1. On 9/20/11 at 11:30 AM, Licensed Practical Nurse #1 was interviewed regarding abuse reporting. During the interview the LPN stated, ""We don't have supervisors on the weekend"". On 9/20/11 at 1:45 PM, Registered Nurse (RN) #1 was interviewed regarding reporting abuse. During the interview, the RN was asked, who was in charge on weekends. The RN stated, ""We used to have a weekend supervisor, not any more. No one is designated to be in charge on weekends. We just call the Director of Nurses (DON) if we have a problem."" On 9/20/11 at 1:50 PM, RN #2 was interviewed. She stated, ""On my weekend I am the supervisor for my shift, 7-3. I don't know about the other shifts."" The Director of Nurses was interviewed on 9/20/11 at 2:00 PM. She confirmed that she did not have a nurse designated to be in charge for each tour of duty. The DON stated, ""I was not aware I was to have a nurse in charge"". Review of the facility policy titled, Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property. Under section E. Identification ""It is the responsibility of every employee... to immediately report any incidents of abuse, neglect... to the facility administrator... section 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..."" On the day of the inspection, based on record review and interviews, the facility failed to follow their Policy/Procedure on abuse/neglect for 1 of 1 residents with an allegation of abuse, Resident #1.",2015-01-01
9665,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-09-20,353,D,1,0,Q9U711,"On the day of the inspection, based on record review and interviews, the facility failed to designate a licensed nurse to serve as charge nurse on the weekends. The findings included: Cross Refers to F226 Review of the facility policy on abuse revealed under section 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. On 9/20/11 at 11:30 AM, Licensed Practical Nurse #1 was interviewed regarding abuse reporting. During the interview the LPN stated, ""We don't have supervisors on the weekend"". On 9/20/11 at 1:45 PM, Registered Nurse (RN) #1 was interviewed regarding reporting abuse. During the interview, the RN was asked, who was in charge on weekends. The RN stated, ""We used to have a weekend supervisor, not any more. No one is designated to be in charge on weekends. We just call the Director of Nurses (DON) if we have a problem."" On 9/20/11 at 1:50 PM, RN #2 was interviewed. She stated, ""On my weekend I am the supervisor for my shift, 7-3. I don't know about the other shifts."" The Director of Nurses was interviewed on 9/20/11 at 2:00 PM. She confirmed that she did not have a nurse designated to be in charge for each tour of duty. The DON stated, ""I was not aware I was to have a nurse in charge"".",2015-01-01
9666,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2011-09-26,469,E,1,0,ROGY11,"On the day of the complaint inspection, based on observations, interviews, and review of facility pest control documents, the facility failed to maintain an adequate pest control program to ensure flies did not trouble the residents. The findings included: During the orientation tour of the facility, no pests were noted. However, during the noon meal observations showed flies present in 5 of 7 rooms where residents were eating. One fly was observed around the resident's food in room 207, 208, 210, and 211. A staff member was feeding the residents in 207 and 208. The staff members confirmed that flies were a problem at the facility. Two flies were noted in room 209 while the resident was feeding herself. The resident was making no attempts to swat the flies away from her food. An observation in the dining room revealed no flies. During an interview with Certified Nursing Assistant (CNA) #1, the CNA was asked about flies in the facility. The CNA stated flies were found at the beginning of the 7-3 shift, especially in rooms where residents were heavily incontinent. The CNA stated that once the residents were changed and their tables were wiped down, the flies left. According to the CNA, the flies did seem to return and follow the food at meal times. A group interview with ten alert and oriented residents was held at 2 PM on the day of the complaint inspection. The residents said that flies were always present, but the population increased when the weather was hot or wet. Interviews with the Administrator throughout the inspection revealed the facility had monthly pest control visits for routine pests and for flies. The main problem appeared to be from the door to the smoking area. Despite the blower over the door and the trap lights, the flies still managed to enter the facility. The facility had a population of smokers who went out four times a day causing the door to open multiple times at each smoke break. According to the Administrator, another problem was that occasionally the night shift turned the blower off, and then the day shift failed to turn it back on. Observations of the facility revealed it was located in a country setting amid farms. The smoking area was just outside the building in the area formed by the junction of the facility's two hallways. It was covered, but not enclosed. The blower over the exit door was observed functioning on the day of the inspection. Review of the facility's pest control contract revealed the fly control program had a start date of 12/01/08. The contract stated under Details of Service: ""Flies are accessing the building primarily through smoke break area door. ... to treat the exterior of the building in this area using Exterior Power Spray, Traps and Monitoring, Granular Baits, and Pheromones and Attractants. IT IS OUR RECOMMENDATION THAT ALL MISTING MACHINES SHOULD BE REMOVED. ... will clean and maintain existing Insect Light Traps and add one Vector Plasma Light Trap at the smoking break area door."" An interview with the Administrator revealed she had contacted the pest control company and was informed they were providing the maximum treatment available for the facility.",2015-01-01
9667,UNIHEALTH POST ACUTE CARE OF MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2011-02-16,309,E,0,1,R8RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews, the facility failed to ensure that 2 of 23 residents reviewed received necessary care and services. Resident #16 and # 17's blood pressure was not monitored related to [MEDICAL TREATMENT] as ordered. Resident # 16's [MEDICAL TREATMENT] was not monitored per the plan of care. The findings were as follows: Resident #17 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review on 2/16/11 at approximately 12:25pm revealed a Physician's order for ""B/P (Blood Pressure) monitor and record before and after [MEDICAL TREATMENT]"". Review of the Medication Administration Record [REDACTED]. December's MAR indicated [REDACTED]. Interview with the Nurse Consultant at approximately 1:30pm indicated that the December MAR indicated [REDACTED]. Based on the provided information which was reviewed with the Consultant revealed : 12/06/11 - B/P not recorded before or after [MEDICAL TREATMENT] 12/10/11 - B/P not recorded before [MEDICAL TREATMENT] 12/13/11 - B/P not recorded before or after [MEDICAL TREATMENT] 12/17/11 - B/P not recorded before or after [MEDICAL TREATMENT] 12/20/11 - B/P not recorded after [MEDICAL TREATMENT] 12/27/11 - B/P not recorded after [MEDICAL TREATMENT] On 2/16/11 at approximately 3:35pm the nursing notes and communication forms were reviewed with the Director of Nursing (DON) for the month of January. Based on the review, the following was noted: 1/10/11 - B/P not recorded after [MEDICAL TREATMENT] 1/21/11 - B/P not recorded after [MEDICAL TREATMENT] 1/24/11 - B/P not recorded after [MEDICAL TREATMENT] 1/26/11 - B/P not recorded after [MEDICAL TREATMENT] 1/31/11 - B/P not recorded before or after [MEDICAL TREATMENT] Interview with both the DON and the Nurse Consultant verified that the Physician's orders stated the B/P was to be to monitored and recorded before and after going to [MEDICAL TREATMENT]. Review of the facility policy ""[MEDICAL TREATMENT] Residents/Patients"" states under ""Procedure 1. Take blood pressure and pulse before going out to [MEDICAL TREATMENT]. Procedure 2. Take blood pressure and pulse upon return from [MEDICAL TREATMENT]."" The facility admitted Resident #16 on 1/15/10 with [DIAGNOSES REDACTED]. Review of the medical record on 2/16/11 revealed Resident #16 received [MEDICAL TREATMENT] three times per week. Further review of the medical record revealed the current plan of care identified ""potential for clotting of access shunt"" as a problem area. Interventions included ""auscultate and palpate for bruit and thrill at shunt site every shift and prn."" The care plan identified [MEDICAL TREATMENT] as another problem area with interventions including ""B/P (blood pressure) and pulse before and after [MEDICAL TREATMENT]."" Review of the January 2011 Medication Administration Record [REDACTED]. Further record review indicated staff checked for thrill and bruit on [MEDICAL TREATMENT] days; however, there was no other documentation indicating that the thrill and bruit was checked daily per shift. In addition, there was no documentation in the medical record to indicate staff obtained Resident #16's blood pressure and pulse before and after [MEDICAL TREATMENT] per the care plan. During an interview on 2/16/11, Licensed Practical Nurse (LPN) #1 was asked to review the above findings. LPN #1 confirmed that staff documented checking the thrill and bruit on the days of [MEDICAL TREATMENT]; however, there was no documentation to indicate this was checked daily per shift. In addition, LPN #1 confirmed that there was no documentation to indicate staff obtained Resident #16's blood pressure and pulse prior to and after [MEDICAL TREATMENT].",2015-01-01
9668,UNIHEALTH POST ACUTE CARE OF MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2011-02-16,272,D,0,1,R8RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the facility policy titled ""Smoke Free Policy"", the facility failed to assure that each resident received an accurate assessment for smoking for 1 of 2 sampled residents for smoking. The facility failed to complete a quarterly Smoking Assessment Form per protocol for Resident #25. The findings included: The facility admitted Resident #25 on 04-12-06 with [DIAGNOSES REDACTED]. Record review on 02-16-11 at approximately 1:00 PM of Resident #25's Care Plan dated 04-27-10 and updated 01-13-11 with Problem of ""Needs supervision with smoking due to impaired cognition"" revealed in Approaches section: ""Supervise patient during smoke breaks"". Further record review on 02-16-11 at approximately 1:00 PM of Resident #25's Smoking Assessment Form revealed a Smoking Assessment Form had not been completed since 07-09-10. The Smoking Assessment Form stated ""All patients (pts)/residents (res) will be assessed on admission, re-admission, with significant change in condition, and at least quarterly"". During an interview on 02-16-11 at 2:20 PM with Licensed Practical Nurse (LPN) #1, she, after record review, verified the quarterly Smoking Assessment Form for Resident #25 had not been completed since 07-09-10. LPN #1 stated, ""No, I didn't know they were to be done quarterly. I thought they were done annually"". Review on 02-16-11 at 2:30 PM of the facility policy titled ""Smoke Free Policy"" stated in section ""Smoking Assessment Form: patients/residents will be assessed for risk hazards prior to smoking in designated areas. The Smoking Assessment Form to be completed"". Further review of the facility policy titled ""Smoke Free Policy"" revealed in section ""Determination of Supervision Needs, Procedure #2.: Each patient/resident will be assessed, utilizing the Smoking Assessment Form, by a licensed nurse upon admission, re-admission, with a significant change, and at least quarterly thereafter"".",2015-01-01
9669,UNIHEALTH POST ACUTE CARE OF MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2011-02-16,514,D,0,1,R8RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 14 residents reviewed. The facility was unable to provide documentation of an changed Resident # 6's order for Aspirin. Nursing staff failed to document the administration of Prostat for Resident # 1. The December 2010 Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #6 on 10/05/07 with [DIAGNOSES REDACTED]. Review of the medical record on 2/15/11 revealed the February cumulative Physician's Orders contained an order for [REDACTED]. Review of the January 2011 Medication Administration Record [REDACTED]. Review of the medical record revealed no physician's order to discontinue the Aspirin was available on the record. In an interview on 2/16/11, Licensed Practical Nurse (LPN) #1 was asked to verify that Aspirin 81 mg was listed on the current Physician's Orders and to verify that the February 2011 MAR indicated [REDACTED]. LPN #1 was unable to locate the order at that time. LPN #1 was asked to inform the surveyor if the order to discontinue was located. No order was provided prior to exit from the facility. The facility admitted Resident #1 on 10/05/07 with [DIAGNOSES REDACTED]. Review of the medical record on 2/14/11 revealed a current Physician's Order for Prostat 64 30 ml (milliliters) via tube every day with 90 ml water flush. Review of the February 2011 Medication Administration Record [REDACTED]. Staff did not document that Prostat was administered on those dates. The Administrator reviewed the February 2011 MAR indicated [REDACTED] Resident #17 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review on 2/16/11 at approximately 12:25pm revealed a Physician's order for ""B/P (Blood Pressure) monitor and record before and after [MEDICAL TREATMENT]"". Review of the Medication Administration Record [REDACTED]. December's MAR indicated [REDACTED]. Interview with the Nurse Consultant at approximately 1:30pm indicated that the December MAR indicated [REDACTED]",2015-01-01
9670,UNIHEALTH POST ACUTE CARE OF MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2011-02-16,322,D,0,1,R8RS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation and interview, the facility dfailed to administer Resident # 3's gastric feeding as ordered. (One of three sampled residents reviewed for enteral feedings.) The findings included: The facility admitted Resident #3 on 12/28/10 with [DIAGNOSES REDACTED]. Record review on 2/15/11 revealed a physician's orders [REDACTED]. Observation of Resident #3 on 2/14/11 at 5:38 PM, 2/15/11 at 11:15 AM, 4:15 AM, and 6:00 PM revealed Glucerna 1.5 infusing at a rate of 60 ml/hour. Per Registered Dietician's recommendation dated 1/31/11, Resident #3 was to receive Glucerna 1.5 at 65 ml/hour which would give the resident 2340 kcal/day. At the rate of 60 ml/hour, Resident #3 received 180 kcal less per day than recommended. During an interview with the Administrator on 2/15/11 at 6:00 PM, after observing Resident #3's tube feeding, she confirmed that the tube feeding was not infusing at the physician's orders [REDACTED].",2015-01-01
9671,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,225,D,0,1,5MWX11,"On the days of the survey, based on record review and staff interview, the facility failed to report alleged violations of abuse and/or misappropriation of funds for 2 of 3 investigations reviewed for reporting. The findings included: On 2/1/2011 at 11:10 AM, the administrator was interviewed regarding abuse policies and procedures including reporting alleged incidents. The administrator stated that he followed the grid provided by certification on reporting incidents. The facility's Abuse Policy/Procedure stated under the section titled ""Reporting"" stated, ""The center must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the center and to officials in accordance with state law....(including to the state survey and certification agency)."" ""CMS believes ""immediately"" means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter time frame requirement."" The facility did not report the incidents to the appropriate state agencies within a 24 hour period. Review of the reported investigations included an investigation of misappropriation of resident property. On 4/1/2010, it was reported that a resident's cell phone was missing. On 4/2/2010 a family member reported that the cell phone had been stolen. The facility did not report the incident to the appropriate agencies until 4/5/2010. On 1/25/2010 a police detective reported to the facility that an allegation of abuse had been made to the police department. The facility reported the incident on 1/29/2011 as an injury of unknown origin.",2015-01-01
9672,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,253,E,0,1,5MWX11,"On the days of the survey, based on observations and staff interview, the facility failed to maintain a sanitary, orderly, and comfortable environment in resident rooms for 4 of 4 units. Rooms were noted to have peeling paint, scuff marks, and/or some areas of disrepainr. The findings included: On 1/31/2011 through 2/3/2011, residents rooms were observed to be in disrepair. A walk through of the building was done with the Maintenance Person on 2/3/2011 from 9:30 AM until 11:30 AM. The Administrator was present at intervals during the tour. On the 100 Hall, room 100 was observed to have scuffed and scraped walls. Room 101 had cracked, broken plaster and severely scarred walls. The bathroom contained a sliding mirror that could be pushed to the far right or left. When pushed to either side and not centered, the metal clips holding the mirror to the wall were open and exposed with sharp edges. Room 102 had a gouged hole behind the head of bed ""A"", which was visible over the head of the bed. There was a large hole in the plaster and the baseboard was loose. There was a sliding mirror in the bathroom of room 102 that could be moved far left or right of the mirror being centered. Leaving metal clips exposed. The threshold between the bathroom and the resident room was separated, leaving a gap in the floor between the two areas. Room 103 had holes in the wall behind the bed. The overhead light had been removed from where bed ""A"" would have been, leaving a large unpainted area. There were holes in the bathroom wall above the baseboard. The door frames were scraped of paint. Room 111 had peeling ceiling paint. On the 200 Hall, Room 201 had loose baseboard under the air conditioner with holes in the wall above the baseboard. There were scuff marks on the walls. The bathroom of 201 had scuff marks on the walls with chipped paint. The threshold of the bathroom was separated, leaving a gap in the floor between the two areas. Room 202 had loose broken baseboards. Room 203 walls were scuffed. There was loose (bulging) paint over bed ""B"". The walls in the bathroom were scuffed and scraped. There was a sliding mirror and the threshold was separated. Room 204 bathroom had a strip missing behind the sink and the sink was pulling away from the wall. Room 205 had scuffed walls with paint peeling off the wall at the head of the bed of bed ""A"". The ceiling over bed ""B"", had a large stained area. The Maintenance person identified the stain as a water stain. The bathroom had peeling caulking and a sliding mirror with metal clips. Room 206 wall was scuffed. There was a missing electrical cover next to bed ""B"". The bathroom had scuffed walls, a sliding mirror with metal clips and separated threshold. Room 207 had scuffed walls with a large gouged hole behind the head of the bed for bed ""A"". There were holes in the wall next to the window. There was a brown discolored area at the head of bed ""B"". The threshold in the bathroom was separated leaving a gap between the areas. The bathroom walls were scuffed. Room 208 The threshold was separated. Room 209 had scuffed walls with holes in the wall behind the head of the bed of bed ""B"". The air conditioner cover was loose, not securely on. Room 210 there were holes in the wall at the head of the bed of bed ""A"". The baseboard was missing in front of bed ""B"". The wall under the bathroom sink had plaster exposed. The countertop for the sink had missing formica. Room 211 had scuffed walls. There were holes in the bathroom next to the mirror. There was a sliding mirror. The mirror, when slid from the center left exposed sharp edged metal clips.. The walls were scraped. Room 213 Air conditioner vents had missing pieces. There was chipped paint over bed ""B"". There was a brown substance on mirror. The hold bar had a brown stain. Room 214 had scuff marks on the bathroom walls. There was torn plaster by the air conditioner. There was plaster/mudding not sanded over the light. Room 215 bathroom had scuffed walls with peeling paint behind the light. The fastening ring was loose from the grab bar. The grab bar had exposed sharp edges that would normally be covered by the fastening ring. There was a brown substance observed on the sprayer. There was unsanded plaster/mudding around the soap dispenser. The sink was loose from the wall. Room 216 bathroom had patched areas that were not painted over. The walls were scuffed. There was a hole in the wall over head of the bed. The Maintenance person stated that the hole was caused by a trapeze. A grab bar ring was loose in the bathroom leaving exposed sharp edges that would have been covered by the ring. Room 217 the walls were scuffed and there was a slit in the wall left of the door. There was paint peeling over the overhead light. The light cover had chipped paint. The bathroom had scuffed walls. The sink was loose from the wall with a thick loose caulking. On the 300 hall, room 300 had a broken floor tile. Room 301 had wallpaper that was bubbled over the bed. The floor outside of the bathroom was very sticky, your shoes stuck to the floor. In the bathroom was a rolling mirror with metal clips. Room 305 had torn wallpaper over the head of the bed. The bathroom had patched areas that had not been painted. Room 306 had a stained ceiling over the bed that the Maintenance person identified as a water stain. Room On the 400 hall, room 401 had ceiling paint peeling. There were large areas of missing paint. The wallpaper at the head of the bed was torn. There was a chipped floor tile. Room 402 had paint off of the wall by the window. The bathroom floor had a lack stain. The threshold between the bathroom and room was pulling away leaving a gap between the two areas. Room 405 bathroom had a black stain around the toilet. There was a sliding mirror with metal clips. Room 408 had a cracked wall below the window. There was torn wallpaper at the head of the bed of bed ""A"" and bed ""B"". During the walk through, the Administrator stated that they plan to renovate the building this year. He was unable to give any specific time frames of when renovations were to be done. The Administrator presented a letter stating that the facility had contacted them on 1/12/2011. The facility was scheduled to be ""scoped"" (looked at) on February 8, 2011. There were no time frames as to when repairs/rennovations were to be done. During the walk through, the Maintenance person stated that all of the resident bathrooms contained the sliding mirrors.",2015-01-01
9673,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,280,D,0,1,5MWX11,"**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 revise/update a care plan for Resident #2 for falls for 1 of 15 residents reviewed. The findings included: The facility admitted Resident #2 on 7/11/08 with [DIAGNOSES REDACTED]. During review of the medical record on 1/31/2011, it was noted that the resident had sustained the Subdural Hemorrhage from a fall before admission. On 11/11/2010 the resident had a jerking motion and fell from her wheelchair. Review of the MDS (Minimum Data Set) signed off on 11/11/2010, had the resident scored as having had 2 falls either since admission or since the previous MDS. (MDS are completed every 90 days). The falls assessment dated [DATE] had the resident checked for being on Antipsychotics and Antidepressants. Under ""Disease and Conditions"" she was checked as having loss of arm or leg movement and [MEDICAL CONDITION]. The assessment had been checked ""no"" for care plan initiated or revised. Review of the care plan, dated with a target date of 2/19/2011, there was no care plan for falls, potential for falls or history of falls. The hospice Clinical Note-Nursing, dated 11/12/2010, was reviewed. Under the section titled, ""Alteration in Physical Mobility"", there was documentation ""fall high risk"". The physician's orders [REDACTED]. The care plan for ADL (Activities of Daily Living) had interventions for a high back wheelchair with a lap buddy, cushion and lateral supports. On 2/1/2011 at 9:45 AM, the resident was observed sitting in a reclined gerichair. The Director of Nurses (DON) was interviewed on 2/2/2011 at approximately 3:00 PM. The DON was asked why there was not a care plan for falls since the resident had had a history of [REDACTED].? The DON stated that the resident's condition had deteriorated and the resident wasn't at risk. The resident had a history of [REDACTED]. There was no care plan for the staff to follow for falls prevention.",2015-01-01
9674,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,322,D,0,1,5MWX11,"On the days of the survey, based on observation, interview and review of information provided by the facility, the facility failed to perform a gastrostomy tube flush per company policy for Resident # 7, one of two tube flushes observed. The findings included: On 2/1/2011 at 2:05 PM, LPN #1 administered Protein Powder mix through the resident's gastrostomy tube. LPN #1 followed the administration of the Protein Powder with 30 ml (milliliters) of water. The facility's policy for the procedure for the tube flush for Medication Administration was reviewed and the procedure stated, ""Flush tube with a minimum of 30 ml. of water.... instill each medication...... The nurse did not flush the gastrostomy tube before giving the Protein Powder. On 2/3/2010 at 11:00 am, the Nurse was interviewed regarding the tube flush. LPN #1 confirmed the preflush was not administered and stated, ""I know, I had the water with me. I forgot to give it."" The purpose of the tube flush was to keep the gastrostomy tube flowing freely and to prevent the tube from becoming clogged.",2015-01-01
9675,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,441,D,0,1,5MWX11,"Cn the days of the survey, based on observation, interviews and review of the facility's in-service entitled Infection Control-Cleaning Scissors , the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. During observation of Pressure Ulcer care, Licensed Practical Nurse (LPN) #2 failed to clean scissors prior to placing them in her pocket and exiting the room. The findings included: On 2/1/11 at 10:10 AM, during a wound care observation for Resident #9, LPN #2 cleaned her scissors prior to starting the treatment. She then had to exit the room to obtain a box of gloves. Prior to exiting the room, she placed the clean scissors in her uniform pocket. Upon re-entering the resident's room, LPN #2 used the scissors to cut a gauze wrap dressing from the resident's foot. After completion of the care, LPN #2 placed the scissors back in her uniform pocket without cleaning them. LPN #2 exited the room, went into the soiled utility room and them back to the Treatment Cart to sign the resident's treatment record. LPN #2 left the cart and went back to the nurses' station with the unclean scissors in her pocket. On 2/1/11 the surveyors observations were reviewed with the LPN, she did not dispute the findings. Review of the facility's inservice entitled Infection Control-Cleaning Scissors dated 1/18/2011 indicated that LPN #2 had attended the inservice.",2015-01-01
9676,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,505,D,0,1,5MWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to promptly notify the attending physician of the laboratory (lab) findings for a Urine Culture when ordered to do so. Resident #4's Urine Culture was not called to the physician as ordered. The findings included: Resident #4 had a physician's orders [REDACTED]. (physician)..."" The order also included [MEDICATION NAME] 500 milligrams (mg) now and [MEDICATION NAME] 250 mg. every day for 7 days. Review of the Nurses' Notes dated 5/21/2010 indicated that the nurses were aware of the order. The nurses' notes dated 12/22/2010 to 12/24/2010 contained no documentation of the physician being notified of the urine culture results. The lab results were received by the facility on 12/22/2010 with a negative result. The physician signed the lab sheet on 12/30/2010. On 2/1/11, in an interview with Registered Nurse #3, she verified that the lab results had not been called to the physician and that the results were not signed until 12/30/2010.",2015-01-01
9677,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,371,F,0,1,5MWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on observation and interviews, the facility failed to maintain sanitary conditions while serving meals from the tray line. The findings included: On 2/2/11 at 11:27 AM, Dietary Cook #1 stopped serving from the tray line, opened the oven door, placed an oven mitt over her left gloved hand, retrieved a container holding carrots and placed the container on the ledge of the steam table. She closed the oven door, removed the oven mitt from her gloved hand, served carrots from the container, replaced the oven mitt on her gloved left hand, re-opened the oven door and replaced the carrots in the oven. She then continued to serve meals from the tray line without changing her gloves or washing her hands. At approximately 11:29 AM, Dietary Cook #1 again stopped serving from the steam table, opened the oven door and retrieved a container of baked chicken with the oven mitt on her gloved left hand. After replacing the chicken in the oven and removing the oven mitt, Cook #1 then held the piece of chicken on the plate with her gloved left hand and used a pair of tongs in the right hand to break up the chicken without changing her gloves or washing her hands. When done, she then removed her left glove and applied a clean glove but did not wash her hands. At 11:32 AM on 2/2/11, the Food Service Director stated that foods were left in the oven to stay hot due to not having enough room on the steam table. Currently being held in the oven were carrots, baked chicken, pureed chicken and grilled cheese sandwiches. At 11:38 AM, when asked if she saw anything that would be cause for concern, the Registered Dietician, who had also been observing the tray line, did not voice any concerns regarding the tray line. When asked specifically, she did confirm that the cook had contaminated her gloves when retrieving items from the oven with the oven mitt over her gloves and should have changed her gloves. On 2/1/11 at approximately 9:30 AM, 2 bottles of Promote Nutritional Formula for Tube Feeding were noted with an expiration date of 12/1/2010 in the Nourishment Room on the [MEDICATION NAME] Unit. RN Unit Manager #1 confirmed the expiration date and that the formulas were for resident use. She stated that the Central Supply clerk was responsible for checking the Nourishment Room for expired Tube Feeding Formulas and other nutritional supplements. On 2/1/11 during the interview with the RN Unit Manager, the Central Supply Clerk stated that she checks the Nourishment rooms every two weeks and that the [MEDICATION NAME] Hall Nourishment room was scheduled to be checked on Friday 2/4/11.",2015-01-01
9678,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,504,D,0,1,5MWX11,"**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 ensure that all laboratory tests had a current physician order. The findings included: On 2/1/11 at 11:48 AM, record review revealed Resident #6 had a Sedimentation (Sed) Rate drawn on 1/17/11 and a Complete Blood Count (CBC) drawn on 1/24/11. No current order could be found on the record for these laboratory tests. On 2/2/11 at approximately 1:35 PM, review of laboratory test results for resident #10 revealed a PT ([MEDICATION NAME] Time)/INR (international normalized ratio) drawn 12/6/10. No order was found in the record, however an order was noted dated 11/15/10 changing the frequency of the PT/INR to every two weeks. Review of the Lab Book on 2/2/11 at 10:15 AM with RN Unit Manager #1 revealed the labs for Resident #6 were listed in the book and had not been removed/deleted/or otherwise noted not to be drawn. During an interview on 2/2/11 at 10:15 AM, RN Unit Manager #1 confirmed there was no order for these two tests. She stated that Resident #6 had been admitted to the hospital and that those labs had been ordered prior to his hospitalization . She further stated that upon return from the hospital all previous orders should be cancelled and that the Unit Managers were responsible for that task. At 2:15 PM on 2/2/11, RN Unit Manager #1 stated the Resident #10 was having a PT/INR drawn weekly. She stated when the frequency was changed to every two weeks, the December calendar for labs had already been written and that the calendars are sometimes written two months in advance. She stated that it should have been removed from the lab book when the order was received to change the frequency.",2015-01-01
9679,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,159,B,0,1,5MWX11,"On the days of the survey, based on record reviews and interviews, the facility failed to maintain a petty cash fund that was available to the residents seven days a week. The findings included: On 2/2/11 at 4:30 PM a review of the resident funds was done with the facility Payroll Clerk/ Human Resources Assistant. During the review, when asked how the petty cash for the residents was handled, she stated that the residents would come to her office and get the money that they needed. When asked if the funds were available on the weekends she stated no and that she had been employed at the facility for eleven years and there had never been a petty cash fund. During a review with the Administrator on 2/2/11 at 5:10 PM, he stated that there had never been a request for petty cash on the weekends except for about a year ago. He stated he just happened to be in the building on a weekend and a resident asked for cash from the petty fund and he was in the building to give it to him. He further stated that he was on call 24 hours a day, seven days a week and the staff knew that he would come in to get funds from the safe. When asked if that was posted in writing so all staff would know that process. the Administrator stated no.",2015-01-01
9680,PRUITTHEALTH NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-09-06,221,D,1,0,1SKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on observations, record review and interview the facility failed to ensure one of one resident reviewed with restraints had the necessary physician's orders [REDACTED]. Resident #2 was wearing bilateral mittens without a physician's orders [REDACTED]. The findings included: The facility admitted Resident #2 on [DATE] with a readmission on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #2 on [DATE] at 9:15 AM, revealed the resident in bed with bilateral hand mittens on. Review of the physician's orders [REDACTED]. No other orders were written related to the restraints. No orders were written to check and release the restraints. The restraints had not been added to the Medication or Treatment Records. Review of the Initial Assessment for Physical Devices revealed on [DATE] an assessment was completed for bilateral mittens and an anti disconnect device to trach. Review of the Care Plan dated [DATE] revealed it had been updated to include ""mittens to both hands for 48 hours, anti disconnect device applied"". During an interview on [DATE] at 9:30 AM, the Administrator confirmed the bilateral hand mittens and the anti disconnect device to the trach. During a follow up interview the Administrator confirmed the restraint order was for 48 hours only and the order expired on [DATE]. The Administrator stated that ,[DATE] was a Saturday and no administrative staff were in the building. She also stated that there was no system in place to catch those errors. The Administrator continued, and stated that the facility staff should have re-assessed the resident's need for a restraint, contacted the physician and obtained a new order for the restraints. The Administrator, Senior Nurse Consultant and the Unit I Manager all confirmed there was no monitoring or documentation of the restraints for Resident #2.",2015-01-01
9681,PRUITTHEALTH NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-09-06,328,D,1,0,1SKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on observations, record review and interview the facility failed to ensure one of three residents reviewed with tracheostomies received the necessary care and services. Resident #2 had a rubber band looped around [MEDICAL CONDITION] and enclosed suction circuit preventing the tubing from disconnecting. Certified Nursing Assistant (CNA#) #1 was observed to silence and reset a ventilator. The findings included: The facility admitted Resident #2 on 5/11/11 with a readmission on 9/1/2011 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. No other orders were written related to the use of a rubber band. The rubber band had not been added to the Medication or Treatment Records. Review of the Initial Assessment for Physical Devices revealed on 9/2/2011 an assessment was completed for bilateral mittens and an anti disconnect device to trach. Review of the Care Plan dated 6/2/2011 revealed it had been updated to include ""mittens to both hands for 48 hours, anti disconnect device applied"". Observation of Resident #2 on 9/6/2011 at 9:15 AM, revealed the resident in bed with bilateral hand mittens on. The resident'[MEDICAL CONDITION] observed to be dislodged approximately one inch. A rubber band was observed to be looped around the entire flange with part of the rubber band exposed to the resident's skin and stoma site. The other end of the rubber band was looped twice around the top of the suction circuit. During an interview on 9/6/2011 at 9:20 AM, Respiratory Therapist (RT) #1 stated that the rubber band had been placed by facility staff and was used as an ""anti-disconnect device"". Observation on 9/6/2011 at 9:30 AM, CNA#1 was observed to silence and reset Resident #2's ventilator. No Respiratory Therapist or Nurse was in the room at the time. The Administrator also witnessed CNA#1 silence and reset the ventilator. During an interview on 9/6/2011 at 9:40 AM, the Senior Nurse Consultant stated that the use of a rubber band was put in place for Resident #2 as an intervention to prevent her from dislodging [MEDICAL CONDITION]. She stated that there were no policies related to the use of a rubber band. During an interview on 9/6/2011 at 10 AM, the Respiratory Therapy Manager stated that the commercially available ""Stronghold Anti Disconnect Device"" did not fit the resident's type [MEDICAL CONDITION] that was why the rubber band was used. She stated that the rubber band was not an approved device and stated that there were no policies related to the use of rubber bands or any anti disconnect devices. During a telephone interview with the manufacturers of the [MEDICAL CONDITION], the Ventilator Tubing and the Suction Circuit, all stated that a rubber band was not an approved device to use. The clinician for the Suction Circuit stated that the safety hazards could be the breaking of the rubber band, inhalation of the rubber band, skin irritation and inability to mechanically ventilate in an emergency situation. During an interview on 9/6/2011 at 12:45 PM, the Pulmonology Consultant stated that the use of a rubber band was routine practice in the hospital. He stated that he was not aware of any safety issues and was ""perfectly acceptable"". He also stated that he was not aware of any policies, research or literature that spoke to the use and efficacy of the rubber band. During an interview on 9/6/2011 at 2:15 PM, the RT Manager stated that CNAs were trained in ""responding to alarms"". She confirmed however, that CNAs were not trained specifically on interpretation of ventilator alarms and how/when to silence and reset the alarms. The RT Manager stated that there were no policies in place related to CNAs managing/silencing alarms. During an interview on 9/6/2011 at 2:20 PM, the Administrator confirmed there were no policies in place related to CNAs silencing alarms or the use of any type of anti-disconnect devices. Review of the Shepard Center Home Ventilator teaching revealed instructions on how to use two rubber bands to prevent [MEDICAL CONDITION] from dislodging. The illustrations indicated that two rubber bands were to be used. One rubber band was to be looped through the [MEDICAL CONDITION] slit on each side. The rubber band was not to come in contact with the underneath side of the flange nor the resident's stoma site. The rubber bands were then to be crisscrossed over top of the tubing. The rubber bands were not twisted back on themselves and the crisscrossing method assured a quick release. The Administrator confirmed Resident #2's use of the rubber band was not utilized as depicted in the illustrations.",2015-01-01
9682,PRUITTHEALTH NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2011-09-06,490,E,1,0,1SKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on observations, record review, interview and review of the facility's policies and procedures, the facility's administration failed to ensure policies and procedures were in place related to anti-disconnect devices and related to CNAs silencing ventilators. The findings included: Observation of Resident #2 on 9/6/2011 at 9:15 AM, revealed the resident in bed with bilateral hand mittens on. The resident'[MEDICAL CONDITION] observed to be dislodged approximately one inch. A rubber band was observed to be looped around the entire flange with part of the rubber band exposed to the resident's skin and stoma site. The other end of the rubber band was looped twice around the top of the suction circuit. Observation on 9/6/2011 at 9:30 AM, CNA#1 was observed to silence and reset Resident #2's ventilator. No Respiratory Therapist or Nurse was in the room at the time. The Administrator also witnessed CNA#1 silence and reset the ventilator. During an interview on 9/6/2011 at 2:20 PM, the Administrator confirmed there were no policies in place related to CNAs silencing alarms or the use of any type of anti-disconnect devices. Cross Refer to F328 as it relates to the use of a rubber band as an anti disconnect device without the appropriate orders, monitoring or policies in place. Also as it relates to the facility's failure to assure only trained and competent staff interpreted, silenced and reset ventilators.",2015-01-01
9683,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2011-05-04,309,D,0,1,T5V311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled ""Protocol For [MEDICAL TREATMENT]"", the facility failed to provide necessary services to maintain the highest practicable physical well being possible for one of one residents reviewed for care and services related to [MEDICAL TREATMENT]. Vital Signs were not checked post [MEDICAL TREATMENT] and monitoring of the [MEDICAL TREATMENT] (catheter) for signs of infection or bleeding had not been documented for Resident #17. The findings included: The facility admitted Resident #17 on 4/1/05 and readmitted her on 11/8/10 with [DIAGNOSES REDACTED]. Review of admission physician's orders [REDACTED]. Review of Nurse's Notes dated 2/24/11 through 5/2/11 revealed multiple entries for the resident going out to [MEDICAL TREATMENT] and returning, however, vital signs post [MEDICAL TREATMENT] were documented only one time on 3/26/11 after the [MEDICAL TREATMENT] center had called reporting the resident had complained of pain. There was one mention of the [MEDICAL TREATMENT] on a note dated 4/26/11 that stated ""[MEDICAL TREATMENT] port intact no s/s (signs, symptoms) of infection"". No additional documentation in the Nurse's Notes for this time frame was found related to monitoring of the [MEDICAL TREATMENT]. Review of the ""T.P.R. (Temperature, Pulse, Respiration) CHART"" for Resident #17 for March 2011 revealed Resident #17's Vital Signs had been documented 7 times that month, with only 4 of those days being the days she dialyzed. There was no time documented as to when the vital signs had been checked. Review of the April 2011 ""T.P.R. CHART"" revealed vital signs had been documented for 4 days for that month. Review of the physician's orders [REDACTED]. Observation on 5/4/11 at 12:43 PM revealed the resident sitting in her chair. Licensed Practical Nurse (LPN) #2 showed the surveyor the resident's [MEDICAL TREATMENT] which was a catheter in her right upper chest. When asked, LPN #2 stated she checked the catheter 2-3 times a day for any bleeding, redness or swelling. During an interview on 5/4/11 at 1:20 PM, (LPN) #2 was asked where she documented the checks of the [MEDICAL TREATMENT]. She stated that this had never been placed on the Medication Record to be documented and that she thought ""you just know to do that"". She verified this was not documented on the Treatment Record or Medication Record. During this same interview the Wound Care Nurse stated that she thought that [MEDICAL TREATMENT] site checks had been documented on the Medication Record, but was corrected by LPN #2 who said they hadn't. According to LPN #2, the nurse's only document if something is wrong with the catheter. She stated that if she is in the room doing something she would look at the access site. She stated that vital signs are checked once weekly and as needed, but not routinely after [MEDICAL TREATMENT]. She also stated that the nurse's do body audits weekly and the CNA's (Certified Nursing Assistants) dress the resident daily. During the interview, the Wound Care Nurse stated she looked at the [MEDICAL TREATMENT] daily when she did the Gastrostomy tube dressing change, but stated she did not document that she looked at this. She provided ""Daily/Weekly/Monthly Body Audit and Hydration Report(s)"" for Resident #17 for February through April 2011 that contained a notation that the [MEDICAL TREATMENT] port was ""OK"" or ""WNL"" (within normal limits) on 2/28/11, 3/26/11, and 4/14/11. When asked about communication between the [MEDICAL TREATMENT] center and the facility, LPN #2 stated they communicate by phone or the [MEDICAL TREATMENT] center would send orders via the ambulance personnel at times. She stated any communication would be documented in the Nurse's Notes. During an interview on 5/4/11 at 2:15 PM, the Director of Nursing (DON) stated the facility nurses send a communication request with the resident to the [MEDICAL TREATMENT] center, but stated these had not been filled out and returned by the [MEDICAL TREATMENT] facility. She provided a blank form for review. The form stated ""Request: That the attached communication record be completed with each resident's visit to your Center. The requested information will assist us in providing adequate treatment and follow-up on the plan of care for residents being dialyzed"". She stated that their dietician also worked at the [MEDICAL TREATMENT] center and that they couldn't get the [MEDICAL TREATMENT] center to fill out and return the communication form. Review of the ""Protocol for [MEDICAL TREATMENT] on 5/4/11 revealed the following: ""...2. A [MEDICAL TREATMENT] Communication Record is initiated and sent to the [MEDICAL TREATMENT] Center with each appointment; ensure that it is reviewed upon return. Observe the shunt or access site and document findings prior to transportation to Center..., 4. Instruct nursing staff on the site precautions to include the following measures: .... Catheter and Internal Port Devices ...d. It is important to make sure catheter clamps are clamped and end caps are on securely when not dialyzing, ...6. Assess for sign of infection, including redness, swelling, increased tenderness, and drainage at access site, ...Post-[MEDICAL TREATMENT]- Ongoing Care 1. Check for the following: a. Status of shunts, fistula, graft or cannula site dressing"".",2015-01-01
9684,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2011-05-04,371,F,0,1,T5V311,"On the days of the survey, based on observation and interview, the facility failed to store, prepare, distribute and serve foods under sanitary conditions. The findings included: On 5/4/11 at 11:50 AM, food temperatures were taken with the Certified Dietary Manager (CDM) and the cook. It was observed that 3 trays contained individual plates of previously cooked chicken patty sandwiches wrapped with saran wrap, were placed on top of the oven and steamer. A packet of mayonnaise was on each plate. The temperature of the chicken patty was 98 degrees Farenheit when checked. Three wrapped chicken patty sandwiches were observed already on trays to be placed in tray cart. The CDM stated that they always microwave the sandwich before serving since they are not on the steam table. The sandwiches remained on top of the oven and steamer throughout the trayline service and the last chicken patty sandwich was served at 1:10 PM. The chicken patty sandwiches were microwaved before being sent but the chicken patty was not at the prior holding temperature prior to trayline service. On 5/4/11 at 12:30 PM. the cook was observed using a knife to cut up the chuckwagon beef patty for a mechanical diet and then used the same knife to cut up two chicken patty sandwiches. A dietary aide was observed emptying boxes of food by the coolers and then came over and touched the steam table without sanitizing her hands. A open tray cart with boxes of food stacked on top was emptied of the boxes and then two residen'ts trays were placed on the same cart to be delivered to resident's rooms. The cart was not sanitized before placing trays on the cart. The cook placed a soiled rag on an open cart next to a soiled plate and a soiled pan. The cook then took the soiled rag and wiped the side of a bowl of soup and then placed the soup on a tray to be served to a resident.",2015-01-01
9685,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2011-05-04,279,D,0,1,T5V311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to develop a care plan to address care concerns for Resident # 4 , with a positive lab result for [MEDICAL CONDITIONS]. ( One of eight sampled residents reviewed for care plans.) The findings included: The facility admitted Resident #4 on 3/18/11 with [DIAGNOSES REDACTED]. The resident had documented episodes of diarrhea and a stool specimen for [MEDICAL CONDITION] ([MEDICAL CONDITION]) was ordered by the physician to be done on 4/13/11. The culture was positive for [MEDICAL CONDITION]. The resident was moved to a private room and contact precautions ordered. Record review on 5/3/11 revealed no care plan had been initiated addressing the [MEDICAL CONDITION] or necessary transmission based precautions.. An interview with the DON (Director of Nursing) on 5/3/11 at 2:45 PM confirmed there was no care plan in the medical record. The DON also checked with the Care Plan Coordinator who also confirmed no care plan had been developed related to the [MEDICAL CONDITION].",2015-01-01
9686,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2011-05-04,492,D,0,1,T5V311,"On the days of the survey, based on personnel record review and interview, the facility failed to obtain a license check for a Licensed Practical Nurse prior to the nurse clocking in for orientation and or work. ( 1 of 2 personnel folders checked for licensure checks.) The findings included: Review of personnel folder for LPN #1 (Licensed Practical Nurse) on 5/4/11 revealed no documentation (print out) from the S.C. (South Carolina) Board of Nursing that a license check had been performed by the facility. A sheet was later located that documented the Board was contacted by phone to verify license on 2/22/11. However, the DON (Director of Nursing) and staff person who checks licenses, verified that LPN #1 had a hire date of 2/21/11 and did clock in on that day for orientation, prior to the license check.",2015-01-01
9687,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2011-05-04,514,D,0,1,T5V311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to accurately document for 1 of 14 sampled residents reviewed for clinical record accuracy. Resident #8's clinical record indicated the resident wanted both CPR (Cardiopulmonary Resuscitation) and also DNR (Do Not Resuscitate). The findings included: The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a ""RESIDENT/FAMILY CONSENT FOR CARDIOPULMONARY RESUSCITATION"" (CPR) form dated [DATE] that indicated the resident requested CPR. There was a section checked that indicated ""I understand that CPR constitutes an extraordinary measure and SHOULD be done on"" resident. Further record review revealed a written physician's orders [REDACTED]. An interview on [DATE] at approximately 2:15 PM with (LPN) Licensed Practical Nurse #2 revealed residents that requested DNR's would have a red dot on the binder of their medical record, have a red dot on the door next to their name and have the ""RESIDENT/FAMILY CONSENT FOR CARDIOPULMONARY RESUSCITATION"" form completed to indicate ""I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on "" the resident. After showing LPN #2 the physician's orders [REDACTED]. An observation and interview on [DATE] at approximately 2:20 PM revealed there was no red dot on the door next to the resident name and no red dot documented/noted anywhere on the resident's medical record. When interviewed the resident stated ""I want extraordinary measures to be put in place"" when asked about her understanding of CPR. An interview on [DATE] at approximately 2:55 PM with the (DON) Director of Nursing revealed the DNR order was written in error and the resident was a full code. The DNR order was discontinued on [DATE].",2015-01-01
9688,LIFE CARE CENTER OF COLUMBIA,425337,2514 FARAWAY DRIVE,COLUMBIA,SC,29223,2011-09-29,157,D,1,0,ETHP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, the facility failed to notified the resident's responsible party of the development of pressure ulcers for 1 of 3 residents reviewed who had pressure ulcers (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessments of 6/29/11 and 9/18/11 showed the resident required extensive assistance for bed mobility, dressing, eating, and hygiene. The resident needed total care for transfers and bathing. She was incontinent of bowel and bladder. Review of the medical record revealed the resident had a Stage II ulcer on her sacrum at admission. Both heels were noted to be soft and mushy. There was a discolored area on the inner aspect of the left foot. The resident's family was at the bedside during the assessment and were aware of the skin problems. The sacral ulcer healed by 7/19/11. Review of the Pressure Ulcer Status Record, Nurse's Notes, and Telephone Orders revealed the following information: The resident developed a new ulcer on her left inner ankle on 7/6/11. There was no evidence in the medical record showing the family was informed of the area or of the treatment being provided. This area was deemed healed on 7/19/11. On 7/26/11, a Stage II ulcer was found on the resident's right heel, and on 8/15/11 a Stage II ulcer was noted on the resident's left heel. Record review showed no evidence of family notification.",2015-01-01
9689,GHS LAURENS COUNTY MEMORIAL SUBACUTE UNIT,425369,22725 HIGHWAY 76 EAST,CLINTON,SC,29325,2011-08-23,371,F,0,1,IIX011,"On the days of survey, based on observation and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Food items were not labeled, dated or stored appropriately. Cleanliness, glove, hair/beard restraint and handwashing concerns were identified. The findings included: On 8/23/11 at 9:15 AM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). Two pans of raw meat were observed next to a pan of cooked macaroni and cheese in the Walk in Cooler. A pan of raw meat dated 8/17 was next to a bag of vegetables. A pan of hamburger patties on a tray cart were observed above a pan of uncovered cooked macaroni and cheese. The pan of hamburger patties was not labeled or dated. In the Walk in Freezer had a opened frozen pie not dated. Ice was observed on the floor of the Walk in Freezer on both sides. The slicer blade was soiled on the inside blade and on the guard. The CDM stated that the slicer is suppose to be cleaned after each use. The can opener was dirty and not being used at the time. There was a hole observed in the wall behind the dish machine. On 8/23/11 at 10:30 AM, during the observation of obtaining food temperatures, the plate warmer was observed to be soiled. On 8/23/11 at 11:00 AM,a tray line observation was conducted. Cook #1 was observed picking up trash off the floor with gloved hands and touching the trash can lid to throw the trash away. The cook then removed his gloves and without cleansing hands, placed new gloves on. Cook #1 began slicing apple rings, using his gloved hand to touch apples. He then took a dirty cutting board into dish area, removed the gloves, and again reapplied new gloves. Cook # 1 was observed touching raw hamburger meat with gloved hands, removing his gloves, placing new gloves on, touching raw chicken, removing gloves, placing new gloves on, touching bread and turkey meat with gloved hands. Cook #1 did not wash his hands between glove changes at any time. Cook #2 was observed to have 2-3 inches of facial hair hanging from his chin while he prepped food and did not have a beard guard on. A dietary staff member had the back of her hair in a hairnet but the front of her hair was uncovered while she was prepping food. On 8/23/11 at 11:30 AM, Cook #1 was observed entering the kitchen, he went straight to the tray line and began serving trays. He removed gloves to answer the phone and then placed new gloves on and continued serving trays. On 8/23/11 at 2:00 PM, an interview with the CDM was conducted who confirmed all findings.",2015-01-01
9690,GHS LAURENS COUNTY MEMORIAL SUBACUTE UNIT,425369,22725 HIGHWAY 76 EAST,CLINTON,SC,29325,2011-08-23,441,D,0,1,IIX011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired resident care products were removed from storage with other resident care products, available for resident use, in the facility's storage cabinets at the sink inside the Nurses Station. There was also no evidence that personal laundry had been hygienically cleansed for residents who had used facility laundry services. The findings included: On [DATE] at 12:02 PM, observation of the storage cabinets at the sink inside the Nurses Station revealed the following: - One DuoDerm Extra Thin Sterile Dressing expired ,[DATE] - One 760 milliliter (ml) Sterile Water for Inhalation, USP (United Stated Pharmacopeia), Non-Pyrogenic, expired ,[DATE]. During an interview on [DATE] at 12:46 PM, the Director of Nursing (DON) stated that Respiratory Therapy should be checking the respiratory therapy supplies but did not know if they had a schedule. On [DATE] at 3:15 PM, a tour of the laundry room was conducted with the Environmental Services Manager (ESM). It was observed that the facility had one commercial washer and one dryer. The ESM stated that the washer uses LP2000 detergent and that they do not use destainer or other disinfecting product with personal clothing. The ESM stated that they do not check water temperature. He stated only their contract company checked the water temperature for the washer and it was done quarterly. The last statement provided by the company was dated [DATE] with a wash temperature of 149 degrees Fahrenheit. The ESM stated that the washer was suppose to be a high temperature machine but he had no documentation to show water temperatures reached that level.",2015-01-01
9691,GHS LAURENS COUNTY MEMORIAL SUBACUTE UNIT,425369,22725 HIGHWAY 76 EAST,CLINTON,SC,29325,2011-08-23,456,D,0,1,IIX011,"On the days of the survey, based on observation and interview, the facility failed to maintain essential equipment in safe operating conditions, pertaining to the dryer lint collector. The findings included: On 8/23/11 at 3:15 PM, a tour of the laundry room was conducted with the Environmental Services Manager (ESM). It was observed that the lint filter and the inside compartment was completely covered with lint. The ESM stated that the lint collector should be cleaned daily but confirmed it had not been cleaned like it should have been.",2015-01-01
9692,GHS LAURENS COUNTY MEMORIAL SUBACUTE UNIT,425369,22725 HIGHWAY 76 EAST,CLINTON,SC,29325,2011-08-23,502,D,0,1,IIX011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on observation and interview, the facility failed to ensure that expired laboratory items were removed from storage among the other laboratory supplies for 1 of 1 units observed. The findings included: During random observations on [DATE] at 12:00pm, the storage cabinets located outside the medication room revealed expired laboratory supplies: -Marquest Quick Arterial Blood Gas (A.B.G.) 6- dated ,[DATE] 1- dated ,[DATE] 3- dated ,[DATE] -Mucus Specimen Trap 80cc 2- dated ,[DATE] 2- dated ,[DATE] 1- dated ,[DATE] 1- dated ,[DATE] During an interview on [DATE] at 12:45pm, the Director of Nursing (DON) revealed that the expired laboratory supplies belonged to the Respiratory department and she was not aware if the department had a schedule for checking their expired supplies. She then stated that she did not feel that her staff was responsible for checking the Respiratory department supplies for expired items.",2015-01-01
9693,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2011-08-03,309,D,0,1,G5MQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review, interview, and documentation, the facility failed to provide necessary services to attain the highest practicable physical well-being for 1 of 1 residents reviewed with an implantable Cardioverter-defibrillator (Resident #6) The findings included: The facility admitted Resident #6 on 6/21/11. review of the resident's medical record revealed [REDACTED]. (ICD) placement"" done 1/4/10. There was no other documentation of the ICD in the record. A request for further information was made to the Director of Nursing (DON) on 8/3/11 at 9:15 AM. Before exiting the facility on 8/3/11, the survey team was presented with a ""Policy and Procedure for Pacemaker/Defibrillator Review"" (no date), a ""Pacemaker Master List"" (no date), a physician's orders [REDACTED]. from the Heart Center 8/3/11.",2015-01-01
9694,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2011-08-03,315,D,0,1,G5MQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility policy titled Suprapubic Catheter Care, the facility failed to ensure appropriate treatment and services were rendered to prevent urinary tract infections for 1 of 1 resident observed for suprapubic catheter care .(Resident #1) The findings included: The facility admitted Resident #1 on 7/8/11 with [DIAGNOSES REDACTED]. Observation of suprapubic catheter care on 8/2/11 at 2:00 PM revealed Licensed Practical Nurse(LPN)#1 after donning her gloves, lowered the head of the bed. Using soapy water, LPN #1 cleansed around the catheter site and down the front of the catheter using small swiping motions, never changing the position of the washcloth. Using a second washcloth, LPN #1 repeated the the above and wiped up and down the front of the catheter without changing the position of the washcloth. The suprapubic catheter was not anchored during either time during the cleansing process. LPN #1 bagged the linen and tied the bag, removed her right glove, re-gloved the right hand (which was obtained from her right front pocket), helped the resident with his pants, and elevated the head of the bed. LPN #1 took the basin into the bathroom and during the rinsing of the basin, turned the light on, then dried the basin, and placed the basin in the resident's closet. LPN #1 then removed her gloves, washed her hands, and placed the linen in the soiled utility. During an interview with LPN #1 on 8/2/11 at 3:00 PM, when asked if she could think of any concern the surveyor had during the care, she stated that she had not cleaned the overbed table off. During the interview, the surveyor shared the above findings. Review of the facility policy titled Suprapubic Catheter Care listed the following: ""6. Wash around the catheter site with soap and water. Wash the outer part of the catheter tube with soap and water. 7. Pour wash water down the commode. Flush the commode. 8. Discard soiled linen in designated container. 9. Discard disposable items into designated containers. 10. Remove gloves and discard in designated container. Wash and dry your hands thoroughly. 13. Reposition the bed covers. Make the resident comfortable. 15. Clean wash basin and return to designated storage area. 16. Clean the bedside stand and/or overbed table. 17. Wash and dry you hands thoroughly."" .",2015-01-01
9695,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2011-08-03,333,D,0,1,G5MQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and information provided by Network Healthcare titled ""Insulin PEN Administration"", the facility failed to ensure that residents remained free of significant drug errors for 1 of 2 residents reviewed with insulin pen administration.(Resident #9) The facility failed to administer a [MEDICATION NAME] pen in an appropriate manner. The findings included: The facility admitted Resident #9 on 6/9/11 with [DIAGNOSES REDACTED]. During observation of medication pass on 8/2/11 at 8:32 AM, Licensed Practical Nurse(LPN) #2 was observed to pull a [MEDICATION NAME] pen and prime the pen. After administering the [MEDICATION NAME] 20 units to Resident #9, LPN #2 immediately removed the insulin pen. Review of the Network Healthcare information titled ""Insulin PEN Administration"", revealed when administering [MEDICATION NAME]([MEDICATION NAME]) insulin, leave the needle in your skin for 10 seconds before removing it. During an interview on 8/2/11 with LPN #2, she stated that when using an insulin pen, you needed to prime the pen. When LPN #2 was asked was there a time frame for leaving the needle inserted when administering the insulin, she stated that she could not remember.",2015-01-01
9632,LAUREL BAYE HEALTHCARE OF GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2011-10-19,225,D,1,0,PK5911,"**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 assure a reportable incident was reported to the State Survey and Certification Agency. Resident #17's physician ordered side rails was left down and the resident fell out of bed and sustained a [MEDICAL CONDITION]. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed Resident #17 scored a BIMS of ""3."" The resident was coded as requiring extensive two person assistance for bed mobility and total dependence for transfers and locomotion. Review of the Care Plan revealed Resident #17 was care planned to have full padded side rails up to define bed parameters and poor safety awareness. Review of the Certified Nursing Assistant (CNA) Care Plan revealed ""Padded SR (side rails)."" Review of the Incident Report dated 8/6/11 at 12:15 AM revealed ""called to room, resident laying on floor in between the two beds on R (right) side, back leaning up against end table. Laceration to R eyebrow area. Unable to do ROM (range of motion), resident yelling No don't do that."" Resident #17's left side rail had been left down. Review of the facility's investigation revealed CNA #1 left Resident #17's side rail down during his last rounds between 10 and 11 PM. During an interview on 10/17/11 at 4:50 PM, the Unit 2 Manager stated that she investigated Resident #17's fall. She stated that Resident #17's roommate reported that CNA #1 left the side rail down. She stated that she interviewed CNA#1 and he denied letting the side rail down even to perform care. The Unit Manager stated that CNA #1 had recanted that statement and stated that he did leave the side rail down. Review of the facility obtained statement dated 8/8/2011 from LPN (Licensed Practical Nurse) #1 revealed: ""heard yelling, I was called to (Resident #17's room) by CNA, noted resident on floor between bed's on her R(ight) side, back up against end table. Side rail towards window was noted down. Laceration to R eyebrow area. Called Dr, 911 and family. Out to ER for eval and possible sutures to R eyebrow. Witness side rails up x 2 between 9 and 10 PM. During an interview on 10/17/11 at 5:15 PM, LPN #1 confirmed her statement above. She also stated that she was working 7PM-7AM on 8/5-8/6/2011. She stated she passed medications to Resident #17 between 9 and 10 PM and both side rails were up. LPN #1 stated that CNA #1 made his last rounds between 10 and 11PM and he was the last person to perform any care to Resident #17. During an interview on 10/17/11 at 5:25 PM, LPN #2 stated that she informed CNA#1 to not let Resident #17's side rails down for meals. She stated that CNA #1 was not familiar with Resident #17 and felt that it was safer to leave the side rails up. She stated that it would be normal practice to let the side rails down with care and then put them back up when finished. Review of the facility obtained statement dated 8/5/2011 revealed CNA #1 documented: ""I was told throughout shift by (LPN #2) to never let (Resident #17's) side rails down. (LPN#2) helped me pull her up and set her tray up. At 10:00 PM maybe a few minutes before, I changed her and the side rails were up."" During the survey multiple attempts to contact CNA #1 were made without success. During an interview on 10/17/2011 the DON (Director of Nurses) and Clinical Nurse Consultant stated that the incident had been reported to licensure but had not been reported to the State Certification Agency. The DON stated that she did not report the incident because she knew how the fall occurred therefore the fracture was not of unknown origin. The DON and Clinical Nurse Consultant stated that CNA #1 resigned on 8/24/2011. Both stated that he recanted his statement and admitted that he did leave the side rail down the night Resident #17 fell and fractured her femur. The DON confirmed that she did not report the neglect of CNA#1 (knowingly leaving the side rail down). The DON confirmed that it was neglect and should have been reported to the State Certification Agency.",2015-02-01
9633,LAUREL BAYE HEALTHCARE OF GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2011-10-19,226,D,1,0,PK5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, the facility failed to implement their Abuse/Neglect Policy. The facility failed to report an incidents of neglect to the appropriate State Agency. Resident #17's side rail was left down, the resident subsequently fell resulting in a fracture. The findings included: Cross Refer to F 225 as it relates to the facility's failure to report an allegation of neglect. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed Resident #17 was care planned to have full padded side rails up to define bed parameters and poor safety awareness. Review of the Certified Nursing Assistant (CNA) Care Plan revealed ""Padded SR (side rails)."" Review of the Incident Report dated 8/6/11 at 12:15 AM revealed ""called to room, resident laying on floor in between the two beds on R (right) side, back leaning up against end table. Laceration to R eyebrow area. Unable to do ROM (range of motion), resident yelling No don't do that."" Resident #17's left side rail had been left down. Review of the facility's investigation revealed CNA #1 left Resident #17's side rail down during his last rounds between 10 and 11 PM. Review of the facility's policy on Abuse and Neglect revealed: ""The facility will conduct an investigation of any alleged abuse/neglect misappropriation of personal property in accordance with state law. The facility will report all investigations findings to the state agency as per state regulations."" During an interview on 10/17/2011 the DON (Director of Nurses) and Clinical Nurse Consultant stated that the incident had been reported to licensure but had not been reported to the State Certification Agency. The DON confirmed that she did not report the neglect of CNA#1 (knowingly leaving the side rail down). The DON confirmed that it was neglect and should have been reported to the State Certification Agency.",2015-02-01
9634,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2011-10-12,323,G,1,0,B2LO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on observations, record review and interview, the facility failed to ensure 2 of 5 sampled residents received the necessary care and services to prevent accidents. Resident #1 fell on [DATE] and sustained a hip fracture, wrist fracture and a hematoma to the head. Resident #1 did not have her alarm on (the resident had a history of [REDACTED]. Resident #1 also did not have an ordered abduction pillow in place. Resident #4 with a history of removing her clip alarm, fell on [DATE] and sustained a hip fracture. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observations of the resident on 10/12/2011 revealed the resident was up in a reclining gerichair. A soft cast was in place from above her elbow to her fingers on her right arm. No abduction pillow was observed to be in place. Observation of the resident's room revealed an abduction pillow in a chair. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ""1"" on her BIMS Score. Resident #1 also required extensive one person assistance for bed mobility and transfers. Resident #1 did not ambulate and was able to self propel her wheelchair. Review of the Care Plan dated 7/27/2011 revealed a problem area of falls related to poor safety awareness. Approaches included: ""bed sensor alarm, provide frequent reminders to resident to call for assist prior to attempts to get up."" The care plan was updated on 8/12/2011 with wheelchair alarm (clip). Again on 8/29/2011 with lap cushion in w/c (wheelchair) and on 10/7/2011 the care plan was updated to include abduction pillow at all times. The resident continues to have the same clip alarm that the facility was aware she could remove. The Care Plan did not include any interventions for safe sitting when not in the wheelchair. Review of the Physical Device Data Collection Form dated 8/25/2011 revealed Resident #1 had a lap cushion ordered for the following symptoms: ""weakness"", ""leaning"", ""poor safety awareness"" and ""leans forward excessively."" The lap cushion's ""reason for use"" was: ""support, enhance mobility, improve quality of lift, improve physical status, promote calming effect, able to participate in activities and aides c (with) sitting upright."" Review of the Nurse's Notes revealed on 8/8/2011 ""occasionally self transfers."" On 8/8/2011 at 9 PM, Resident #1 was found sitting on the floor in another resident's room with the tab alert alarm sounding. On 8/14/2011 the resident slid from the wheelchair and sustained abrasions and bruising to bilateral arms. On 8/23/2011 at 3:25 PM, Resident #1 was found on the floor at the nursing station, she complained of pain and was sent out to the emergency room . All tests were negative. On 9/4/2011, ""frequent attempts to self ambulate."" On 9/23/2011 at 6:15 PM, ""(up) to w/c (wheelchair). Alarm intact, res(ident) makes multiple attempts to stand unassisted. Res frequently reminded to sit down. At 7:35 PM, ""resident stood up unassisted from couch and fell on to R (right) side, striking temporal area on floor. 3 cm (centimeter) x 2 cm x 1.5 cm purple hematoma evident. (Responsible Party and Provider) aware and NO (new order) received to transport to ER (emergency room ) for eval (evaluation) and treatment of [REDACTED]. Review of the September 2011 physician's orders [REDACTED]."" Review of the Re-admission orders [REDACTED]. Resident #1 was ordered a reclining gerichair for comfort. On 10/4/2011 an order was written for ""abduction pillow at all times."" Review of the Accident/Incident Report dated 10/3/2011 revealed Resident #1 was last observed sitting on the couch by the nurse's station. The resident ""attempted to stand/ambulate unassisted, fell . Subsequent x-rays revealed comminuted right femoral intertrochanteric fx (fracture) with associated deformity. X-rays also revealed non displaced comminuted fx of distal right radius and ulnar styloid process."" The resident also sustained a hematoma to the right temporal area. ""Resident unable to give account of incident due to dx (diagnosis) of dementia. The cause of the incident was: ""resident with decreased safety awareness, and poor judgment r/t (related to) dx dementia, attempted to stand/ambulate unassisted and fell . Resident also had generalized weakness (secondary to) multiple health issues and gait is unsteady. Resident had dx osteoporosis and history of pathological fractures. Resident had removed alarm."" The preventative actions taken were: ""resident's safety needs to be evaluated upon return to the facility."" Review of the facility obtained statement from Licensed Practical Nurse (LPN) #1 revealed, ""when I arrived to work at 6:45 PM, (Resident #1) was sitting on couch c (with) alarm intact, although res was self removing the alarm and re attaching the magnet. I was standing at med cart in view of resident and assisted her to a sitting position approximately 6 or more times. I then received a phone call regarding a resident who was short of breath, in turn I went immediately to assess that resident. I was notified (by another resident) that a resident had fallen, then I went to check on said resident. In front of couch lying on right side was (Resident #1). Upon assessment I noticed a raised hematoma to right temporal area. I called out for help... 911 transport arrived and transported resident to ER."" During a telephone interview on 10/12/2011 at 2:35 PM, LPN #1 confirmed her above statement. She stated that when she arrived to work and received report, Resident #1 was sitting on the couch. She stated that the alarm was present but the resident was removing the alarm. LPN #1 confirmed again that the resident had a history of [REDACTED].#1 stated that Resident #1 on 9/24/2011 was restless and was constantly standing up unassisted. She stated that she received a call about another resident and left the nurses station. She stated that she was notified that a resident had fallen. LPN #1 stated that she found Resident #1 lying on her right side in front of the couch. She stated that the alarm was not on. LPN #1 also stated that the resident's lap cushion was not in use while she was sitting on the couch. LPN #1 then stated that it was common for the resident to sit on the couch. Review of the facility obtained statement from LPN #2 revealed, ""On Saturday, September 24, 2011, (Resident #1) was frequently standing up from her w/c (wheelchair), removing her chair alarm and attempting to seat herself on the couch. Every time that resident stood up and set off her alarm I seated her and reminded her not to stand (without) assistance. I told resident she was going to fall and get hurt if she kept standing without assist..."" LPN #2 was unavailable for interview during the survey. Review of the facility obtained statement from Certified Nursing Assistant (CNA) #1 revealed, ""I (CNA #1) was in the restroom and came out, the nurse was asking me to help get a resident off the floor. We got her to bed and I got her vital signs for the nurse."" During an interview on 10/12/2011 at 3:10 PM, CNA #1 stated that she worked 3-11 shift on 9/24/2011. She stated that she was assigned to Resident #1. CNA #1 stated that Resident #1 had been up and down all day and was restless and fidgety. CNA #1 stated that Resident #1 was sitting on the couch with her clip alarm attached. CNA #1 then stated that Resident #1 was able to remove her alarm and did so on previous occasions. CNA #1 stated that the lap cushion was not in use while the resident was sitting on the couch. She stated that her lap cushion and wheelchair were in front of the bird cage next to the couch. During a telephone interview on 10/12/2011 at 2:20 PM, the Responsible Party stated that he was informed that Resident #1 had fallen from the couch on 9/24/11. He stated that he was unsure why his mother would be on the couch and not in her wheelchair with her ""restraint."" He then stated that Resident #1 was able to remove the lap cushion. During an interview on 10/12/2011, the Physical Therapist (PT) confirmed Resident #1 did not have an abduction pillow in place. She also confirmed the physician's orders [REDACTED]. The PT stated that Resident #1 was not on hip precautions and did not need the abduction pillow. She confirmed that the order had not been changed and was not followed. During an interview on 10/12/2011 at 5 PM, the Administrator and Director of Nurses both confirmed that Resident #1 had a lap cushion in use for positioning to prevent excessive leaning and falls. Both also confirmed that the resident could remove her clip alarm and did so frequently. The Administrator confirmed that the alarm type and not been changed to another type of alarm that the resident could not remove. Both stated that the resident frequently sat on the couch and would not have the ordered lap cushion in place. Both the DON and Administrator confirmed on 9/24/2011 the resident was sitting on the couch prior to the fall without the lap cushion and the resident had removed her alarm. Both confirmed that no staff member was in attendance at the time the fall occurred. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #4 received a BIMS Score of ""2"" Resident #4 was coded as requiring two person extensive assistance with transfers and was dependent for locomotion. Review of the Care Plan dated 7/21/2011 revealed the resident was at risk for falls. Approaches included ""7/28/2011, bed sensor alarm, 8/3/2011, low bed with mat, 8/25/2011 siderails as ordered, 9/15/2011 w/c alarm as ordered and 9/27/2011 med as ordered for Parkinson's."" Review of the Nurse's Notes revealed on 7/24/11 at 8 AM, called to room by CNA. Res sitting on floor beside bed. C/O (complains of) pain to right hip... (Resident #4) stated I was trying to get up and when I stood my feet slid out from under me. Abduction pillow lying on floor beside bed. I asked her how pillow got on floor and she stated I took it off and laid it there for a few minutes. Res bed alarm lying on bed and I asked her did she know what happened to it, why was it not still on her and she stated, well I had to take it off because I couldn't move... hip bone protruding out abnormally."" The responsible party decided not to surgically repair the fracture and the resident returned to the facility on hip precautions. The Responsible Party was unavailable for interview. Review of the Incident/Accident Report dated 7/29/2011 revealed the incident occurred on 7/24 at 8 AM. The description of the incident was: ""Resident removed her abduction pillow and had removed alarm, attempted to stand/ambulate unassisted, fell . Subsequent x-ray report showed proximal right femoral fracture. Review of the facility obtained statement, CNA #2 stated that on 7/24/11 at 6:40 AM, he was finishing rounds and was informed that Resident #4 had removed her clothes (and her alarm) and was standing naked beside her bed. She had a bowel movement... I cleaned her up and put fresh gown on her."" CNA #2 was unavailable for interview during the survey. Review of the facility obtained statement dated 7/24/2011 at 8 AM, LPN #3 documented: ""I was called to (Resident #4's) room and she was sitting on floor beside bed. She had removed her abduction pillow and it was on the floor. She had removed her bed alarm and it was lying on the bed. She stated to me when asked about the alarm and pillow that she moved them so she could get up. She stated that she got up and her feet slid out from under her. I asked her why she got up without ringing her call light, she stated I didn't know I was supposed to...."" LPN #3 was unavailable for interview during the survey. During an interview on 10/12/2011 at 5 PM, the DON and Administrator confirmed the written statements. The Administrator confirmed that the resident had a history of [REDACTED]. Both confirmed that no changes were made to the type of alarm or fall prevention devices prior to the resident's fall and subsequent fracture.",2015-02-01
9635,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-10-18,282,E,1,0,D16D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure 4 or 8 residents reviewed for smoking had their smoking care plans followed by facility staff. Resident #2, 3, 4 and 5 had cigarettes and/or lighters in their possession, inside the building when not smoking. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan dated 7/11/2011 revealed a problem area related to smoking was identified. Approaches included keeping smoking materials at the nurses' station. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Care Plan dated 5/27/2011 revealed the resident was to keep ""smoking materials at nurses' station or other designated area for storage."" The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Care Plan dated 5/16/2011 revealed the resident was to ""place smoking materials at nurses' station or other designated area for storage."" The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Interim Care Plan revealed Resident #5 was to keep ""smoking materials at nurses' station or other designated area for storage."" During initial tour of the facility on 10/18/2011 at 9 AM, Resident #2 and #3 were observed outside in the courtyard smoking without supervision. At 9:45 AM, Resident #2 and #3 were in their rooms. No cigarettes were returned to the nursing staff. No packs of cigarettes or lighters were observed in the medication room. Four cartons of cigarettes were observed in a cabinet. During an interview on 10/18/2011, the Unit One Manager stated that neither Resident #2 nor #3 had requested cigarettes even though they had been out to smoke that morning. She stated that only the nursing staff could give the resident's their cigarettes. The Unit One Manager was observed to ask Resident #3 where his cigarettes were, Resident #3 responded in his pocket. The Unit One Manager left the resident with his cigarettes and proceeded to Resident #2's room. Resident #2 stated that her cigarettes were in her housecoat that was laid across the chair in between the two beds. (Resident #2's roommate was in the bed). The resident stated that she forgot to give them to the nurse on her way back in from smoking. During an interview on 10/18/2011 at 10:30 AM, Registered Nurse #1 stated that she cared for Resident #4 and #5. She stated that she had not given out any cigarettes to any resident that morning. She then stated that she put Resident #4's cigarettes away ""just now."" She stated that he did not have a lighter and that he normally had one. RN #1 was asked how the resident lit his cigarette and she stated that he borrowed from another resident or staff member. During an interview on 10/18/2011 at 11:45 AM, Resident #3 stated that he still had his cigarettes and lighter in his pocket. He stated that he knew he was supposed to give them to the nurses but he does not give them back. He stated that the nurses keep his unopened packs and that he keeps the open pack and lighter. Resident #3 stated again that he kept the open pack of cigarettes and lighter at all times. During an interview on 10/18/2011 at 11:45 AM, Resident #5 stated that the Social Services Director took her cigarettes this morning because ""DHEC's (Department of Health and Environmental Control) in the building."" During an interview on 10/17/2011 at 12 PM, the Social Services Director stated that he did confiscate Resident #5's cigarettes. He also stated that he went to the 600 Unit to make sure Resident #6, 7, 8 and 9's smoking materials were locked up. The Director of Nurses joined the interview and stated that no resident is supposed to have smoking materials in their possession if they are not smoking. She stated that the nurses were to give the resident's cigarettes and lighters and it was the resident's responsibility to return the materials when they were done. During an interview on 10/18/2011 at 3:45 PM, the Administrator and DON confirmed that the care plans were not followed related to the storage of smoking materials. They also stated that no resident was to have smoking materials in their possession if they were not smoking. Both the Administrator and DON agreed that the deficient practice placed residents at risk.",2015-02-01
9636,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-10-18,323,E,1,0,D16D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure 4 of 8 residents reviewed for smoking returned their smoking paraphernalia to the designated person. Resident #2, 3, 4 and 5 had cigarettes and or lighters in their possession, inside the building when not smoking. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) revealed Resident #2 received a 15/15 BIMS score. The resident was noted to propel herself in the wheelchair. Review of the Smoking Evaluation dated 7/11/2011 revealed all "" yes "" was checked designating the resident was an ""independent smoker."" Further review revealed: ""... INTERDISCIPLINARY TEAM (IDT) DETERMINATION. If all the answers on the evaluation are YES, the patient is determined to be an Independent Smoker. If any of the answers on the evaluation are NO, the patient is determined to be an At Risk Smoker... Independent Smoker: Capable and independent, requires no supervision to smoke. At Risk Smoker: Requires staff, family, friend for physical support or supervision to smoke."" Review of Resident #2's Care Plan dated 7/11/2011 revealed a problem area related to smoking was identified. Approaches included keeping smoking materials at the nurses' station. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 13/15 on the BIMS. The resident was noted to propel himself in the wheelchair. Review of the Advance Directives revealed Resident #3 did not have Decisional Capacity due to Dementia. Review of the Smoking Evaluation dated 5/26/11 revealed Resident #3 received two ""NO"" answers. However, the resident was assessed to be an independent smoker. Another evaluation was conducted. No date and no signature were documented. The question: ""Patient Observation: Patient can demonstrate safe smoking techniques: holding cigarette, lighting cigarette, extinguishing matches, lighter and cigarette after use and disposal of ashes"" was not answered. Even though the assessment was incomplete, the resident was assessed as an independent smoker. Review of the Care Plan dated 5/27/2011 revealed the resident was to keep ""smoking materials at nurses' station or other designated area for storage."" The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #4 received a 15/15 on his BIMS score. Review of the Smoking Evaluation dated 5/16/2011 revealed the resident was assessed as an independent smoker. Review of the Care Plan dated 5/16/2011 revealed the resident was to ""place smoking materials at nurses' station or other designated area for storage."" The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Smoking Evaluation dated 10/12/2011 revealed Resident #5 had one ""NO"" checked. The resident was not ""able to make decisions regarding tasks of daily life, e.g. decisions are consistent and reasonable."" However she was still assessed as an independent smoker. Review of the Interim Care Plan revealed Resident #5 was to keep ""smoking materials at nurses' station or other designated area for storage."" During initial tour of the facility on 10/18/2011 at 9 AM, Resident #2 and #3 were observed to be outside in the courtyard smoking without any supervision. At 9:45 AM, Resident #2 and #3 were in their rooms. No cigarettes had been returned to the nursing staff. No packs of cigarettes or lighters were observed to be in the medication room. Four cartons of cigarettes were observed in a cabinet. During an interview on 10/18/2011, the Unit One Manager stated that neither Resident #2 nor #3 had requested cigarettes even though they had been out to smoke that morning. She stated that only the nursing staff could give the resident's their cigarettes. The Unit One Manager was observed to ask Resident #3 where his cigarettes were, Resident #3 responded in his pocket. The Unit One Manager left the resident with his cigarettes and proceeded to Resident #2's room. Resident #2 stated that her cigarettes were in her housecoat that was laid across the chair in between the two beds. (Resident #2's roommate was in the bed). The resident stated that she forgot to give them to the nurse on her way back in from smoking. During an interview on 10/18/2011 at 10:30 AM, Registered Nurse #1 stated that she cared for Resident #4 and #5. She stated that she had not given out any cigarettes to any resident that morning. She then stated that she put Resident #4's cigarettes away ""just now."" She stated that he did not have a lighter and that he normally had one. RN #1 was asked how the resident lit his cigarette and she stated that he borrowed from another resident or staff member. During an interview on 10/18/2011 at 11:45 AM, Resident #3 stated that he still had his cigarettes and lighter in his pocket. He stated that he knew he was supposed to give them to the nurses but he does not give them back. He stated that the nurses keep his unopened packs and that he keeps the open pack and lighter. Resident #3 stated again that he kept the open pack of cigarettes and lighter at all times. During an interview on 10/18/2011 at 11:45 AM, Resident #5 stated that the Social Services Director took her cigarettes this morning because ""DHEC's (Department of Health and Environmental Control) in the building."" During an interview on 10/17/2011 at 12 PM, the Social Services Director stated that he did confiscate Resident #5's cigarettes. He also stated that he went to the 600 Unit to make sure Resident #6, 7, 8 and 9's smoking materials were locked up. The Director of Nurses joined the interview and stated that no resident is supposed to have smoking materials in their possession if they are not smoking. She stated that the nurses were to give the resident's cigarettes and lighters and it was the resident's responsibility to return the materials when they were done. Both the DON and the SSD stated that the facility had only ""safe smokers"" currently and that no resident required supervision to smoke. During an interview on 10/18/2011 at 3:45 PM, the Administrator and DON confirmed the facility's system on Smokers was not implemented effectively. Both confirmed the assessments were not accurate for 2 residents and confirmed that 2 residents' assessments were greater than one year old. Both confirmed the facility's policy was not followed related to smokers. The Administrator and DON also confirmed that the care plans were not followed related to the storage of smoking materials. They also stated that no resident was to have smoking materials in their possession if they were not smoking. Both the Administrator and DON agreed that the deficient practice placed residents at risk. Review of the facility's policy on ""Smoking Guidelines"" revealed: ""Evaluate patients that smoke utilizing the Smoking Evaluation tool either: upon admission, when a previous non smoking patient takes up smoking, if unsafe smoking practices are observed in a current smoker, or when a patient that smokes has a significant change in medical condition... If the patient is determined to be an at risk smoker, the patient is required to wear a smoking vest or apron if needed and is supervised while smoking... Retention, storage and distribution of smoking accessories are to be kept under the control of center staff when not in use. This includes cigarettes, pipes, lighters, matches, lighter fluid etc. Staff members distribute smoking accessories to patients at center designated smoking times... Instruct patients, families and visitors not to share lighted cigarettes, lighters or other smoking accessories with other patients... Direct personal supervision is provided at all times to At Risk Smokers while smoking. Other patients cannot, under any circumstances, provide supervision to At Risk Smokers.""",2015-02-01
9637,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-10-18,278,D,1,0,D16D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure 2 of 8 residents reviewed for smoking had accurate assessments. Resident #3 and #5's Smoking Evaluation was inaccurate. The findings included: Review of the Smoking Evaluation Form revealed: ""...INTERDISCIPLINARY TEAM (IDT) DETERMINATION. If all the answers on the evaluation are YES, the patient is determined to be an Independent Smoker. If any of the answers on the evaluation are NO, the patient is determined to be an At Risk Smoker. Independent Smoker: capable and independent, requires no supervision to smoke. At Risk Smoker: requires staff, family, friend for physical support or supervision to smoke..."" The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 13/15 on the BIMS. The resident was noted to propel himself in the wheelchair. Review of the Advance Directives revealed Resident #3 did not have Decisional Capacity due to Dementia. Review of the Smoking Evaluation dated 5/26/2011 revealed Resident #3 received two ""NO"" answers. However, the resident was assessed to be an independent smoker. Another evaluation was conducted. No date and no signature were documented. The question: ""Patient Observation: Patient can demonstrate safe smoking techniques: holding cigarette, lighting cigarette, extinguishing matches, lighter and cigarette after use and disposal of ashes"" was not answered. Even though the assessment was incomplete, the resident was assessed as an independent smoker. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Smoking Evaluation dated 10/12/2011 revealed Resident #5 had one ""NO"" checked. The resident was not ""able to make decisions regarding tasks of daily life, e.g. decisions are consistent and reasonable."" However she was still assessed as an independent smoker. During an interview on 10/18/2011 at 3:45 PM, the Administrator and Director of Nurses (DON) confirmed the assessments were not accurate for the 2 residents. Both confirmed the facility's policy was not followed related to smokers. Both the Administrator and DON agreed that the deficient practice placed residents at risk.",2015-02-01
9638,INMAN HEALTHCARE,425122,51 N MAIN ST,INMAN,SC,29349,2011-09-07,371,F,0,1,2CD911,"On the days of the survey, based on observations and interview, the facility failed to label and date food items stored in the refrigerator. Ice cream cups were not stored an an appropriate temperature and were observed to be soft. The findings included: On initial tour of the facility's dietary department on 09/06/2011 at 11:15 AM with the Dietary Manager present, observation of the reach in refrigerator revealed a tray with several cups of thickened water, an assortment of juices and bowls of pureed dessert that were not labeled nor dated. Observation of the ice cream freezer on 09/06/2011 at 11:30 AM with the Dietary Manager, revealed cups of soft, mushy ice cream. The thermometer registered 20 degrees Fahrenheit (F). During a repeated observation on 09/06/2011 at 3 :00 PM, the ice cream cups remained soft and the thermometer registered 6 degrees Fahrenheit (F). The Dietary Manager did not dispute the above findings.",2015-02-01
9639,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2011-01-13,309,E,0,1,CL1611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to administer medications as prescribed by the physician for 1 of 1 residents reviewed with orders for [MEDICATION NAME] (Resident # 2) and 1 of 1 residents reviewed receiving [MEDICATION NAME]. (Resident # 9) The findings included: The facility admitted Resident # 2 on 11-20-05 with [DIAGNOSES REDACTED]. Upon viewing Resident # 2 during the initial tour on 1-12-11 at approximately 1:30 PM, this surveyor noted a large amount of drool on the clothing of the resident. Resident # 2 also had protective clothing to prevent soiling, which staff stated had been supplied by the resident's family. Subsequent review of the Medical Record revealed a physician's orders [REDACTED]. [MEDICATION NAME] Liquid 25 mg (milligrams) via PEG (gastric tube) @ HS (at bedtime)."" Review of the MAR (Medication Administration Record) for the months of September and October, revealed that the medication was only documented as having been administered on September 29th, and 30th. The order was not carried forward onto the October MAR, and there was no documentation that the order had been discontinued. On 1-12-11 at 3:30 PM, during an interview with Licensed Practical Nurse (LPN) # 3, she stated that Resident # 2 was not currently on [MEDICATION NAME], but that she had been receiving it prior to a hospitalization in September. Further chart review revealed Resident #2 was in the hospital from 8-31-10 to 9-3-10. During an interview with Resident # 2's Physician on 1-13-11 at approximately 1:45 PM, she stated that she was not aware that Resident # 2 was not receiving the [MEDICATION NAME] as ordered, and she would address the oversight immediately. The facility admitted Resident # 9 on 6-18-10 with [DIAGNOSES REDACTED]. Review of the Medical Record on 1-12-11 at approximately 3:45 PM, revealed that the resident had gone to the hospital for treatment of [REDACTED]. The hospital Discharge summary included the following statements (under hospital course): ""The patient's [MEDICATION NAME] levels were marginally elevated at 30.3."" Under Discharge Diagnoses: [REDACTED]. [MEDICATION NAME] toxicity. Recommendation is to recheck a [MEDICATION NAME] level in three days and hold [MEDICATION NAME] until then. The goal should be a [MEDICATION NAME] level of 15-20."" Under Follow-up: ""Follow-up [MEDICATION NAME] level in three days and I will continue [MEDICATION NAME] at a lower dose. Currently, the patient is getting [MEDICATION NAME] 100 milligrams in the morning and 200 milligrams at night. When trough goes below 20, I would probably resume [MEDICATION NAME] 100 milligrams p.o. (by mouth) twice a day. This is just a recommendation. "" The physician's orders [REDACTED]."" Further review of the medical records revealed that when Resident # 9 returned from the hospital on 1-4-11, there was no order for [MEDICATION NAME]. The MAR (Medication Administration Record) had the following order documented: "" Call [MEDICATION NAME] Level to MD for orders on 1-7-11."" The lab was drawn on 1-7-11 and the results ( [MEDICATION NAME] Level Total 16.5) were received by the facility on 1-7-11. During an interview with Licensed Practical Nurse (LPN) # 3 on 1-13-11 at approximately 11:45 AM, she stated that when she received the lab results, she gave them to the Physician's Nurse Practitioner, who was in the building at that time. No additional orders were given to the nursing staff at that time to restart the [MEDICATION NAME], or to order further lab tests. Also, there was no documentation that the nursing staff had voiced a concern to the Nurse Practitioner or the Physician related to the cessation of the [MEDICAL CONDITION] medication. The resident did not receive [MEDICATION NAME] or other [MEDICAL CONDITION] medication from 1-3-11 until after it was brought to the facility's attention on 1-12-11 by the surveyor. At that time, the Physician was notified, a new order for [MEDICATION NAME] was initiated and another lab test was ordered to be done in 1 week. During an interview with Resident # 9's Physician on 1-13-11 at approximately 1:05 PM, he stated that the [MEDICATION NAME] should have been restarted on 1-7-11 and that the Nurse Practitioner was probably not aware that the [MEDICATION NAME] had been put on hold. The Physician further agreed that since the [MEDICATION NAME] level had dropped from 30.3 to 16.5 after not taking the medication for 4 days, that the [MEDICATION NAME] level could have reached a dangerously low level before the medication was restarted on 1-12-11.",2015-02-01
9640,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2011-01-13,425,D,0,1,CL1611,"On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired medications were removed from storage with other medications, available for resident use, in 1 of 3 medication rooms. The findings included: On 1/13/11 at 9:38 AM, observation of the Piedmont (100 Hall) Medication Room revealed the following: -one box of 5 foil pouches (each pouch) containing six 3 milliliter (ml) vials of Ipratropium Bromide 0.5 milligram (mg) and Albuterol Sulfate 3 mg, Inhalation Solution, expired September 2010 -one box of 50 packets of Povidone - Iodine Swabstick's, expired 3/2010. During an interview on 1/13/11 at 10:14 AM, Licensed Practical Nurse (LPN) #2 revealed that the Pharmacist comes once a month and checks the medication room for expired products. The Assistant Director of Nursing did random checks and the Admissions Nurse also checked the medication room monthly.",2015-02-01
9641,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2011-01-13,441,D,0,1,CL1611,"On the days of the survey, based on observation and interview, the facility failed to ensure a Glucometer was cleaned with an appropriate solution before/after resident use. The findings included: On 1/12/11 at 4:25 PM, during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #1 was observed to do a finger stick blood sugar procedure on the resident. LPN # 1 removed a glucometer from the medication cart and cleaned it with an alcohol wipe. After performing the procedure, she replaced the glucometer in the medication cart without cleaning it. During an interview on 1/12/11 at 4:45 PM, LPN #1 was asked to explain her usual procedure for cleaning a glucometer. LPN #1 stated that she cleaned the glucometer with an alcohol swab before and after use on each resident. When asked when she would use the --- Sani-Cloth wipes (also observed on the medication cart). LPN #1 stated that she thought that alcohol wipes and --- Sani-Cloths were the same and either product could be used.",2015-02-01
9642,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2011-10-24,225,D,1,0,6NR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on review of the facility's investigative report of an allegation of abuse and interviews, the facility failed to ensure that all allegations of abuse were reported immediately to the Administrator and failed to report the allegation to the State survey and certification agency and Ombudsman within the allowed twenty-four hour time frame for 1 of 1 alleged abuse investigation reviewed (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED].#1 on 10/6/11 at approximately 10:30 PM. At the time of the alleged abuse, the resident was being assisted to bed by two CNAs. The CNA who witnessed the alleged abuse (CNA #2) failed to immediately report the incident. CNA #2 reported what she observed to the Unit Manager at approximately 3 PM on 10/7/11. This delay in reporting the alleged abuse allowed CNA #1 to work on the 7-3 shift on 10/7/11, placing residents at risk for further potential abuse. CNA #1 was suspended on 10/7/11 pending an investigation. She left the facility at 3:27 PM. The Unit Manager failed to report the allegation of abuse to the Administrator on 10/7/11. She also failed to report the allegation to the State survey and certification agency and Ombudsman. The allegation of abuse was reported to the Administrator on 10/10/11 and he then notified state officials on 10/10/11.",2015-02-01
9643,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-10-25,280,D,1,0,MXVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on observations, records review and interviews, the facility failed to ensure 2 of 8 sampled residents' care plans were reviewed and revised to reflect the current care needs of each resident. Resident #1 was diagnosed with [REDACTED]. Diff) and placed on isolation precautions. The care plan was not updated to reflect the resident's status. Resident #2 was observed to be on contact precautions. The care plan was not updated to reflect the precautions. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 10/24/2011 at 10 AM, revealed a sign on the door indicating Contact Precautions. A container was noted outside the door with gowns and gloves. Review of the physician's orders [REDACTED].#1 had an order for [REDACTED].#1 was prescribed [MEDICATION NAME] three times daily for C.Diff and was started on contact precautions. Review of the Laboratory Data revealed Resident #1 had a positive [DIAGNOSES REDACTED] sample reported on 10/20/2011. Review of the Care Plan revealed it had not been updated to reflect the new [DIAGNOSES REDACTED]. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 10/24/2011 at 10 AM revealed a sign on the door indicating contact precautions. A container was noted outside the door with gowns, gloves and shoe covers. Review of the the Laboratory Reports revealed a report dated 9/11/2011 regarding a culture taken from a breast wound which was positive for Acinetobacter Baumannii. Resident #2 was noted to scratch his skin constantly causing open abrasions and wounds Record review revealed Resident #2 was admitted to the hospital on [DATE] the Discharge Summary dated 10/11/2011 revealed Resident #2 was treated for [REDACTED]. ""... It was noted that there was likely an underlying [MEDICAL CONDITION]/allergic component to the patient's skin condition, as he had increased eosinophils of approximately 800. The patient was treated with antibiotics and had no significant improvement. Additionally, (Consultant Dermatologist) was consulted and pictures were sent via phone. She will follow up with (Resident #2) as an outpatient and undergo a skin biopsy and immunofluorescence."" Review of Resident #2's care plan dated 8/14/2011 revealed the care plan had not been updated to reflect the resident's Acinetobacter infection, the contact isolation, the resident's hospitalization or the resident's [MEDICAL CONDITION]/allergy. During an interview on 10/ 1 at 1:05 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #1 and #2's care plan had not been updated to reflect their current status. She stated that the MDS Coordinators were responsible for updating all residents' care plans. She also stated that when new orders were written the ""pink copy"" is given to the MDS office to then update the care plans. She stated that she did not receive Resident #2's order for isolation until 10/24/2011.",2015-02-01
9644,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-10-25,309,G,1,0,MXVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on observations, records review and interviews the facility failed to ensure that 1 of 8 sampled residents received the necessary care and services to attain or maintain the highest practicable physical and/or psychosocial well being. Resident #2 was placed on isolation precautions without a [DIAGNOSES REDACTED].#2 did not receive the necessary consultant appointments that were ordered to evaluate and/or treat his skin condition. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Observation of Resident #2 on 10/24/2011 at 10 AM revealed a sign on the door indicating Contact Precautions. A container was noted outside of the door with gowns, gloves and shoe covers. Review of the hospital admission History and Physical dated 10/05/2011 indicated Resident #2 was admitted to the hospital ""... for evaluation and management of his nonhealing wounds... The patient also has had chronic problems with itching and has excoriated the wounds... Apparently, he was sent here in the hope that he could see another infectious disease specialist, and in the hope that he might benefit from inpatient assessment and treatment..."" Review of the Hospital Discharge Summary dated 10/11/2011 revealed Resident #2 ""was evaluated initially by... from infectious disease and it was felt that the multiple superficial excoriations with associated [MEDICAL CONDITION] were likely not in need of treatment with antibiotics. The patient has been afebrile except for a low-grade temperature and has had a history of [REDACTED]. Nonetheless, he did not have any dep wound infections, and it was felt that he was likely colonized. Nonetheless, it was felt that a treatment with antibiotics for several days would be worthwhile to see if there was any improvement. The patient was treated with imipenem and [MEDICATION NAME] for 72 hours and he was subsequently reevaluated. In addition, it was noted that there was likely an underlying [MEDICAL CONDITION]/allergic component to the patient's skin condition, as he had increased eosinophils of approximately 800. The patient was treated with antibiotics and had no significant improvement. Additionally, ... from dermotoloty was consulted and pictures were sent via phone. She will follow up Mr. ... as an outpatient and he will undergo a skin biopsy and immunofluorescence... At this time, the patient is being discharged to home/skilled nursing facility, and is being continued on his home medications. He should be seen by wound care and should follow up with... (dermatology)."" Resident #2 returned to the facility on [DATE] and the isolation precautions which were in effect prior to his 10/05/2011 hospitalization , were continued. However, the resident was not under any treatment for [REDACTED]. Review of Resident #2's care plan dated 8/14/2011 revealed the care plan had not been updated to reflect the resident's Acinetobacter infection, the contact isolation, the resident's hospitalization or the resident's [MEDICAL CONDITION]/allergy. Review of the Telephone Orders revealed Resident #2 had an order written [REDACTED]."" This order was in addition to the Discharge Summary dated 10/11/11 for the resident to follow up with Dermatology. The facility contacted the Dermatologist on 10/24/2011 during the inspection, to obtain an appointment for Resident #2. The appointment was made for 12/1/2011. In addition, an appointment for a Psychiatrist was scheduled for Resident #2 on 10/21/11. However, the appointment had been canceled due to the resident's ""isolation precautions."" Review of the physician's orders [REDACTED]. Upon return from the hospital the [MEDICATION NAME] was reduced to an as needed prescription. Review of the Medication Administration Record [REDACTED]. Further record review on 10/25/2011 revealed Resident #2 was prescribed another antibiotic on 10/24/2011 for ""[MEDICAL CONDITION]"" of his arm related to an open area caused by the resident scratching. During an interview on 10/24/2011 at 12 PM, the Medical Director and Attending Physician confirmed Resident #2 was sent to the hospital on 10/5 for IV antibiotics for [MEDICAL CONDITION]. The Physician confirmed Resident #2 was diagnosed with [REDACTED]. He also stated that he contacted the Infectious Disease Physician's who stated that the Acinetobacter infection was not of great concern. The Physician also confirmed that Resident #2 was considered colonized and was not under treatment for [REDACTED]. He also confirmed the resident was on isolation precautions and that there was not a [DIAGNOSES REDACTED]. During an interview on 10/25/2011 at 9:45 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #2 had been on isolation precautions since prior to his hospitalization and continued upon his return. She stated that the reason for the isolation was the Acinetobacter infection. LPN #1 confirmed Resident #2 was not under any treatment for [REDACTED]. LPN #1 confirmed that Resident #2 scratched at his skin and caused open sores. LPN #1 also stated that the Physician placed Resident #2 on antibiotics for [MEDICAL CONDITION]. During an interview on 10/25/2011 at 10 AM, the Assistant Director of Nurses confirmed the Discharge Summary and physician's orders [REDACTED]. She contacted the Dermatology office and relayed that the facility made the appointment for Resident #2 on 10/24/2011. The ADON confirmed the delay in obtaining the appointment. The ADON also confirmed Resident #2's Psychiatry appointment had been canceled. During a follow up interview on 10/25/2011 at 11 AM, the Attending Physician again stated that there was not a [DIAGNOSES REDACTED]. He also stated that outpatient doctor's offices would not accept patients on isolation therefore Resident #2's Psychiatry appointment was canceled. The Physician agreed that the appointment was canceled unnecessarily because the resident should not have been under any precautions. The Physician stated that he was not sure why the [MEDICATION NAME] was reduced to an as needed dose.",2015-02-01
9645,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-10-25,441,F,1,0,MXVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on observations, records review, interviews and review of the facility's Infection Control Manual, the facility failed to track and trend infections. The facility failed to identify and address an outbreak of Clostridium Difficile (C. Diff) in September 2011. The findings included: The facility admitted Resident #1 with diagnosed including: [DIAGNOSES REDACTED]. Observation of Resident #1 on 10/24/2011 at 10 AM, revealed a sign on the door indicating contact precautions. A container was noted outside the door with gowns and gloves. Review of the physician's orders [REDACTED].#1 had an order for [REDACTED]. Diff."" On 10/20/11, Resident #1 was prescribed [MEDICATION NAME] three times daily for [DIAGNOSES REDACTED] and was started on contact precautions. Review of the Laboratory Data revealed Resident #1 had a positive [DIAGNOSES REDACTED] sample reported on 10/20/2011. Review of the Infection Control Log revealed no data for October 2011 had been collected. The facility admitted Resident #2 with diagnosed including: [DIAGNOSES REDACTED]. Observation of Resident #2 on 10/24/2011 at 10 AM revealed a sign on the door indicating contact precautions. A container was noted outside the door with gowns, gloves and shoe covers. Record Review revealed Resident #2 was admitted to the hospital on [DATE]-10/11/2011 for intravenous (IV) antibiotic treatment for [REDACTED]. Resident #2 was noted to scratch his skin constantly causing open abrasions and wounds. Review of the Infection Control Log from September 2011 revealed Resident #2 was listed on the log, however, the only information documented was ""Bactrim DS twice daily."" No other antibiotics were recorded and no organisms or precautions were listed. The facility readmitted Resident #3 with diagnosed including: [DIAGNOSES REDACTED]. Resident #3 was in room [ROOM NUMBER]. Resident #3 was diagnosed with [REDACTED]. Resident #3 was also diagnosed with [REDACTED]. On 9/11/11, the resident was placed on isolation precautions. Review of the Infection Control Log for September 2011 revealed Resident #3 was not listed on the log at all. No [DIAGNOSES REDACTED] was noted anywhere on the log. The facility admitted Resident #4 with diagnosed including: [DIAGNOSES REDACTED]. Resident #4 was in room [ROOM NUMBER]. Resident #4 was diagnosed with [REDACTED]. Resident #4 was noted to have ""recurrent, resistant [DIAGNOSES REDACTED]."" The resident was referred to infectious disease on 9/30/2011. Review of the Infection Control Log from September 2011 revealed Resident #4 was listed on the log twice with two different antibiotics. However, no organism and no diagnoses were listed. Also no [DIAGNOSES REDACTED] was reported. The facility admitted Resident #5 with diagnosed including: [DIAGNOSES REDACTED].#5 was in room [ROOM NUMBER]. Resident #5 was diagnosed with [REDACTED]. Review of the Infection Control Log from September 2011 revealed Resident #5 was not listed on the log at all. The facility admitted Resident #6 with diagnosed including: [DIAGNOSES REDACTED]. Resident #6 was diagnosed with [REDACTED]. The resident was placed on isolation precautions on 9/22/2011. Review of the Infection Control Log from September 2011 revealed Resident #6 was on the log as prescribed [MEDICATION NAME]. However, Resident #6's MRSA was documented and no precautions were documented. The facility admitted Resident #7 with diagnosed including: [DIAGNOSES REDACTED]. Resident #7 was in room [ROOM NUMBER]. Resident #7 was diagnosed with [REDACTED]. Review of the Infection Control Log from September 2011 revealed Resident #7 was not listed on the log at all. No [DIAGNOSES REDACTED] was recorded. The facility admitted Resident #8 with diagnosed including: [DIAGNOSES REDACTED]. Resident #8 was diagnosed with [REDACTED]. Review of the Infection Control Log from September 2011 revealed Resident #8 was not listed on the log. Further review of the log revealed no organisms documented and no evidence that the facility was tracking and trending and monitoring for outbreaks. During record review an outbreak of [DIAGNOSES REDACTED] was noted on the 200 hall (202, 207, 208, and 211) in September 2011. During an interview on 10/24/2011 the Director of Nurses (DON) stated that he started doing Infection Control ""about a week ago."" The DON stated that the facility had identified a concern with infection control because the surveillance data was not being collected due to the transition between DONs. The DON also stated that he compiled the September 2011 Surveillance data from the Pharmacy Antibiotic Reports. The DON confirmed that based on the information listed there was no way to track infections, identify trends or to identify clusters. He also stated that no data for October 2011 had been collected. During an interview on 10/24/2011 at 12:45 PM, the Administrator and DON stated that since the previous DON left at the end of August/beginning of September, no one had been tracking infections. Both stated that they were not aware of any outbreaks. The Administrator stated that an Action Plan had been put in place on 10/11/11 related to the lack of an infection control preventionist. The plan was to ""catch up on all tracking/trending from August 2011 and September 2011. Ensure any issues have been addressed. (Infection Control tracking and trending) process to be continually current and thorough. DON, Assistant Director of Nurses (ADON) and Regional Director of Nursing Compliance to cross check."" The target date was 11/15/2011. During an interview on 10/25/2011 at 11 AM, the Medical Director stated that he was not aware of any outbreaks of infections occurring in September 2011. He stated that to his knowledge no interventions had been initiated related to infection control. The Medical Director was given the information on the above residents and agreed a cluster outbreak of [DIAGNOSES REDACTED] occurred in the facility in September 2011. The Medical Director confirmed the infection control surveillance data was not completed. He also confirmed the Pharmacy Antibiotic Report was incomplete and did not include all residents on antibiotics. The Medical Director stated that based on the surveillance data, the facility could not identify trends, clusters or outbreaks. He also confirmed that if the data were not available then no concerns could be identified and no interventions initiated. The Medical Director confirmed if the data were incomplete and inaccurate then the Quality Assurance (QA) committee would not have the necessary information to identify and develop appropriate plans of action. During an interview on 10/25/2011 at 12:30 PM, the Administrator stated that she was not aware of any outbreaks in September 2011. The Administrator was given the above information and confirmed that an outbreak of [DIAGNOSES REDACTED] occurred in September 2011. The Administrator confirmed that an Action Plan was initiated on 10/11/11 and stated that the DON had compiled the September log as part of the plan. The Administrator confirmed the September Surveillance data was copied from the Pharmacy Antibiotic Report. She also confirmed that the data was incomplete and confirmed that no October data had been collected. The Administrator confirmed that there was a ""systems"" issue related to infection control. The Administrator stated that the data presented to the QA committee was not complete and did not identify the necessary information so the Committee could identify areas of concern and implement appropriate plans of action.",2015-02-01
9646,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-10-25,157,D,1,0,GLOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Inspection, based on record review and staff interview, the facility failed to notify the family or physician in a timely manner of lab results for 1 of 3 residents reviewed for notification of change. Resident # 3 had a urinalysis, which revealed a urinary tract infection. Neither the family nor the physician was notified of the abnormal results until the day after the facility received the results. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The resident was observed on 10/25/2011, lying in bed with the head of the bed elevated, feeding herself. She was alert, oriented and verbally responsive. review of the resident's medical record revealed [REDACTED]. The MDS had coded the resident as requiring extensive assistance with transfers, walking, dressing, hygiene and bathing. She was coded as frequently incontinent of bowel and bladder. Review of the admission MDS dated [DATE], the resident was coded to always be incontinent of bowel and bladder. The resident's nurse's notes dated 5/25/2011 at 6:00 AM stated, ""urine obtained ...for UA (urinalysis) and CS (culture and sensitivity). The nurse's note for 5/26 at 2:00 PM stated, ""UA (urinalysis) 3+ WBC (White Blood Cells), faxed to Dr.... C&S (Culture and Sensitivity) pending... Denies urinary pain, urgency, frequency, burning. No new orders for UA results. Five days later, the nurse's note of 5/31/2011 at 11:00 PM stated, ""Family stating she is continent but is having incontinent episodes. UA results placed in MD (Medical Doctor) to recheck results."" On 6/1/2011 at 12 PM, the nurse's note stated, ""... Resident admits to some burning @ times with voiding."" At 10:00 PM nurse's note stated, ""Started [MEDICATION NAME](antibiotic) 500 mg (milligrams) for UTI (Urinary Tract Infection) ... Res. admits burning on urination."" Review of the Notification of Change Nursing Notes revealed a notification to the family and physician on 5/24/2011 of urinary frequency and orders for urinalysis with a culture and sensitivity. The next notification of change was dated 6/1/2011 at 12:00 PM. ""UA-3+WBC > 100,000 Proteus Mirabillis"". The Nurse Practitioner was notified and new orders were obtained for antibiotics. Family, ..., was called and a message left to call back at 12:30 PM. Urinary Frequency was noted on 5/24/2011, an order for [REDACTED]. The urinalysis report was back on 5/26/2011, it revealed a urinary tract infection. The Culture and Sensitivity report was not sent to the facility until 5/29/2011. The MD nor the family were notified of the results of the culture until 6/1/2011, three days after the culture and sensitivity report was received by the facility. One week elapsed from the time the urine specimen was sent to the lab until the resident received treatment. The DON was interviewed on 10/25/2011 at 4:30 PM regarding the Notification of Change Nurses Note. She confirmed the nurses documented family/physician notification either on the form or in the nurse's notes.",2015-02-01
9647,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-10-25,323,G,1,0,GLOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Inspection, based on limited record review and interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents that had a fall with injuries. Resident # 4 had a fall and a laceration. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Poor safety awareness... Wanderguard placed in left lower extremity for safety. Therapy notified, alarms placed on bed for safety. Daughter stated resident wandered at home and fell several times."" Review of the nurse's note from 4/21/2011 through 4/22/2011 revealed the following: 4/21/2011 at 4:00 AM stated, ""...12:30 AM Started yelling and crawled OOB (out of bed). When CNA (Certified Nursing Assistant) got to room, resident was standing by bed. CNA had to call for A (assistance) from other staff members just to get her in w/c (wheelchair) to bring her to nurses station... 8:00 PM ...Sitting in w/c @ nurses station. Chair alarm on & functioning properly. Res continues to try to get up without assistance. Requires frequent reminding not to get up without assistance... 9:50 PM ...Paged Dr (Doctor)... on call for Dr... . Res is very agitated-will not stay in bed, continues to get out of w/c. Received N.O. (new order) to increase Seroquel to 50 mg (milligrams) BID (twice a day), Ativan 1 mgm IM (intra muscular)/ po (by mouth) then q (every) 6 hours prn (as needed) agitation."" 4/22/2011 at 3:45 AM stated, ""Resident attempting to get OOB continuously, put in w/c and would not sit down. Very agitated and uncooperative... 6:30 AM At 5:45 AM, ... observed resident on floor. She had a gash above R (right) bloody nose and a small bruise on R groin area... 11:10 AM Returned from ER (emergency room )... Laceration above OD (right eye) 4 staples placed by ER..."" An Elopement Risk Review was performed by the facility on 4/20/2011. The review included behaviors of, ""wandering with no purpose, oblivious to needs or safety, searching behavior and increased confusion/ anxiety/disorientation"". A Fall Risk Assessment completed on 4/20/2011 scored Resident #4 a 16. The rating scale stated a score of 10 or greater represented high risk. Review of the facility investigation included an Unusual Occurrence Incident Report that description the incident dated 4/22/2011 that stated, ""... Resident leaned forward in w/c and fell to floor as CNA (#1) ... tried to catch her. "" CNA #1 in a facility obtained statement dated 4/22/2011 at 5:45 AM stated, ""While doing my rounds, I headed back to the nurses station and saw Ms... (Resident #4) bending over to grab something off the floor, that wasn't there. I told her to sit back and at that time ... (CNA #2) came out of room 215. We both ran to grab her but she hit the floor headfirst... She was bleeding from her head above the right eye, and her nose. She also had a bruise on her right hip... Ms... (Resident #4) had been sitting up since 3:30 a (AM) in her chair. She was violent and very agitated so...(RN) gave her a shot of Ativan, this did not take affect. We were taking her from room to room with us doing rounds. CNA #2 in a facility obtained statement dated 4/22/2011 at 5:45 AM stated, ""... I was coming out of room 215 from doing my rounds and saw ... (Resident #4) falling forward from her chair. I help ... (CNA #1) assist her after the fall. She hit the floor headfirst, she have a gash on her forehead. her nose is bruised and swollen and a bruise on her right hip. ... (CNA #1) got her up at 3:30 am because she would not stay in bed. She kept getting (sic) up all night. Me and ... (CNA #1) was taking turns watching her as we were doing our last rounds."" Registered Nurse (RN) #1 in a facility obtained statement dated 4/22/2011 at 5:45 AM, on duty at the time of the incident gave a statement that said CNA #1 was one on one with the resident. The resident leaned forward to pick something off the floor that wasn't there and ... CNA #1 tried to grab her, but was unable to catch her. A Post Fall Rehab Screen was conducted on 4/23/2011 by the Physical Therapist. The Post Fall Screen under Previous/Current Fall Prevention had Safety Alarm checked. Written in, by the alarm, was ""Bed to bed & w/c. It indicated the resident had a bed and wheelchair alarm. A phone interview was conducted with CNA #1 on 10/31/2011. CNA #1 stated the resident had been hallucinating all night. ""We did one on one with her all night."" One of us would do rounds and the other would watch her. (CNA #2) had her outside of room 215. (Resident #4) was leaning over. I was running to her and (CNA #2) was coming out of the room 215. We both could not get to her before she fell ."" The Administrator was interviewed on 11/1/2011 regarding one on one observation. The Administrator stated the facility did not have a policy for one on one. She stated that one on one was in close proximity. If they had been actual one on one, the staffing would have been adjusted and a CNA would have been assigned to the resident and nothing else. Resident #4 had been admitted with a history of falls and no safety awareness. The facility assessed the resident to be at high risk for falls. There was repeated documentation of the resident climbing out of bed and standing up from wheelchair. The facility was aware of the resident's behaviors and safety risks and did not provide adequate supervision to prevent the resident from a fall with injuries.",2015-02-01
9648,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,164,D,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility privacy policies, the facility failed to provide privacy during personal care for one of two sampled residents observed for catheter care and for one randomly observed sampled resident. Full visual privacy was not provided for Resident #5 during a random observation of provision of personal care nor during provision of suprapubic catheter care. The findings included: The facility admitted Resident #5 on 10-22-09 with a suprapubic catheter in place secondary to [DIAGNOSES REDACTED]. On 2-22-11 at 1:55 PM, the surveyor knocked and entered the resident's room after obtaining permission to do so. Upon entering the semi-private room, the surveyor heard the privacy curtain being drawn along the track and observed a Certified Nursing Assistant (CNA) emptying the resident's catheter drainage bag on the side of Bed-1. Resident #5 was in the bed, fully uncovered, with only a shirt, disposable brief, and socks on. The resident's shirt was pulled up and abdomen exposed. One privacy curtain was pulled even with the footboard of the bed on the door side of the bed. The privacy curtain between Bed-1 and Bed-2 was pulled three-quarters of the way between the two beds. There was no curtain pulled around the bottom of the bed, so the roommate who was seated in a wheelchair at the foot of his bed (Bed-2) was able to observe any care being administered to Resident #5. Prior to observation of suprapubic catheter care on 2-23-11 at 11:50 AM, CNAs #3 and #4 were instructed to perform the procedure as they normally would. Again, the privacy curtains were placed as above noted so that the roommate who was seated in a wheelchair at the foot of his bed directly observed the catheter care. During the course of the treatment, Resident #5's genitals were exposed as a leg band was placed on the resident's thigh to secure the catheter tubing. During an interview following the treatment, CNAs #3 and #4 verified that they had not secured full visual privacy for the resident during the procedure. CNA #3 also confirmed that the roommate was self mobile in his wheelchair. During an interview on 2-23-11 at 1:55 PM, the Director of Nurses stated that the privacy curtains should have been pulled completely around the bed. Review of a copy of the New Employee and Annual Orientation Guidelines provided by the Administrator on 2-23-11 at 3:10 PM revealed that privacy/dignity should be afforded to residents by ""pull(ing) all privacy curtains"". A second untitled policy provided by the Administrator at 2:50 PM noted that ""Each resident shall have privacy in...personal care...""",2015-02-01
9649,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,323,D,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews, the facility failed to implement fall prevention measures as ordered by the physician for two of eight sampled residents reviewed for use of bed/chair alarms. Resident #6 was observed without an alarm in place over a period of approximately four hours. On both days of the survey, Resident #18 was observed with a clip type alarm in place instead of a pressure sensitive alarm as ordered by the physician. The findings included: The facility admitted Resident #6 on 6-22-09. Record review on 2-22-11 at approximately 6 PM revealed a history of falls per the 5-5-10 Annual Minimum Data Set (MDS) Assessment and 2-11 cumulative physician's orders [REDACTED]. Nurse's Notes dated 1-21-11 stated: ""2:45 PM Res(ident) transferring self from w/c (wheelchair) to lift chair. Res slipped to floor in seated position. Res states 'I didn't slide far enough up and slid to floor'..."" There was no mention of an alarm in place at the time of the fall. Review of the 11-30-10 Quarterly MDS (most recent) revealed that Resident #6 required extensive physical assistance of two persons for transfers. The 12-8-10 Fall Risk Assessment scored the resident at ""17"" with a total score of 10 or above representing high risk for falls. During an interview on 2-22-11, Licensed Practical Nurse (LPN) #5 clarified that a ""tender"" was a pressure activated alarm. The Director of Nurses also confirmed this on 2-23-11 at 1:55 PM. Review of the 12-8-10 interdisciplinary Care Plan revealed a problem with an onset date of 6-22-09: ""Resident is at risk for falls...r/t (related to) Psychotropic Drug Use and anxiety."" Approaches listed for requiring ""assist(ance) with ADLs (activities of daily living) r/t dx (diagnosis) deformity of orbit (knee) and Alzheimer's"" included ""Bed/chair tender as ordered"". Review of the Plan of Care Sheet (Nurse Aide Care Plan) revealed that the resident was to have a ""bed/chair tender"" and be monitored ""for sedation, drowsiness, and poor sitting balance due to psychotropic drug use"". Observations on 2-22-11 at 2:30 PM, 4:30 PM, and 6:05 PM revealed the resident dozing in a lift chair at the foot of her bed with her wheelchair directly in front of her. A clip type alarm was attached to the back of the wheelchair. The call light was not within reach and no alarm was observed in place to signal the staff for needed assistance should the resident attempt self transfer. During an interview on 2-22-11 at 6:30 PM, the Assistant Director of Nurses checked the resident and confirmed that the alarm in use was not the type ordered by the physician and that there was no alarm in place as ordered. The facility admitted Resident #18 on 8-26-09 with [DIAGNOSES REDACTED]. Record review on 2-23-11 at approximately 12:40 PM revealed 2-11 cumulative physician's orders [REDACTED]. Review of the 12-1-10 Significant Change MDS revealed that Resident #6 was totally dependent for transfers. Review of the 12-8-10 interdisciplinary Care Plan revealed a problem with an onset date of 8-26-09: ""Resident is at risk for falls...r/t Psychotropic Drug Use."" Approaches listed for this problem included ""Pad alarm to chair as ordered"". Review of the Plan of Care Sheet (Nurse Aide Care Plan) revealed that the resident was to have a ""pad alarm to wheelchair/gerichair"". Observations during the Initial Tour on 2-22-11 at approximately 10:30 AM and on 2-23-10 at 12:35 PM and 1:15 PM revealed the resident seated in a gerichair fidgeting and/or leaning forward with a clip type alarm in use. During an interview on 2-23-11 at 1:15 PM, Certified Nursing Assistant (CNA) #1, who was assigned to care for Resident #18 that day, checked the resident with the surveyor and verified that a clip type alarm was in use. She reviewed the CNA Care Plan, confirmed that it referred to a ""pad"" alarm, but stated that staff had not been using a pad alarm in the gerichair and ""might have used it when she was in a wheelchair."" At 1:20 PM, LPNs #2 and #3 verified that the resident had been in a gerichair when out of bed almost exclusively since the significant change assessment was completed in 12-10. At 1:30 PM, LPN #3 checked the resident and verified that the type of alarm ordered by the physician was not in place.",2015-02-01
9650,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,367,D,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, and interviews, the facility failed to provide a physician ordered diet in the appropriate form for 1 of 9 residents reviewed for therapeutic diet.(Resident #11) The findings included: The facility admitted Resident #11 on 1/18/11 with [DIAGNOSES REDACTED]. Record review on 2/23/11 revealed a physician's orders [REDACTED]. Further record review revealed a physician's orders [REDACTED]. Speech therapy was noted to have begun on 2/21/11. During observation of the evening meal on 2/22/11 at 6:40 PM, CNA(Certified Nursing Assistant)#5 was observed feeding Resident #11. Review of the tray card revealed a Regular - NAS diet had been served. Resident #11 was served string beans, red rice, fruit cup, roll, tea, water, and 2% milk. During an interview with CNA #5 on 2/23/11 at 3:25 PM, CNA #5 confirmed that the resident had been served a Regular - NAS diet the prior evening and that he had noticed the resident pocketing food and had informed the nursing staff. During an interview with the Dietary Manager on 2/23/11 at 4:00 PM, she confirmed that the order for a Puree - NAS had been received and entered in to the system on 2/21/11. She also stated that tray cards are pre-printed and that may be the reason the resident had been served the Regular - NAS diet.",2015-02-01
9651,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,250,D,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interviews and review of the facility policy and procedure entitled ""Palliative Care"", the facility failed to provide social services to maintain the highest practicable psychosocial well-being for 2 of 2 sampled residents on ""comfort care"" and one of three residents reviewed for abuse allegations. Social services failed to provide services to support the psychosocial and spiritual concerns for Residents #17 and #18 pertaining to ""comfort care"". Social Services failed to provide services for Resident #20 who reported an allegation of verbal abuse which was not thoroughly investigated by the facility. There was no documented evidence of the resident receiving counseling following the allegation of abuse. The Resident stopped going to the dining room for meals as a result of the allegation. The findings included: Review of Resident #17's chart on 2/23/11 at 12:30 PM revealed that the Physician's Progress Note dated 10/27/10 noted that the resident had comfort measures only. There was no physician orders specifically for ""comfort care"". It was noted that many of the resident's medications were discontinued on the 10/01/10 to 10/31/10 Physician's Orders. Per review of the Social Services Progress Notes, there was no documentation noting that the resident was placed on ""comfort care"" or that it had been discussed with the resident's family. There was no documentation in the Nursing Notes indicating the resident was on ""comfort care"". Review of the care plan dated 2/15/11 did not reveal that the resident had been care planned for comfort care. An interview with Certified Nursing Assistant (CNA) #4 on 2/23/11 at 1:30 PM revealed that the resident was on ""comfort care"". She stated that for ""comfort care"", they turn the resident every 2 hours, and keep the resident dry. An interview conducted with the Social Services Director on 2/23/11 at 1:35 PM revealed that Resident #17 was on ""comfort care"". She stated that residents on ""comfort care"" usually are taken off of medications or have medications decreased by the physician. She stated that she documented in the Social Services Progress Notes if a resident was on ""comfort care"" and she was available if needed for support for the resident and the family throughout the resident's stay at the facility. The Social Services Director stated that the facility did have a care plan for ""comfort care"" but acknowledged that she could not find where Resident #17 had been care planned for provision of this service. During an interview on 2/23/11 at 1:50 PM, the Assistant Director of Nursing (ADON) confirmed that the resident was noted to be on comfort measures only in the 10/27/10 Physician's Progress Note. The ADON acknowledged that there was no Physician's Order for the resident to be placed on ""comfort care"". The facility policy and procedure for ""Palliative Care"" was provided by the Administrator on 2/23/11 at 2:50 PM when asked for policy/procedure related to ""comfort care"". It included: ""1. Palliative care is goal-directed through planning, implementation, and evaluation by the interdisciplinary team. 2. Disciplines represented in the interdisciplinary team include medicine, nursing, pharmacy, dietary, social work service, recreation, and pastoral care. 3. Nursing coordinates the plan of care and collaborates closely with other disciplines as needed. 4. Emphasis is placed on management of physical and psychological needs of the resident and psychosocial needs of the family... 7. The care of the dying resident is focused on the following...acknowledge the psychosocial and spiritual concerns of the resident and the family regarding dying and the expression of grief by the resident and family..."" The facility admitted Resident #20 on 1/18/1999 with [DIAGNOSES REDACTED]. On 2/23/2011 during an interview at 12:30 PM, the resident stated, ""about 4 weeks ago I asked for a ham sandwich. I was told that the ham was frozen. I asked one of the CNAs (Certified Nursing Assistants) to get me a hamburger from .... The CNA brought me a hamburger. I was sitting in my room and the young man from the kitchen came down from the kitchen and said to me, 'Here , Here is your damn sandwich. Quit telling lies on the kitchen. All you do is sit on your ass and tell lies.' "" The resident stated that she had reported the incident to the DON (Director of Nurses). ""She (DON)went and talked to the people in the dining room. The people in the dining room didn't know what happened. He came to my room, not in the dining room. My children told me to stay out of the dining room. I don't go to the dining room anymore, only to activities there - Bingo."" The resident's medical record was reviewed on 2/23/11 at 1:00 PM. A Social Services note was written on 2/4/2011, stating, ""An incident was reported to me this morning..... This resident reported to the .......RN (Registered Nurse) that yesterday (2/3/11)....went to the kitchen to get a ham sandwich. Resident states that she was told that the ham was frozen, and that she could not get a ham sandwich. Resident then sent someone out to ...to get her something to eat. Resident stated that after she had gotten her food .... (name of dietary employee) from the kitchen came in her room with a sandwich and cursed at her. Resident states ... told her that she needed to stop telling those damn lies about the kitchen....I also attempted to contact resident's daughter who is her RP (Responsible Party)... and was unable to reach her."" On 2/23/2011 at 1:30 PM, the Social Services Director (SSD) was interviewed regarding the alleged incident. The SSD stated that the incident had been reported to her the next morning (2/4/2011). She then reported it to the DON (Director of Nurses) and the Dietary Manager. The SSD stated that she had tried to reach the resident's family several times but was never able to reach them, left messages on a cell phone voice mail. Review of the resident's MDS (Minimum Data Set) of 11/30/10, had the resident coded as being alert and oriented and making her own decisions. Review of the resident care plan dated 12/7/10 under problem #6, Social, listed the problem of behaviors with [DIAGNOSES REDACTED]. Under the approaches it is listed that the resident has tendency to tell untruths concerning not being offered ADL (Activities of Daily Living) assistance or receiving medications as ordered. Another approach listed was ""Do not argue with resident"". Another approach listed was, ""Resident deemed competent"". There was no documentation of Social Services follow-up to resident's self limitation of social interaction by not attending meals in the dining room. There was no documented evidence of the resident receiving counseling following the allegation of abuse. There was no documented interventions by social services related to the resident who previously at her meals in the dining room and was now eating in her room. An allegation of abuse was reported on 2/4/2011 that allegedly occurred on 2/3/2011. On 2/23/2011 the resident involved in the allegation continued to report the incident. The resident stated that she no longer goes to the dining room for meals, only for activities. During the days of the survey the resident was not observed in the dining room during meals The facility admitted Resident #18 on 8-26-09 with [DIAGNOSES REDACTED]. Record review on 2-23-11 at 12:40 PM revealed 2-11 Physician's Orders for ""Comfort measures"" which had been brought forward from a 10-28-10 Physician's Telephone Order. Review of the interdisciplinary Care Plan and Plan of Care Sheet (Certified Nursing Assistant Care Plan) noted that the resident was on ""comfort measures"". No specific interventions were noted on the Care Plan. There was no evidence in the medical record that hospice services were offered. Review of Social Services Progress Notes revealed no mention of provision of ""comfort measures"" or evidence of attempts to provide social interventions with the resident and/or family related to the end of life process, family support, counseling, and/or spiritual interventions. During an interview on 2-23-11 at 12:40 PM, the Assistant Director of Nurses was unable to specifically identify what services were provided by the facility when a resident was placed on ""comfort measures"" except to possibly discontinue medications and laboratory services as ordered by the physician. When asked about provision of medically-related social services such as counseling ans spiritual end of life care, the nurse referred the surveyor to that department. During an interview on 2-23-11 at 1:35 PM, Social Services defined ""comfort measures"" as meeting the resident's needs and keeping her comfortable, ""pretty much like a hospice order"". Social Services stated that she would expect to see interventions on the Care Plan specifically related to ""comfort measures"". She further stated that residents were only placed on hospice services if they requested it or the physician ordered it. When asked how families were informed of the services available and what her role in provision of ""comfort measures"" was, she responded ""I am available to answer any questions."" She indicated no contact with the family had been made by social services. When lack of social interventions was discussed with the Administrator on 2-23-11, she provided a copy of a 10-28-10 Nurse's Notes which she stated was the only documentation she could locate regarding family involvement. She could find no additional social service interventions had been provided since that time.",2015-02-01
9652,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,279,D,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the facility policy and procedure entitled ""Palliative Care"", the facility failed to develop a comprehensive care plan regarding comfort care on 2 of 2 residents reviewed for ""comfort care"". A care plan was not developed for Resident #17 and #18 to delineate measurable goals and approaches to meet the resident's needs for ""comfort care"". The findings included: Review of Resident #17's chart on 2/23/11 at 12:30 PM, revealled a Physician's Progress Note dated 10/27/10 which noted that the resident had comfort measures only. There were no Physician's Orders noted for ""comfort care"". Further review revealled that many of the resident's medications were discontinued on the 10/01/10 to 10/31/10 Physician's Orders. There was no documentation in the Social Services notes stating that the resident was placed on ""comfort care"" or that it was discussed with the resident's family. Nursing documentation did not indicate the resident was on comfort care. Per review of the care plan dated 2/15/11 the resident was not care planned for comfort care. An interview with Certified Nursing Assistant (CNA) #4 on 2/23/11 at 1:30 PM revealed that the resident was on ""comfort care"". She stated that for ""comfort care"", they turn the resident every 2 hours, and keep the resident dry. An interview conducted with Social Services Director on 2/23/11 at 1:35 PM revealed that the resident was on ""comfort care"". She stated that residents on ""comfort care"" usually are taken off of medications or have medications decreased by the physician. She stated that she documents in the Social Services Progress Notes if a resident is on ""comfort care"" and she is available if needed for support for the resident and the family throughout the resident's stay at the facility. The Social Services Director stated that the facility did have a care plan for ""comfort care"" but acknowledged that she could not find where Resident #17 had been care planned for provision of this service. Per review of the facility policy and procedure for ""Palliative Care"" provided by the administrator on (2/23/11 at 2:50 PM) when asked for policy/procedure related to ""comfort care"", procedures included: ""1. Palliative care is goal-directed through planning, implementation, and evaluation by the interdisciplinary team. 2. Disciplines represented in the interdisciplinary team include medicine, nursing, pharmacy, dietary, social work service, recreation, and pastoral care. 3. Nursing coordinates the plan of care and collaborates closely with other disciplines as needed. 4. Emphasis is placed on management of physical and psychological needs of the resident and psychosocial needs of the family... 7. The care of the dying resident is focused on the following...acknowledge the psychosocial and spiritual concerns of the resident and the family regarding dying and the expression of grief by the resident and family..."" The facility admitted Resident #18 on 8-26-09 with [DIAGNOSES REDACTED]. Record review on 2-23-11 at 12:40 PM revealed 2-11 Physician's Orders for ""Comfort measures"" which had been brought forward from a 10-28-10 Physician's Telephone Order. Review of the interdisciplinary Care Plan and Plan of Care Sheet (Certified Nursing Assistant Care Plan) noted that the resident was on ""comfort measures"". No specific interventions were noted on the Care Plan. Review of Social Services Progress Notes revealed no mention of provision of ""comfort measures"" or evidence of attempts to provide social interventions with the resident and/or family related to the end of life process, family support, counseling, and/or spiritual interventions. During an interview on 2-23-11 at 12:40 PM, the Assistant Director of Nurses reviewed the care plan and confirmed lack of interventions related to ""comfort measures"". She was unable to specifically identify what services were provided by the facility when a resident was placed on ""comfort measures"" except to possibly discontinue medications and laboratory services as ordered by the physician. When asked about provision of medically-related social services such as counseling ans spititual end of life care, the nurse referred the surveyor to that department. During an interview on 2-23-11 at 1:35 PM, Social Services defined ""comfort measures"" as meeting the resident's needs and keeping her comfortable, ""pretty much like a hospice order"". Social Services stated that she would expect to see interventions on the Care Plan specifically related to ""comfort measures"".",2015-02-01
9653,CALHOUN CONVALESCENT CENTER,425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2011-02-23,225,G,0,1,5CKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interviews and record review, the facility failed to thoroughly investigate or report 1 of 1 allegations of abuse. Resident #20 reported to the facility an allegation of verbal abuse that was not thoroughly investigated, nor reported to state agencies. The findings included: The facility admitted Resident #20 on 1/18/1999 with [DIAGNOSES REDACTED]. On 2/23/2011 during an interview at 12:30 PM, the resident stated: ""About 4 weeks ago I asked for a ham sandwich. I was told that the ham was frozen. I asked one of the CNAs (Certified Nursing Assistants) to get me a hamburger from .... The CNA brought me a hamburger. I was sitting in my room and the young man from the kitchen came down from the kitchen and said to me, 'Here, Here is your damn sandwich. Quit telling lies on the kitchen. All you do is sit on your ass and tell lies.' "" The resident stated that she had reported the incident to the DON (Director of Nurses). ""She (DON)went and talked to the people in the dining room. The people in the dining room didn't know what happened. He came to my room, not in the dining room. My children told me to stay out of the dining room. I don't go to the dining room anymore, only to activities there, Bingo."" During the days of the survey the resident was not observed in the dining room during meals The resident's medical record was reviewed on 2/23/11 at 1:00 PM. A Social Services note was written on 2/4/2011, stating, ""An incident was reported to me this morning..... This resident reported to the .......RN (Registered Nurse) that yesterday (2/3/11)....went to the kitchen to get a ham sandwich. Resident states that she was told that the ham was frozen, and that she could not get a ham sandwich. Resident then sent someone out to....to get her something to eat. Resident stated that after she had gotten her food .... (name of dietary employee) from the kitchen came in her room with a sandwich and cursed at her. Resident states ... told her that she needed to stop telling those damn lies about the kitchen....I also attempted to contact resident's daughter who is her RP (Responsible Party)... and was unable to reach her."" On 2/23/2011 at 1:30 PM, the Social Services Director (SSD) was interviewed regarding the alleged incident. The SSD stated that the incident had been reported to her the next morning (2/4/2011). She then reported it to the DON (Director of Nurses) and the Dietary Manager. The SSD stated that she had tried to reach the resident's family several times but was never able to reach them, she therefore left messages on a cell phone voice mail. On 2/23/2011 at 1:40 PM, the DON was interviewed regarding the alleged incident. The DON stated that she had investigated the incident with the Dietary Manager. A nurse had witnessed the dietary employee take the tray into the resident's room. The employee told the resident that she should have checked the tray. The employee did not cuss at the resident, he did cuss in the hallway. ""We didn't substantiate the complaint. There was a witness and I did not report it."" The investigation of the incident was requested. The investigation included an Employee Disciplinary Report, a statement of the nurse that witnessed the incident, and a typed and handwritten statement from the alleged perpetrator. There was no statement from the resident. There were no statements from other staff that were working on the unit or any other alert or oriented residents that may have witnessed the alleged event. There were no other residents statements regarding any concerns they may have had with the employee. Under employee remarks on the Employee Disciplinary Report, there was a handwritten statement that included: "".... pointed out all 4 (four) sandwiches to the nurse and commented the tray had not been touched and that res. (resident) shouldn't be telling those damn lies about dietary."" The nurses statement stated that the resident wanted 2 ham sandwiches because she did not want the supper they had. He (dietary employee) said she had 2 ham sandwiches and 2 peanut butter and jelly sandwiches on the tray and, ""she must not even looked at the tray. ...She must not looked at the Dam (sic) tray. ...then went into residents room to speak with her but I did not here (sic) any ang (sic) appropriate language used at that time."" The typed statement from the dietary employee stated, ""Prior to entering (resident) room I told the nurse ... that she (resident) must not have even checked the damn tray....I stood in the doorway of (resident) room and asked why she lied to the nurse."" The handwritten statement from the dietary employee stated that he went to resident room and asked why the resident was telling that dietary didn't give what the resident had asked for. The Administrator was interviewed on 2/23/11 at 4:00 PM and reviewed the investigation. The Administrator stated that she was aware of the incident. The reason that a full investigation was not done was because a nurse had witnessed the incident and stated that it did not happen. The Administrator also stated that the resident has a history of telling untruths. Review of the resident's MDS (Minimum Data Set) of 11/30/10, had the resident coded as being alert and oriented and making her own decisions. Review of the resident care plan dated 12/7/10 under problem #6, Social, listed the problem of behaviors with [DIAGNOSES REDACTED]. Under the approaches it is listed that the resident has tendency to tell untruths concerning not being offered ADL (Activities of Daily Living) assistance or receiving medications as ordered. Another approach listed was ""Do not argue with resident"". Another approach listed was, ""Resident deemed competent"". The Abuse Policy provided by the facility on 2/22/2011, was reviewed. ""Upon report of any allegations or violations the Administrator or his/her designated representative will thoroughly investigate the situation......"" ""The investigation will include but not limited to the following facts: 3. The resident's statement concerning the incident. Allegations of abuse are reported within 24 hours to the Nursing Home Ombudsman and SCDHEC. (South Carolina Department of Health and Environmental Control) There was no evidence provided that the facility conducted a thorough investigation of the alleged incident. The allegation was not reported to state agencies. On 2/23/2011 the resident involved in the allegation continued to report the incident.",2015-02-01
9654,SUMTER VALLEY NURSING AND REHAB CENTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2011-10-12,225,D,1,0,UYIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of the facility's reportable investigations, the facility failed to ensure that a thorough investigation was conducted for 1 of 4 investigations reviewed (#13). Resident #13 fell from bed on 9/19/11 while in the care of a Certified Nursing Assistant (CNA) and sustained a head injury. The findings included: Resident #13 with [DIAGNOSES REDACTED]. The resident required total care. Review of the Minimum Data Set of 8/18/11 revealed she required the assistance of one person for hygiene and bathing. On 9/19/11, CNA #4 began providing perineal care to the resident. The bed moved, causing the resident to fall to the floor. Resident #13 sustained a hematoma to the left forehead. The hospital evaluation showed a subdural bleed. Review of the facility's investigation failed to show information related to specific details such as which side of the bed the resident fell from and which cord the CNA tripped over. A discrepancy over whether the bed wheels were locked or not was not clarified; the nurse's note stated the locks were engaged but did not hold while the facility report said the CNA failed to engage the wheel locks. The facility's report did not include the information that the resident was using an air mattress and was not using side rails at the time of the accident. Observations made of the resident on 10/10/11 revealed her bed did not have an air mattress, and half side rails were in place at the head of the bed. An interview with the Director of Nursing (DON) at 3:15 PM on 10/10/11 revealed she did not have the CNA provide a re-enactment of the incident. When asked where the resident fell and how the CNA was positioned, she could not say. While moving the bed away from the wall, the DON pointed out the bed's electrical cord as the cord the CNA tripped over. An interview on 10/10/11 at 3:25 PM with the Licensed Practical Nurse who responded to the CNA's call for help revealed the resident fell between the bed and the wall, and the CNA tripped over the call light cord that was draped over the foot of the bed.",2015-02-01
9655,AGAPE REHABILITATION OF CONWAY,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2011-04-06,167,C,0,1,CZEA11,"On the days of the survey based on observations and interviews, the facility failed to post the last Recertification Survey of February 2010 per Regulatory requirement. The findings included: On 4/4/2011 at 6:00 PM, the Survey Posting book was observed in the lobby of the front entrance. Review of the POS [REDACTED]. The Survey Book contained ""Medicare.gov Nursing Home Compare - Previous Fire Inspection, and Medicare .gov Nursing Home Compare Previous Health Inspection"". The Survey Posting book was observed on 4/5/11 at 10:00 AM and 2:00 PM, the actual survey results with the plan of correction was not available. During an interview with the DON (Director of Nurses) on 4/5/11 at 4:00 PM, she stated that she was unaware that the actual survey was to be posted. On 4/6/11 at 11:00 AM, the Administrator stated that the Recertification Survey had been placed in the book. During the resident group interview on 4/5/2011 at 2:00 PM, the residents stated they were unaware of the posting of the survey results.",2015-02-01
9656,AGAPE REHABILITATION OF CONWAY,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2011-04-06,496,D,0,1,CZEA11,"On the days of the survey, based on record review and interview, the facility failed to assure that 1 of 3 certified nursing assistants had a current South Carolina (SC) Nurse Aide Certification and that the South Carolina Registry was checked prior to hire. One personnel file reviewed revealed a CNA had a certification from North Carolina but did not have a current SC certification. The findings included: On the days of the survey, three Certified Nursing Assistant files were reviewed. One file revealed the CNA was certified in North Carolina and only the registry from North Carolina had been checked prior to employment. There was no evidence provided that the CNA held a current South Carolina (SC) certification or that the South Carolina registry had been checked prior to hire. According the the South Carolina Nurse Aide Program, a CNA ""cannot work in SC until the process is completed.""",2015-02-01
9657,AGAPE REHABILITATION OF CONWAY,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2011-04-06,309,D,0,1,CZEA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews, the facility failed to maintain intake and output for 1 of 1 resident, Resident #5, admitted with fluid restriction. The findings included: The facility admitted resident #5 on 3/30/2011 with [DIAGNOSES REDACTED]. The Admission Cumulative orders dated 3/30/11 contained an order for [REDACTED]. A Medical Nutritional Therapy Assessment was completed on 3/31/11, that stated resident was on 1,000 cc fluid restriction. Review of the Intake and Output record on 3/30/2011 had documented on the 11-7 shift 420 cc of intake. On 4/1/11 the intake was documented to be 300 cc on the 7-3 shift. There was no documented intake on the 3-11 or the 11-7 shift. On 4/2/11, the 7-3 shift had documented 420 cc intake, there was nothing documented for the 3-11 or 11-7 shift. There was no documentation for 4/3/11 of any intake. A Fluid Restriction Worksheet was available that defined the amounts of fluids by shift and what was to be provided by dietary and the amounts to be provided by Nursing. The amounts of fluids that were scheduled by the Fluid Restriction Worksheet did not match the intake record of the resident. On 4/6/11 at 10:30 AM, RN (Registered Nurse) #2 reviewed the Intake and Output record and fluid restriction sheet. She agreed the records did not match and the fluid was not distributed as outlined. The resident's actual fluid intake could not be determined with the Intake record not being completed.",2015-02-01
9658,AGAPE REHABILITATION OF CONWAY,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2011-04-06,441,D,0,1,CZEA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and policy review, the facility failed to provide infection control through proper handwashing for 1 of 1 residents observed for catheter care. Resident #3 had red drainage during catheter care. The CNA after cleaning the red drainage did not remove her gloves and touched various items in the room. The findings included: The facility admitted Resident #3 on 3/10/11 with [DIAGNOSES REDACTED]. During observation of catheter care on 4/5/11 at 10:15 AM, CNA #1 (Certified Nursing Assistant) wiped around the glans penis and obtained bright red staining on the 4 cloth wipes used. After completing the catheter care, with her contaminated gloves still on, she lowered the bed, elevated the head of the bed using the electric control, repositioned the brief and refastened the brief, obtained the graduate out of the bathroom, touched the privacy curtain and the privacy bag over the catheter bag, and pulled up the bedding . The facility policy provided by the facility on Catheter Care, states after completing the catheter care, ""...remove gloves....Wash and dry hands thoroughly. Reposition bed cover. Make the resident comfortable.....""",2015-02-01
9659,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-10-13,153,D,1,0,BFJD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to provide requested medical records within 24 hours for 1 of 1 residents who requested their medical record. Resident #1 did not receive requested medical records in a timely manner. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. During record review on 10/11/2011, the resident was noted to have a BIMS (Brief Interview for Mental Status), score of 11 on her quarterly MDS (Minimum Data Set) of 9/24/2011. Her initial MDS of 7/13/201 coded her as 13. Review of her Social Service notes of 9/6/2011 revealed a note, ""Family request pt (patient) info from chart. MSW (masters prepared social worker) fax request to Legal Services...."" In an interview on 10/12/2011 at 12:45 PM, the resident's family member stated she received the requested information until, ""last week"". On 10/12/2011 the person responsible for medical records gave a statement regarding the requested medical records of resident #1. The resident's family requested the information on September 6, 2011. The resident signed to allow the release of the medical record on September 9, 2011. There was a meeting with the family member and the therapist. The facility thought the family had their questions answered and no longer needed the records. On September 29, 2011 the family member called and asked for the records. The facility had the records available on September 29, 2011. The family member picked up the records on October 3, 2011. The medical records should have been available with in 24 hours after the resident signed for the release of information.",2015-02-01
9660,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-10-13,250,E,1,0,BFJD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observations the facility failed to provide medically related social services to 3 of 4 sampled residents with psychosocial issues. Residents #1, #2, and #3, had [DIAGNOSES REDACTED]. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. During record review on [DATE], the resident was noted to have a BIMS (Brief Interview for Mental Status), score of 11 on her quarterly Minimum Data Set (MDS) of [DATE]. Her initial MDS of [DATE] coded her as 13. Resident #1 was interviewed on [DATE] at 8:55 AM. She stated, ""I love being here. I lived alone for [AGE] years. They have been real good to me here... (Resident # 2) has asked me to be roommates with her. We are going to share a room on the other side. I want to stay here."" When the surveyor was leaving the resident's room, housekeeping was entering the room and informed the resident she was going home ""today"". The resident was asked if she was aware she was going home, she stated, ""No"". The resident's care plan dated [DATE] included a problem of depression, at risk for side effects from antidepressant medication use. Review of the Social Services (SS) notes revealed a Social Services note dated, [DATE]. ""Family meeting to discuss discharge... MSW (Master Social Work) continue to follow."" There was no evidence the Social Worker had discussed the pending discharge with the resident or asked the resident what her plans were. There was no evidence that the resident received any Social Services intervention, for psychosocial needs during her stay at the facility. The Social Services Director (SSD) was interviewed on [DATE] at 1:15 PM. She stated she had not talked with Resident #1 regarding the resident's plans for discharge. When asked if she had ever talked to the resident, the SSD stated, I talked to her in the hall."" The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the medical record revealed a MDS dated [DATE] with a BIMS score of 14. The resident was coded as alert and able to make decisions regarding Activities of Daily Living. Under the mood section of the MDS, which was signed as completed by Social Services (SS), the resident was coded for feeling down, depressed or hopeless, and feeling bad about self. During an interview with the resident on [DATE] at 2:15 PM, the resident started to cry. She stated, ""I am suppose to move... I would like to stay in this room for the rest of my life. I really would be happy. I know it's impossible..."" Review of the care plan originated on [DATE], a problem that included, ...medication for management of depression/anxiety disorder was observed. Review of the Social Service Progress Notes included notes of [DATE] and [DATE]. There was no documentation of any psychosocial interventions related to the resident's depression, anxiety disorder. A Social Services (SS) note written on [DATE], after the SSD was notified of the resident crying about changing rooms. ""__ (Resident name) have room change for social reasons. Son (RP) (Responsible Party) agrees. MSW saw in room... No sign of distress noted."" The facility admitted resident #4 with [DIAGNOSES REDACTED]. Review of the Initial MDS of [DATE] revealed a BIMS score of 15, alert and oriented and able to make decisions regarding his activities of daily living. The hospital discharge summary dated [DATE], under the summary section stated he was transferred to the hospital from the facility. ""His wife died , he went to the funeral and he ran out of oxygen while at the funeral..."" Review of the Social History and Initial Assessment form dated [DATE], included a family history of ""Married, plan to return home"". Current family support and significant relationships: ""Family very supportive... have 1 daughter"". The Social Services Progress notes were reviewed. The notes start date was [DATE]. The note stated, ""__ ( resident name) On [DATE] pt (patient) d/c (discharge) in hospital MSW awaited return on [DATE] __ readmitted . Recent loss of spouse pt. may stay long term or possible return home MSW spoke to __ in hallway, he is unsure of plan. MSW contact (dtr) to set up meeting to discuss plans."" The next and final note written [DATE]. ""On [DATE] MSW spoke to __ (resident) per __ (resident) still agree to move to semi private room when available. No signs of distress. MSW will continue to follow. During an interview with the resident on [DATE], he talked of his wife's death and missing her. He stated that he was supposed to go home but would now be staying at the facility. There were no Social Service interventions for the psychosocial needs of the resident.",2015-02-01
9661,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-10-13,281,E,1,0,BFJD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on interviews, record review and observations, the facility failed to administer medications in a way to meet professional standards. Medications were not administered in a timely manner for the 200/300 unit. The findings included: In response to a complaint received by this office regarding timeliness of medication administration a group interview was conducted with residents identified by the facility as being interviewable. Two of 4 residents interviewed stated that they did not receive their medications on a regular schedule. ""Something happened. We don't get them like we use to. We never know when we are going to get our medicine."" Review of Resident Council Minutes documented the following concerns: on 8/24/2011 a concern: ""Night medicine does not get passed out on time; on 9/28/2011 ""Medicines not being passed out on time."" The response from the department supervisor dated 9/28/11 included, ""Address at staff meeting"". Review of the Grievance File revealed 1 of 6 grievances included a grievance from a resident related to not receiving his medications as ordered. The grievance stated, ""...he either didn't get them, got them after meals or only received one pill."" The pharmacy reported the medication was supposed to be given with meals. The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the medical record revealed a MDS dated [DATE] with a BIMS score of 14. The resident was coded to be alert and able to make decisions regarding Activities of Daily Living. In an interview on 10/12/2011 at 2:15 PM, Resident #2 stated, ""Monday, I got my morning medicine after 1:00 PM. I am suppose to get a pill at noon."" The resident asked what time it was and was informed it was 2:20 PM. She stated, ""Well, I haven't gotten it yet... You never know when you are going to get your pills or who is going to give them to you."" The 9:00 AM medication pass was observed on 10/12/2011 beginning observation at 9:45 AM. Between 9:45 AM and 11:05 AM, three residents received their medications ordered for 9:00 AM. The three residents combined received a total of 29 medications. During the observed medication pass, the nurse was stopped between the first and second resident observed, at 10:05 AM to prepare a resident for [MEDICAL TREATMENT]. At 10:10 AM she prepared the medication for the second resident. She dropped the medication and had to prepare the medications a second time. While preparing the second set of medications the nurse was stopped by an x-ray technician requesting information on a resident. The nurse asked the technician to ask at the desk. The nurse administered the second resident's 9:00 AM medication at 10:40 AM. At 10:45 AM the technician stopped the nurse again to obtain a signature. The nurse began preparing the third resident's medication at 10:45 AM. The nurse completed giving medications to the three residents at 11:05 AM. 7 residents remained who had not received their medications, room's 303, 301, 215 B, 212, 210, 305 and 219. Review of the Medication Administration Routine Hours Policy stated the medications were routinely given at 9 AM, 1 PM, 5 PM, and 9 PM. ""Medications are administered as ordered and should be given no more than 60 minutes on either side of the scheduled hour."" The medications were not administered within the 60 minute before and after the hour period allotted for administration.",2015-02-01
9662,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2011-10-13,328,D,1,0,BFJD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observations, the facility failed to provide appropriate services for 1 of 1 resident that required Continuous Positive Airway Pressure ([MEDICAL CONDITION]). Resident #4 used a [MEDICAL CONDITION] at night but did not have a physician's order for the [MEDICAL CONDITION]. The findings included: The facility admitted resident #4 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) of 7/26/2011 revealed a BIMS score of 15, he was coded as alert and oriented and able to make decisions regarding his activities of daily living. The resident was interviewed on 10/12/2011 at 2:45 PM. When asked about his oxygen use, he stated, ""I was on O2 (oxygen). I use a [MEDICAL CONDITION] and concentrator sometimes. After I got back from the hospital I had to use it. On 10/13/2011 at 10:00 AM, a [MEDICAL CONDITION] machine was observed at the resident's bedside. Tubing was clean and a gel mask was connected to the [MEDICAL CONDITION]. ""I have sleep apnea. I take care of it myself, I always have. This is my machine from home. I brought it with me and I took it to the hospital with me. I have had another sleep study since I got out the hospital. Respiratory therapy checked the machine when I was in the hospital."" Review of the medical record revealed no physician's order for the use of [REDACTED]. There was no mention of the [MEDICAL CONDITION]. RN #1 was interviewed on 10/13/2011; she stated resident #4 handled the care of his [MEDICAL CONDITION] himself. The facility provided a policy for [MEDICAL CONDITION]/[MEDICAL CONDITION]. #1 under the section titled, Procedure, it states, ""Upon receipt of a physician's order, initiation will be made of [MEDICAL CONDITION]/[MEDICAL CONDITION] ventilation on the prescribed patient/resident."" Although the resident had received [MEDICAL CONDITION] treatments since admission the facility failed to obtain a physician's order for the use of [REDACTED]",2015-02-01
9536,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2012-03-20,156,C,0,1,905Q11,"On the days of the survey, based on review of Medicare Denial Letters/Liability Notices and interview, the facility failed to provide the resident and/or responsible party with the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) or one of the five Centers for Medicare and Medicaid Services (CMS) approved beneficiary notice forms for 3 of 3 residents reviewed. The findings included: Review of the Medicare Denial Letter/Liability Notices on 3/20/12 at 11:00 AM revealed that 3 of 3 residents reviewed had not been issued the SNFABN form or one of the five CMS approved beneficiary notice forms. During an interview with the Business Office Coordinator (BOC) on 3/20/12 at 2:15 PM, she confirmed the facility was not using the form, ""but it was in the admission packet the entire time."" The BOC also stated she just realized today the facility was not using the SNFABN form or one of the five CMS approved beneficiary notice forms.",2015-03-01
9537,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2012-03-20,315,D,0,1,905Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, record review and review of the facility policy entitled, ""Catheter Care: Indwelling Catheter/Addendum to Catheter Care: Indwelling Catheter"", the facility failed to provide appropriate catheter care for 2 of 2 residents observed for catheter care. Facility Certified Nursing Assistants (CNA)s failed to practice acceptable infection control standards during catheter care for Residents #6 and #20. The findings included: The facility admitted Resident # 20 on 3/12/09 with [DIAGNOSES REDACTED]. Suprapubic catheter care was provided on 3/20/12 at 9:00 AM by CNA #3 and CNA #4. CNA #3 was observed to clean around the suprapubic insertion site with a clean disposable wipe and anchored the tubing approximately 4-5 inches distally from the insertion site. Utilizing a new disposable wipe, CNA #3 then cleaned the tubing using an up and down method rather than downward away from the insertion site with one swipe. He then disposed of the wipe, used a clean disposable wipe and repeated the same up and down method from the suprapubic catheter site. On 3/20/12 at 2:00 PM, during an interview with CNA #3 about Resident #20's suprapubic catheter care, it was confirmed that he did not secure the catheter tubing close to the insertion site, that he did not use one downward swipe of the tubing and he did use an up and down method for cleaning the tubing. CNA #3 was asked if he has had training on suprapubic catheter care and he responded, ""Yes, somewhat"". On 3/20/12 at 2:55 PM, an interview was conducted with the Director of Nursing (DON) regarding the expected practice of suprapubic catheter care related to infection control standards. She confirmed the importance of anchoring the tubing close to the insertion site and using one downward swipe away from the suprapubic catheter site. A copy of the facility's policy for suprapubic catheter care was obtained, ""Catheter Care: Indwelling Catheter/Addendum to Catheter Care: Indwelling Catheter"", dated 5/2009 and stated, ""Clean downward away from the insertion site with one stroke."" The facility admitted Resident #6 on 12/6/11 with [DIAGNOSES REDACTED]. Observation on 3/19/12 at 2:02 PM revealed Resident #6 lying in bed. Certified Nursing Assistants (CNAs) #1 and #2 were present to provide catheter care. CNA #1 took her left hand and partially separated the labia majora. She wiped down the right side of the labia and disposed of the wipe. She wiped down the left side of the labia and disposed of the wipe. Then, without fully separating the labia and exposing the meatus, she wiped down the middle with a separate wipe and disposed of the wipe. She then anchored the catheter tubing a few inches away from the insertion site and wiped down the catheter with a separate wipe. During an interview on 3/19/12 at 2:35 PM, both CNAs verified CNA #1 did not separate the labia fully to expose the meatus to clean appropriately. They verified she did not anchor the catheter tubing at the insertion site and did not clean the catheter from the insertion site downward. Review of the policy provided by the facility entitled ""Catheter Care: Indwelling Catheter"" on 3/19/12 at 2:37 PM revealed for perineal care for a female, that nursing staff were to ""...Gently separate labia and wash area around catheter insertion site using downward [MEDICAL CONDITION] from pubic to rectal area...""; and that for catheter care they were to ""Apply cleansing agent to clean wet washcloth and wipe in circular motion along length of catheter for about 10 cm (centimeters) or 4 inches. Clean downward away form insertion site with one stroke. Repeat as needed...."".",2015-03-01
9538,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2012-03-20,309,D,0,1,905Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, and interviews, the facility failed to provide care and services to maintain the highest practicable physical well-being possible for one of two residents reviewed for pacemakers and one of one residents reviewed with Hospice. Facility staff were not able to provide a schedule of pacemaker checks for Resident #2 nor were they knowledgeable of when Resident #2's last pacemaker check had been done. There was no Hospice plan of care on the record for Resident #16 that identified the care and services which Hospice was to provide, including the frequency of visits by the various Hospice Disciplines. The findings included: The facility admitted Resident #2 on 2/22/12 with [DIAGNOSES REDACTED]. Review on 3/19/12 at 3:30 PM of the facility Care Plan dated 2/22/12 (revised 3/1/12) revealed an entry for ""[MEDICAL CONDITION] related to Hypertension, pacemaker"". The goal was that the resident would ""...remain free of complications r/t (related to) pacemaker"" and included an intervention for ""...Pacemaker check as ordered"". During an interview on 3/20/12 at 8:50 AM, Registered Nurse (RN) #1 was asked if the resident had a pacemaker. Review of the chart with RN #1 revealed a hospital Transfer Summary dated 2/22/12. There was no indication from this summary that the resident had a pacemaker. Continued review revealed a History and Physical dated 2/24/12 which stated the resident was sent to the facility for Rehabilitation. Documented on the exam was ""Left chest wall pacemaker"". Observation on 3/20/12 at 8:55 AM with RN #1 revealed Resident #2 lying in bed, the outline of a pacemaker was noted on his left chest. RN #1 and the surveyor reviewed the Physician order [REDACTED]. RN #1 was unaware of what type of pacemaker checks were required or who the cardiologist was for Resident #2. She asked Licensed Practical Nurse(LPN) #2 who also did not know. RN #1 could find no pacemaker checks scheduled on the unit calendar. Review of the March 2012 Medication Administration Record [REDACTED]. During a phone interview on 3/20/12 at approximately 10:20 AM, the resident's daughter stated the facility had just called her to ask her about her father's pacemaker and cardiologist. She stated he's had the pacemaker for about 2 years. During an interview on 3/20/12 at 10:40 AM, a Cardiology Office Note dated 1/31/12 was reviewed with RN #1. According to the note, Resident #2 had a pacemaker due to Sick Sinus Syndrome and the device had been interrogated that day and had ""good pacing and sensing parameters"". Cardiology recommended a follow up in 6 months to repeat the device interrogation. His next appointment was scheduled for July 27, 2012. According to RN #1, the facility had not been aware of this pacemaker check or the one scheduled for July until the cardiology note was received. She verified a nurse from the facility had called the resident's daughter to get information as to who the cardiologist was for Resident #2 so they could get information relative to any scheduled pacemaker checks. During an interview on 3/20/12 at 11:05 AM, Minimum Data Set (MDS)Coordinator #1 stated she had reviewed the skin audits and the Physician's documentation of a pacemaker and had added this information to the Care Plan on 3/1/12. She stated she made a comment during clinicals; sometime after 3/1/12 and mentioned that she had found a pacemaker and that it needed checks. When asked what clinicals were, she stated that every morning there is an eagle room meeting where all department heads and administrative staff discuss concerns. She stated the next Care Plan review for Resident #2 would not be until May, and she probably would have found that the pacemaker checks had not been scheduled at that time. The facility admitted Resident #16 on 5/10/09 with [DIAGNOSES REDACTED]. On 3/20/12 at approximately 2:40 PM, record review revealed Resident #16 was admitted to Hospice on 12/11/11 for General Debility and [MEDICAL CONDITION]. Further review revealed documentation of CNA (Certified Nursing Assistant) visits for 12/13/11 through 12/16/11, 12/19/11 and 12/27/11 through 12/28/11. Social Service documentation was in the record for 12/13/11, 12/21/11 and 2/6/11. There was no documentation of visits by the Hospice Chaplain. There was also no Hospice Plan of Care in the record that identified the care and services which Hospice was to provide, including the frequency of visits by the various Hospice Disciplines. At 3:05 PM, Registered Nurse (RN) #3 confirmed these findings and stated that the Hospice Disciplines did not document in the computer as facility staff did. She also indicated that Hospice documentation was kept in each resident's record and that there was no separate location for Hospice documentation. Review of the Interdisciplinary Care Plan Care Conference Sheet indicated no conference had been held after the Significant Change in Status Assessment was completed on 12/20/11. A Care Conference was held on the day of the survey and there was no indication that any of the Hospice Disciplines had attended. Review of the Hospice contract on 3/20/12 at approximately 4:00 PM indicated that Hospice was to provide a Plan of Care that identified the Hospice services to be provided and ""details concerning the scope and frequency of such Hospice Services."" The contract also indicated that ""Hospice shall furnish Nursing Facility with a copy of the Hospice Plan of Care."" During an interview with the Director of Nursing (DON) on 3/20/12 at approximately 4:15 PM, the DON stated that half of the CNA visits had been located in the thinned record for Resident #16 but that she had to get the other half sent over from the Hospice office. She also confirmed that she had been unable to locate a Hospice Plan of Care. At approximately 4:25 PM the facility provided a copy of the Hospice Plan of Care that had been faxed to the facility at 4:20 PM.",2015-03-01
9539,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,371,F,0,1,720011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on observations, interview, and review of the facility provided policy ""Managing Dietary Service,"" the facility failed to store and serve food under sanitary conditions. Observations of the main kitchen revealed meat thawed incorrectly, a male employee without a beard restraint, inappropriate use of jewelry, correctly calibrating a thermometer, high storeroom temperature, free standing refrigerator temperature too high, and a white substance in the convection oven door. The findings included: A ""Kitchen/Food Service Observation"" was done on 6/20/11 at 10:45 AM with the Assistant Food Service Supervisor (AFSS)and the following unsanitary food issues noted: 2 frozen turkey breasts were thawing in the walk in cooler on a shelf above a carton of egg substitute. Food debris was observed on the floor of the walk- in cooler at the end of Hall C. The free standing refrigerator at the end of the tray line was in the defrost cycle with an inside temperature of 52 degrees and a carton of milk stored inside at 45.7 degrees. Observations of the kitchen on 6/20/11 at 11:45 AM with the AFSS revealed: A male employee with a goatee working with food and not wearing a beard restraint. Dietary staff serving food from the steam table wearing hoop earrings. A tray line refrigerator containing 2 thermometers running in a defrost cycle. One thermometer read 56 degrees and the other one reading 70 degrees. The temperature of a carton of milk noted on the table, sitting in a pan of ice and used for the tray line read 41.5 degrees. The AFSS had to be cued on checking the digital instant read thermometer because there was not a thick slurry of ice in an insulated container with the sensor placed in the center of the container and reaching a temperature of 32 degrees after 3 minutes. She stated that it was a new thermometer and was uncertain how often the thermometer was checked. Observations of the kitchen on 6/20/11 at 1:45 PM revealed: A hard white substance along the edge of the left hand glass door of the convection oven. A Thermometer in the dry good storeroom registered 88 degrees. Observations of the main kitchen on 6/21/11 at 4:30 PM revealed: A tray line refrigerator with an inside temperature of 56 degrees. Observation of the store room thermometer reading 90 degrees. The [MEDICATION NAME] Faith HCC Managing Dietary Services Manuals were provided. Volumes 1 and 2 had been reviewed and approved by the Registered Dietitian, Certified Dietary Manager, and Nursing Home Administrator on 1/31/11. Part 11 Page 1 of 3 under ""Food Handling Practices documented: ""limit jewelry to wedding bands. The manual also stated the store room temperature should range from 50-85 degrees.",2015-03-01
9540,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,253,D,0,1,720011,"On the days of the survey, based on random observations, torn areas were observed on a sofa and a gerichair in the sitting area on the skilled unit. The findings included: During random observations on the days of the survey and during tour with the Maintenance Director present, torn areas were noted on the right arm of a sofa and sofa seat located on the skilled unit. The torn areas were jagged with sharp edges. Foam was protruding. from the sofa.. A gerichair was observed in the same area with multiple cracks in the vinyl covering of the foot rest and the left arm of the chair. Sharp edges were noted which had the potential to cause skin tears to frail skin of a resident.",2015-03-01
9541,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,309,D,0,1,720011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, interview, and review of the manufacturer's recommendation for application of [MEDICATION NAME]es, facility staff did not follow physician's orders [REDACTED].#10. Additionally, the staff failed to notify the physician of consultants recommendation orders to review/ approve recommendations related to pain management and medication for depression for Resident #7. (One of one sampled residents identified with concerns related to the application of medication patches and one of one sampled residents reviewed with co follow up of a consulting physian's recommendations.). The findings included: The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. Record review on 6/21/11 revealed the resident had gone out of the facility for a follow up visit with the Orthopedist. A Report of Consultation Sheet, dated 6/8/11, noted the following: Consider Pain Management with [MEDICATION NAME]/[MEDICATION NAME], [MEDICATION NAME] 200 mg ( milligram) PO (by mouth) daily. An interview with LPN # 2 ( Licensed Practical Nurse ) revealed that an order had been received from the Orthopedic physician on 6/8/11 visit, and the primary physician had not been notified., The orders had not been acted upon as of 6/20/11. The resident's primary physician was interviewed on 6/22/11 at 8:40 AM. The staff usually call or fax him the recommendations. He stated, "" I will usually follow the consultant's recommendations after I review the resident's chart and medications. "" He did not remember receiving a call on 6/8/11 nor anytime before he left on vacation on June 13th. He was not aware of the consultant's recommendation for this resident. The facility admitted Resident # 10 on 5/5/11 with [DIAGNOSES REDACTED]. Record review on 6/21/11 revealed an order for [REDACTED]. Review of MARS (Medication Administration Records) for May and June 2011 revealed only 3 or 4 application sites had been used throughout the months. On the May MAR, there was no documentation for which site had been used for the sates of : 5/7,8,9,10,11,12,13,17, and 18. During an interview with the Nurse Consultant, she confirmed that the staff had not rotated the sites as ordered for the months of May and June. They should be rotated for 14 days. The staff did not rotate the patches as they should have.",2015-03-01
9542,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,463,D,0,1,720011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random observations and interview, Resident #4's call bell was observed on the floor, not within the resident's reach, leaving the resident with no means of directly contacting caregivers. The findings included: The facility admitted Resident #4 on 3/2/11 with [DIAGNOSES REDACTED]. During a Tube Flush treatment on 6/21/11 at 12:40 PM, the nurse (Licensed Practical Nurse #1) did not replace the call bell within the resident's reach after completing the procedure, but left the call bell lying on the floor next to the bedside table. On 6/22/11 at 10:50 AM the call bell was again observed lying on the floor, out of the resident's reach. The concern was verified by the Nurse Consultant on 6/22/11 at 11 AM. Per the MDS (Minimum Data Set), the resident required the extensive assistance of 1 person to transfer and did not ambulate. The resident had short and long term memory deficits and was unable to make decisions",2015-03-01
9543,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,332,D,0,1,720011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey,based on observations, record reviews and interview, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 10 %. There were 4 errors out of 40 opportunities for error. The findings included: Error #1: On 6/20/11 at 12:46 PM, during observation of medication pass on the AB Hall, Licensed Practical Nurse (LPN) # was observed to administer two puffs from an Atrovent HFA metered dose oral inhaler, to Resident A , with 12 seconds between puffs. The Drug Facts and Comparisons book (updated monthly), page 669b, states (in reference to administration technique for aerosol inhalers): ""Allow greater than or equal to 1 minute between inhalations (puffs)."" Error #2: On 6/21/11 at 7:15 AM, during observation of medication pass on C Hall, LPN # was observed to administer two [MEDICATION NAME] 800 milligram (mg) tablets and 4 other medications to Resident B . Review of the current physician's orders [REDACTED]. The medications were administered at 7:20 AM (with a Nepro Shake). The resident's breakfast tray arrived at 7:52 AM. Error #3: On 6/21/11 at 7:50 AM, during observation of medication pass on C Hall, LPN # was observed to administer one [MEDICATION NAME] Sodium 25 mcg (microgram) tablet and 10 other medications to Resident C while the resident was eating his breakfast. Review of the current physician's orders [REDACTED]. Error #4: On 6/21/11 at 9:31 AM, during observation of medication pass on the Skilled Unit, LPN # was observed to instill one drop of [MEDICATION NAME] 1% Ophthalmic Suspension into the right eye of Resident D without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under ""General Considerations in Topical Ophthalmic Drug Therapy""): ""Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug."". During an interview on 6/21/10 at 9:35 AM, LPN # revealed that she was not aware that the [MEDICATION NAME] Ophthalmic Suspension should have been shaken before instillation into the resident's eye.",2015-03-01
9544,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,425,D,0,1,720011,"On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that medications were stored in a dry, sanitary environment in 1 of 3 medication rooms. The findings included: On 6/20/11 at 3:30 PM, observation of the A B Hall medication storage closet revealed the following: -1 box of 12 Promethazine HCl Suppositories 25mg (milligram) -1 box of 12 Promethazine HCl Suppositories 12.5 mg - four 10 ml (milliliter) Novolog Insulin Aspart Injection - one 10 ml Lantus Insulin Glargine Injection - one 10 ml Novolin R (Regular) Injection All of the above listed products were stored in the bottom of the medication room refrigerator in standing water. All of the boxes containing the above listed medications were completely soaked with water to the extent that the insulin vials, the plastic wrapped suppositories and the manufacturer's information leaflets in the boxes were soaked with water. During an interview on 6/20/11 at 3:50 PM, Registered Nurse (RN) # revealed that the night nurses check the medication storage closet, including the medication refrigerator. In addition to expiration dates, they are supposed to check the condition of the medications.",2015-03-01
9545,FAITH HEALTHCARE CENTER,425009,617 WEST MARION STREET,FLORENCE,SC,29501,2011-06-23,441,D,0,1,720011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired resident care products were removed from storage with other resident care products, available for resident use, in the facility's C Hall medication room and Licensed Practical Nurse #4 (LPN) failed to remove her gloves prior to adjusting Resident #3's linen and shirt after performing catheter care. The findings included: On [DATE] at 2:57 PM, observation of the facility's C Hall Medication Room revealed one Disposable Cannula Cuffless Tracheostomy Tube with an expiration date of ,[DATE]. During an interview on [DATE] at 3:19 PM, Licensed Practical Nurse (LPN) # stated that no residents on this hall (C Hall) had a tracheostomy tube. It was further explained that the medication nurses and Central Supply were responsible for checking the medication room for expired products. However, there was no set schedule. Resident # 3 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED].# 4 was observed providing catheter care. The LPN completed the care, adjusted the resident's brief , pulled the bed linens up to his waist and straightened his shirt without first removing the gloves used to provide catheter care. On [DATE] LPN # 4 confirmed that she should have removed the gloves and washed her hands.",2015-03-01
9546,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2011-03-02,441,E,0,1,XRFP11,"On the days of the suvey, based on observation and review of the facility policy entitled ""Hand Hygiene"" copied/ provided on 3/2/11 at 12:00 PM by the Registered Dietitian (RD) , the facility failed to provide a sanitary environment to help prevent the development of disease and infection in 2 of 3 dining rooms observed. Staff was observed not washing hands between resident to resident contact, not sanitizing tables between staff meals and resident meals, and staff touched food with bare hands. Findings included: During lunch observation in the Restorative Dining room, on 3/1/11 at 12:25 PM, a Certified Nursing Assistant (CNA) was observed picking up one residents spoon to feed a resident and then picked up a different residents spoon to feed that resident. The same CNA picked up a residents dirty napkin to wipe the resident's face and then picked up the other resident's spoon and continued feeding that resident using the same hand. A random observation of a CNA during lunch revealed that the CNA provided a drink to a resident touching the straw, then picked up another resident's drink touching the straw. The CNA then touched a resident's clothing protector to wipe the residents mouth. With the same hand the CNA touched another resident's hand to help that resident put a spoon to the resident's mouth. Five CNA's in the dining room helping 2 residents at a time were observed touching resident's spoons, napkins, hands, and drinks for both residents and did not sanitize hands between resident contact. During observation at the supper meal on 3/1/11 at 5:46 PM in the Restorative Dining room, a CNA assisting three residents with their meals. The CNA wiped one residents mouth with the resident's clothing protector, assisted another resident by touching her hand to give her a bite of food, and then took a knife away from the third resident and handed the resident a spoon. The CNA continued to help all three residents throughout the meal and did not sanitize her hands. Per review of the policy entitled ""Hand Hygiene"" provided on 3/2/11 at 12:00 PM, which states ""Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require handwashing: Before and after direct resident contact; Before and after eating or handling food; Before and after assisting a resident with meals..."" On 3/1/11 at 11:55 AM four staff members were observed eating their lunch at two different tables in the dining room beside the kitchen. A large number of residents had already been brought into the dining room and placed at tables for lunch. The staff placed their used trays on a cart beside the dining room door, where they remained during the residents meal time. As soon as the staff left the two tables, residents were placed at the tables without the tables being cleaned between the staff and residents. During the same meal observation, a CNA (Certified Nursing Assistant) was observed to remove a sandwich from a plastic bag and using her bare hands proceeded to hold the sandwich while cutting it into four parts. This was also observed being done for a second resident by the same CNA. During a random observation of a meal on unit 4 at 12:25 PM on 2/28/2011, Certified Nursing Assistant (CNA) #3 was observed to remove a sandwich for a resident with her bare hands. The CNA was also observed to place her bare left hand on the sandwich, holding it while she removed the outer edges of the bread and cut the sandwich in half for the resident.",2015-03-01
9547,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2011-03-02,241,D,0,1,XRFP11,"On the days of the survey, based on random observations of the lunch and evening meals; observation of a staff member who entered a resident's bathroom washed her hands while the resident was using the bathroom without acknowledging the resident and interviews, the facility failed to promote care for residents in a manner and in an environment that enhanced their dignity. (Observation of dining in 1 of 3 dining rooms observed during meals and 1 random observation of a nurse entering a resident's bathroom to wash her hands while a resident was in the bathroom.) The findings included: During random meal (lunch) observation on 2/28/11 at approximately 12:15 PM in the Restorative Dining Room near Unit 2 and 3, multiple residents were noted seated waiting to be served and/or fed by staff. One food cart was observed in the Restorative Dining room containing multiple stacked dirty food trays that had been used by the staff. The cart contained uneaten food, dirty dishes, used napkins and other debris that had been used by staff. The food cart containing soiled items remained in the dining rooming while the residents were being served and/or fed by staff during the entire meal. Additionally, there were 8 to 9 empty food carts stored in a corner of the Restorative Dining Room near residents while they were fed or eating during the lunch observation. The Restorative Dining area also had 2 large drink machines, cabinets and regular chairs used by staff in the dining room. The residents were observed crowded together and before a resident could enter or leave the dining room; the staff was observed moving/repositioning other residents in the dining room in order accommodate the residents that were entering or leaving dining room. During random observation of the evening meal on 3/01/11 at approximately 5:28 PM multiple residents were observed eating or being fed by staff in the Restorative Dining Room with one food cart used to store dirty food trays used by staff. The cart contained dirty trays with foods served during the lunch meal for the day. There were 9 to 11 empty food carts stored in a corner of the Restorative Dining area while the resident were eating or being fed by staff. The dining room continued to be congested due to the dining room being used for storage of food carts, drink machines, cabinets and chairs used by the staff. On 3/1/11 at 3 PM LPN #1 (Licensed Practical Nurse), during a catheter care observation, was observed to open the bathroom door in the room and enter the bathroom to wash her hands. A resident from the connecting room was in the bathroom seated on the commode. The nurse left the door open while she continued to wash her hands. A CNA (Certified Nursing Assistant) entered the bathroom to assist the resident, also leaving the door open from the resident's room. When the observation was shared with the Director of Nursing and the Administrator, it was verified that the nurse should not have washed her hands while the resident was using the bathroom. In the Restorative Dining room on 3/1/11 at 11:40 AM, an open tray cart containing 12 dirty employee trays was left in the dining area uncovered before the lunch meal. At 12:25 PM it was observed that 22 dirty employee trays were on the open tray cart uncovered and left in the front of the dining room throughout the meal. In the Restorative Dining room on 3/1/11 at 12:25 PM, serving lids with trash piled inside were observed in the middle of seven out of eight tables while residents were observed eating their meals. Per interview with Certified Nursing Assistant (CNA) #2 on 3/1/11 at 12:50 PM who stated that all the dirty trays on the open tray cart are employee trays.",2015-03-01
9548,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2011-03-02,371,F,0,1,XRFP11,"On the days of the survey, based on interviews, and random observations, meal trays which were delivered to the dining room but the resident chose to eat in their rooms, were not delivered timely. Additionally, dietary staff failed to clean the thermometer between obtaining temperatures of each food item on the tray line and had incorrect concentration of sanitizing agent in the red bucket with the cleaning cloths. The findings included: On 3/1/11 at 4:30 PM, the kitchen supervisor was observed to check food temperatures of the food on the tray line before serving. The thermometer was calibrated and cleaned with an alcohol wipe before obtaining the temperature of the first meat. Ground beef and pork were temperature tested without cleaning the thermometer between the foods. The thermometer was not cleaned between checking the tomato soup and cream of chicken soup, the pureed bread and spinach, the pinto beans and pork, cauliflower and mashed potatoes. During an interview on 3/2/11 at 8:30 AM, the supervisor stated, "" I thought I didn't need to clean the thermometer between each food."" When the red bucket with cleaning cloths was checked by the supervisor on 3/1/11 at 5 PM, the concentration of sanitizing agent was less than the 50 ppm (parts per million) required. During meal observation on 3/1/11 at 12:25 PM it was observed that an open tray cart had three full trays sitting in the Restorative Dining room throughout the meal. At 12:45 PM the 3 trays were placed back in the kitchen and place on an open room tray cart. The trays were then sent back to the floor to be passed by staff. An interview was conducted at 3/1/11 at 12:50 PM with Certified Nursing Assistant (CNA) #2 who stated that the first trays that come out of the kitchen go to the dining rooms and if a resident does not make it to the dining room for the meal then the trays are placed in the Restorative Dining room until the room tray carts are ready. The trays from the main dining rooms that are left over will be place on the room tray carts and sent to the floor to be passed out by staff at that time. During meal observation on 3/1/11 at 5:30 PM, it was noted that the main dining room trays were being passed at that time. In the Restorative Dining room at 5:46 PM, it was noted that 5 trays from the main dining room were brought back to the Restorative Dining room and left out on an open tray cart. The trays left in the Restorative Dining were placed on the room tray cart at 6:15PM. One of the trays that had been left out was not delivered until 6:35 PM.",2015-03-01
9549,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2011-03-02,325,D,0,1,XRFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide a correct therapeutic diet to 1 of 6 residents reviewed for a therapeutic diet. Resident #3, with known dysphagia, was served a mechanical soft diet instead of a pureed diet as ordered by the physician. Findings included: On 3/1/11 at 5:45 PM, Resident #3 was observed in the Restorative Dining room eating a Mechanical Soft diet that included a piece of cornbread. A Certified Nursing Assistant (CNA) was seated next to the resident and assisted the resident with her meal. The resident started eating the cornbread with some difficulty. The resident was observed multiple times hyperextending her neck with her mouth wide open. The CNA asked the resident if she was okay. The CNA then continued to assist the resident with her meal. On 3/1/11 at 6:00 PM, an open tray cart was observed in the Restorative Dining room with 5 trays left on it. It was revealed that one of the trays belonged to Resident #3. Resident #3 had been given another resident's tray instead of her own. A few minutes later, staff checked the tray cart and realized the resident had the wrong tray. The resident's tray was switched at that time. On 3/1/11 at 2:45 PM, per review of the physician's orders [REDACTED]. On 2/11/11 it was ordered for speech therapy to screen the resident related to difficulty swallowing regular liquids. On 2/14/11 it was ordered for speech therapy to evaluate and treat as indicated. Per review of the Physician telephone orders dated 3/1/11 at 2:55 PM which stated that Resident #3 was seen for her last dysphagia treatment this day and then d/c'd (discontinued) secondary to completing her treatment goal. On 3/2/11 at 9:00 AM, per review of the Speech Therapist evaluation dated 3/1/11 which revealed that the resident has poor swallow safety awareness, inconsistent tolerance noted with more textured foods. Resident will remain on puree only diet with regular liquids. On 3/2/11 at 8:30 AM, an interview with the Director of Nursing (DON) was conducted. She stated that the resident did not have any allergies [REDACTED]. She stated that speech has been working with the resident and the resident has been getting trials of a mechanical soft diet. On 3/2/11 at 11:10 AM, an interview with the Speech Therapist (ST) was conducted. The ST stated that Resident #3 was in speech therapy to see if she was able to advance her diet. She stated that the resident has impulsive behaviors and will put too much food in her mouth at one time. The ST stated that she was giving the resident trials of a mechanical soft diet only if she is with the resident to work with her. She stated that the resident overall tolerated the puree diet well. The resident is known for hyperflexing her neck due to having [MEDICAL CONDITION], making the resident unsafe with eating at times. The ST stated that she feels the resident is unsafe to be on a mechanical soft diet at this time and stated that it is not safe for the resident to eat a mechanical soft diet with a Certified Nursing Assistant (CNA) supervising the resident.",2015-03-01
9550,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,431,D,0,1,J6ZP11,"On the days of the survey through observations, interview and review of the facility's policy pertaining to ""Medication Storage"", the facility failed to ensure that all biological's were in locked compartments in accordance with State and Federal laws for 1 of 2 treatment carts observed to be unsecured. Findings include: Observations on 8-8-2011 from 4:30 PM until 5:10 PM revealed the treatment cart on the ""Jones"" unit unsecured and unsupervised. During the 40 minute observation eight (8) staff walked by the treatment cart as well as, six (6) residents and five (5) family members/visitors. An inventory taken of the treatment cart at 5:12 PM with the Director of Nursing (DON) revealed the following topical's and other items which included but was not limited to : 1. eight (8) moisture barrier creams; 2. two (2) victim A & D ointments; 3. one (1) Fluocinonide cream; 4. three (3) Kendall curafil wound dressing gels; 5. one (1) Dovonex cream; 6. two (2) Nystatin cream; 7. three (3) Santyl ointments; 8. three (3) Aspercreme; 9. Clobetasol prop foam; 10. wound and skin cleanser; 11. two (2) Preparation H; 12. Hibiclens solution; and 13. one (1) pair of scissors. The DON confirmed this surveyors findings and explained that the treatment cart was to be locked at all times except when being used. Review of the facility's ""medication storage"" policy states that ""Medications shall be stored and safeguarded in a locked medicine preparation room or locked cabinet at or near the staff work area to prevent access for unauthorized individuals"".",2015-03-01
9551,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,309,E,0,1,J6ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review and interview, the facility failed to provide the necessary services to maintain the highest practicable physical will-being for 1 of 1 residents with an arteriovenous (a/v) shunt. The facility was not checking for thrill and bruit. (Resident #8) The findings included: The facility admitted Resident # 8 on 4/20/11 with [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] treatment three days a week. Review of the medical record revealed no documentation that the a/v shunt was being checked since admission for thrill and bruit except for one nursing note dated 5/26/11. Review of physician orders [REDACTED]."" In an interview with the Director of Nursing (DON) on 8/9/10 at 11:45 AM, she stated that thrill and bruit checks would be on the treatment form, but they had not been done. Review of the care plan dated 8/3/11 documented problem ""[MEDICAL TREATMENT] R thigh AV shunt"" with approaches to ""observe for s/s (signs/symptoms) of complications infections"" and ""BP (blood pressure) before and after."" A new physician's orders [REDACTED].@ (at) thigh shunt V (check) q (every) shift.""",2015-03-01
9552,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,157,D,0,1,J6ZP11,"**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 ensure the responsible party for 1 of 3 residents on antibiotics was notified of the resident's change in condition. (Resident #6) The findings included: The facility admitted Resident #6 on 8/7/01 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review on 8/8/11 of nurse's notes and physician orders [REDACTED].(resident) R(right) eye red, watery c(with) slight drainage. Made MD (medical doctor) aware. A physician's orders [REDACTED]. 2) 7/9/11 - Physician order [REDACTED].(previous) [DEVICE] tx (treatment) order. 4) 8/2/11 - Physician order [REDACTED]. Further review of the medical record revealed no documentation that the responsible party was notified of these changes in condition and/or medication changes. During an interview with the Director of Nursing on 8/12/11, she confirmed that no documentation of notification of the responsible could be found.",2015-03-01
9553,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,441,D,0,1,J6ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, review of facility policy titled ""Handwashing/Hand Hygiene and interview, the facility failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 1 of 3 residents observed during gastrostomy tube flush.(Resident #6) A staff member used inappropriate handwashing and touched items in the room with gloved hands. The findings included: The facility admitted Resident #6 on 8/7/01 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Observation of gastrostomy tube (GT) flush on 8/9/11 at 12:05 PM revealed the following: LPN(Licensed Practical Nurse)#1, after knocking on the resident's door, donned one glove, stepped out of the room for a stethoscope, and donned the second glove. LPN #1 collected approximately 40 cc (cubic centimeters) of water and mixed the water with a medication. Continuing to wear the same gloves, she entered the restroom a second time, LPN #1 collected 200 cc of water and then collected 140 cc of Promote with fiber. After pulling the privacy curtain, 20 cc of air was placed into the GT to confirm placement and residual was checked. Seventy cubic centimeters of water was administered, medication was given through the GT, approximately 20 cc of water was placed, Promote was given, and 110 cc of water was flushed through the tube. LPN #1 removed her gloves, and without washing her hands, donned another pair of gloves and rinsed the syringe/plunger, placed the syringe/plunger in the basket, and wiped the table off with a wet paper towel. LPN #1 removed her gloves and washed her hands. Review of the facility policy ""Handwashing/Hand Hygiene"" revealed under section 1. Appropriate ten(10) to fifteen(15) second handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: a. Before and after direct contact with residents; d. after removing gloves; e. after handling items potentially contaminated with blood, body fluids, or secretions. Nurses notes dated 8/7/11 documented that the resident continued to have dark drainage from around the GT site. Contact precautions were discontinued on 8/8/11. During an interview with LPN #1 on 8/10/11, she did not recognize the concerns listed above.",2015-03-01
9554,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,314,D,0,1,J6ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and review of the facility's policy entitled Procedure for Clean Dressing Change the facility failed to provide necessary treatment to promote healing and prevent infection during wound care for Resident #8, 1 of 2 residents observed for wound care. The findings included: The facility originally admitted Resident #8 in 2005 and she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observation of the wound treatment on 8/10/11 at 12:08 PM, Licensed Practical Nurse (LPN) #4 failed to clean the wound appropriately to prevent infection. After positioning the resident and removing the soiled dressing, LPN #4 removed her gloves, washed her hands and donned clean gloves. She then wiped the medial peri-wound with a 4 x 4 gauze sponge moistened with wound cleanser. She then repeated the process on the lateral peri-wound. LPN #4 then wiped from approximately 2 inches above the wound downward, through the wound bed to approximately 2 inches below the wound and patted the wound dry, removed her gloves washed her hands, applied clean gloves and finished dressing the wound. At 12:20 PM on 8/10/11, the Unit Manager, LPN #5, confirmed that LPN #4 wiped top to bottom from above the wound and through the wound wound bed. She further confirmed that the wound bed would be contaminated with that process and verified the wound should have been cleaned from the inside of the wound outward. LPN #4 also confirmed that she wiped from above the wound and through the wound bed. Review of the facility's policy entitled Procedure for Clean Dressing Change revealed ""PROCEDURE: ...12. Clean wound as ordered. (Swipe one side of the per-wound and discard gauze. Repeat procedure to the opposite side of the wound and lastly cleanse the wound bed from the center of the wound outward). Carefully dry the skin around the wound.""",2015-03-01
9555,"GEORGETOWN HEALTHCARE & REHAB, INC",425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2011-08-10,332,D,0,1,J6ZP11,"**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's policies entitled Preparation and General Guidelines: Medication Administration-General Guidelines and Specific Medication Administration Procedures: Oral Medication Administration. the facility the facility failed to ensure that it was free of medication error rates of 5% or greater. The medication error rate was 7.1%. There were 3 errors out of 42 opportunities for error. The findings included: Error #1: During the medication pass on 8/8/11 at 4:03 PM, LPN (Licensed Practical Nurse) #2 administered [MEDICATION NAME] to Resident #9. LPN #2 shook the [MEDICATION NAME] inhaler and administered 1 puff at 4:10 PM. LPN #2 waited 2 minutes, then shook the inhaler again and administered a second puff. She then sanitized her hands and proceeded to administer the resident's insulin. LPN #2 did not provide additional water or instruct the resident to rinse her mouth and spit after the administration of the [MEDICATION NAME]. Record Review of the 8/1/11 physician's orders [REDACTED]. Inhale (2) inhalations twice daily (Rinse mouth well after use & (and) spit water out-Do not swallow.) On 8/10/11, during an interview at 10:55 AM, LPN #2 confirmed that she should have instructed the resident to rinse and spit after administering the [MEDICATION NAME]. Error #2: During the medication pass on 8/8/11 at 4:27 PM, LPN #3 administered liquid [MEDICATION NAME] to Resident ""B."" Prior to pouring the medication, she checked the Medication Administration Record [REDACTED]. LPN #3 shook the medication bottle then poured the medication into a graduated medicine cup. The cup had graduated marks at 5 ml, 7.5 ml and 10 ml. She poured the medication to just over the 7.5 ml mark. During an interview on 8/9/11 at 10:48 AM, the DON (Director of Nursing) stated that ""any kind of liquid should be measured at eye level."" When asked if she meant into a graduated medicine cup and if that included [MEDICATION NAME] she stated ""yes."" At 10:48 AM, the DON stated they did not have a policy specific to the administration of [MEDICATION NAME] but verified that measuring 8 ml of a medication into a graduated medication cup with marks at at 5 ml, 7.5 ml and 10 ml was not appropriate. She further stated that she would have expected the nurse to call the pharmacy to obtain the necessary measuring utensil. At 11:05 AM, the Consultant Pharmacist confirmed that the nurse would need to use a syringe to measure 8 ml of a liquid medication. She further stated that she would have expected the nurse to call the pharmacy if no syringes were available in the facility. The Pharmacist also stated that she had observed a medication pass the previous week. Review of the Medication Pass Observation Report dated 8/2/11 revealed that she had not observed the administration of liquid [MEDICATION NAME]. Review of the policy Preparation and General Guidelines: Medication Administration-General Guidelines revealed A. Preparation, #7 ""When administering potent medications in liquid form or those requiring precise measurement, ..., devices provided by the manufacturer or obtained from the provider pharmacy, (e.g., oral syringes) are used to allow accurate measurement of doses."" Review of the policy Specific Medication Administration Procedures: Oral Medication Administration revealed ""Procedures, B. For liquid medications: [REDACTED]."" On 8/10/11, review of the 8/1/11 monthly physician's orders [REDACTED].>[MEDICATION NAME] 125 mg/5 ml S(uspension) Take 8 ml (200 mg) by mouth twice daily."" Error #3: During the medication pass on 8/8/11 at 4:46 PM, LPN #1 administered [MEDICATION NAME] 0.25 mg. to Resident ""C."" Record review on 8/10/11 at approximately 10:30 AM of the 8/1/11 monthly physician's orders [REDACTED].> [MEDICATION NAME] 0.25 mg tablet Take (1) tablet by mouth at bedtime."" The medication was scheduled for 8:00 PM. During an interview on 8/10/11 at 10:58 AM, LPN #1 stated the [MEDICATION NAME] had been being given at 4:00 PM. She further confirmed that the medication was scheduled to be given at bedtime per the physician's orders [REDACTED].#1 also confirmed that there was no order changing the time to 4:00 PM and stated that if the order stated at bedtime then ""it should be given at 8:00 PM.""",2015-03-01
9556,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,367,D,0,1,JW5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews and record review, the facility failed to provide a therapeutic diet and correctly list food allergies [REDACTED]. Resident #5 was ordered a mechanical soft diet but received a heart healthy diet. The resident had a significant food allergy to seafood that was listed as fish on the dietary slip. The resident was observed to receive clam chowder soup a during meal observation. The findings included: The facility readmitted Resident #5 on 5/12/11 with [DIAGNOSES REDACTED]. Record review on 5/16/11 revealed allergies [REDACTED]. During meal observation, on 5/16/11 at approximately 5:45 PM, the resident was served a cup of clam chowder along with a salad and unsweetened tea. The resident did not eat the soup. The resident had a physician order [REDACTED]."" The next order was on 5/10/11 which stated ""SLP clarification orders. SLP to tx qd (every day) 5X/wk (five times a week) X 30 days (for 30 days) for oral - pharyngeal dysphagia. Modalities to include dysphagia tx, dietary texture/consistency............"" Another order by the Speech Language Pathologist dated 5/10/11 stated ""Provide mechanical soft diet."" On 5/15/11 there was an order which stated ""Please confirm diet order as mechanical soft."" On the May 2011 Cumulative Physician order [REDACTED]. Another meal observation was done on 5/17/11 at 12:15 PM. The resident was served a 2000 mg. (milligram) sodium (cardiac) diet. The dietary slip listed fish as an allergy. An interview with the unit clerk on 5/17/11 at approximately 12:20 PM revealed that diet orders are changed on the computer by herself or any other staff member noting physician orders. This information is then sent to the correct department. She then showed this surveyor that the resident was ordered a heart healthy diet in the computer. She did not know why the nurse who noted the last order on 5/15/11 did not enter the information into the computer. An interview with the Registered Dietician (RD) revealed that he was responsible for putting the allergies [REDACTED]. The unit clerk then stated that the diet and the allergies [REDACTED]. Further interview with the RD acknowledged that there was a difference between a fish allergy and a seafood allergy and that serving the resident clam chowder could potentially put the resident in danger. He was not aware that the resident was served clam chowder. Interview with the resident and her son revealed that the resident had a severe seafood allergy and that 'her throat swells shut' when she consumes seafood.",2015-03-01
9557,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,253,E,0,1,JW5S11,"On the days of the survey, based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary and comfortable interior for one of two resident units and 6 of 10 resident rooms reviewed for environment. The rooms for Residents #3, #7, #19, #13, #9, and #4 and the Unit on the main level of the facility were observed with multiple areas of soil build-up and chipped, marred walls. The findings included: The facility admitted Resident # 4 (Room 31) on 7/14/09. During review of the resident room on 5/17/11 at approximately 2:30 PM, the floor and baseboard underneath the sink was observed with a heavy build-up of dark substance. The facility admitted Resident #9 (Room 21) on 4/27/11. During review of the resident room on 5/17/11 at approximately 2:30 PM, the floor and baseboard underneath the sink was observed with a heavy build-up of dark substance. The facility admitted Resident #13 (Room 19) on 10/01/11. During review of the resident room on 5/17/11 at approximately 2:30 PM, the floor and baseboard underneath the sink was observed with a heavy build-up of dark substance. During random observations throughout the survey and during the General Environmental Tour of the facility on 5/17/11 from approximately 2:30 PM - 3:30 PM and 5/18/11 at approximately 10:30 AM, the following additional areas of concern were noted: (1) Stone Wing - area around the Nurses Station: 1. The Clean Storage Room floor had a build-up of dark residue/substance on the floor. 2. The floor of the Dirty Utility Room had a build-up of dark residue/substance on the floor and the sink had a build-up of dark substance. 3. The Equipment Room contained a Hydration Cart with an ice chest observed with a build-up of pink substance along the top interior edge of the chest. 4. The air/heating units in the hallway near the Nurses Station were observed with a build-up of dark substance and numerous scratches and scuffs on the exterior of the units. 5. The walls along the exterior of the Nurses Station and in the corridors around the perimeter of the Nurses Station were observed with numerous scratches and scuffs. 6. The double doors leading to the unit had a build-up of dirt/dust on the floor at the door frames. 7. Environmental concerns were identified in the following resident rooms: Room 26 - no window blind at the windows. Room 27 - build-up of brown substance on the floor underneath the sink and in the doorway to the room. Room 23 - build-up of dark substance on the floor and baseboard underneath the sink. Room 28 - build-up of dark substance on the floor and baseboard underneath the sink and in the doorway to the room. Room 29 - discoloration around the top/back of the sink. Room 30 - build-up of dark substance on the floor underneath the sink and in the doorway to the room. (2) Marion Wing sitting area: 1. An overstuffed chair was observed with a 4-6 inch tear on the front edge of the seat cushion. 2. The double doors leading to the unit had a build-up of dirt/dust on the floor at the door frames. 3. The hallways were observed with numerous scratches/scuffs. 4. Environmental concerns were identified in the following resident rooms: Room 33 - build-up of dark substance on the floor underneath the sink and build-up of rust-colored substance around the sink. Room 36 - build-up of dark substance on the floor and baseboards underneath the sink. Room 37 - build-up of dark substance on the floor underneath the sink. Room 41 - sink with missing calking and rust-colored substance on the back surface and build-up of dark substance on the floor and baseboards underneath the sink. Room 43 - build-up of dark substance on the baseboards around the sink and left wall of the room. Room 45 - build-up of dark substance on the floor in the doorway to the room. Room 46 - build-up of dark substance on the floor underneath the sink. (3) Brice Wing: 1. The double doors leading to the unit had a build-up of dirt/dust on the floor at the door frames. 2. Room 38 - build-up of dark substance on the floor and baseboards underneath the sink. 3. Room 56 - build-up of dark substance on the floor underneath the sink. The Environmental Tour on 5/18/11 at 10:30 AM was conducted with the facility's Administrator, Director of Plant Operations, and Lead Floor Technician. The Administrator confirmed the above findings at the time of the tour. Following the Environmental Tour, the Administrator provided an Environmental Services Weekly Mop/Buff and Waxing Schedule for the facility. Review of the document indicated the schedule did not identify individual resident rooms/areas to be cleaned and did not identify or note frequency for deep-cleaning of resident rooms. The facility admitted Resident #3 (room 48B) on 10/13/10. During the Resident Room Review on 10/18/11 at 10:05 AM, the following environmental concerns were observed: numerous patches of missing paint on room walls of both residents; missing floor tile square under Resident 3's picture on wall; and heavy build up of dark substance along floor baseboards. The facility admitted Resident #7 (room 55) on 10/4/10. During the Resident Room Review on 5/18/11 at approximately 10:10 AM, the door to the room was observed heavily scratched up. The facility admitted Resident #19 (room 54B) on 5/9/11. During the Resident Room Review on 5/18/11 at approximately 10:12 AM, there was a heavy build up of dark substance along the floor baseboards in the room and bathroom. There were wheel chair leg supports stored on the floor in the bathroom.",2015-03-01
9558,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,151,F,0,1,JW5S11,"On the days of the survey based on interviews and record review, the facility failed to inform 12 of 12 residents in the Group Interview of their resident rights. The findings included: A Group Interview was conducted on 5/17/11 at 11:15 AM and 12 residents identified as alert and oriented by the facility were present. When questioned by the surveyor about the right to vote, make a living will and if they knew about the survey results and where posted, all 12 residents stated that they had not been informed of this information. All 12 residents in the group did know who or what the ombudsman was, were not aware that they could see their medical record and stated that no one had discussed any of these rights with them In a review of the Resident Council Minutes for January 2011, February 2011, March 2011, and April 2011 on 05/17/11 at 4:00 PM there was no documentation in the minutes that any of the resident rights were discussed with the residents. In an interview with the Administrator on 5/18/11 at 10:15 AM he stated he thought that the Activity Director had talked with the Resident Council members about the survey results at some point, but no documentation was provided to the surveyor to support this.",2015-03-01
9559,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,250,D,0,1,JW5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, interviews, and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents reviewed for psychosocial needs. The facility failed to recognize and meet the psychosocial needs for Resident #10 related to discharge planning, separation from spouse, and her anxiety The findings included: The facility admitted Resident #10 on 4/21/11 with the following [DIAGNOSES REDACTED]. The resident was recognized by the facility as interviewable and was on the facility provided Interviewable List. The record review on 5/16/11 revealed that the resident signed her Advanced Directives and her ""Do Not Resuscitate"" form. Resident #10 was selected for an Individual Interview and an interview was initiated on 5/16/11 at 5:30 PM with the resident. At the onset of the interview the resident began to cry and stated that after her physical therapy ended she would have to return to her (previous residential facility) prior to coming to the nursing home. She stated she did not want to return there. When asked why, she replied that a nurse there had fussed at her and called her a ""baby"" when she had diarrhea due to a change in her medicine. She stated the nurse there was often ""mean"" to her. She continued to sob and stated that her husband of [AGE] years had recently (about 3 weeks ago) been moved out of this facility to a nursing home in Rock Hill. She further stated she missed him and worried about him. She stated she had married him when she was 14 and they were rarely apart. The interview had to be postponed due to the resident's tearfulness. On 5/17/11 at 12:35 PM the interview was resumed and again the resident talked about missing her husband and apologized for crying. She stated she could not help but cry because she missed her husband and hated the (previous residential facility) so much and did not want to return there. A third visit to her room was made on 5/17/11 at 2:45 PM to complete the interview and again the resident became tearful about her situation and stated she had been trying to ""figure out"" how she could visit her husband, although she no longer drives and the insurance on her car had been dropped. When questioned if she had talked with the social services/social worker about this, she stated she had not met her and did not know who that was. She did state that she had been told by a staff member at this facility that she must return to the (previous residential facility) once her therapy ended. In a review of the resident's record on 5/16/11 and 5/17/11 a nurse's note written on 4/25/11 at 9:55PM stated ""Has voiced numerous concerns over 'going back to (previous residential facility).' Has stated she wants to stay here to complete her therapy. Note left for (social worker) regarding resident's concerns."" Another nurse's note dated 4/27/11 at 6 PM stated ""Very talkative, talking about her husband and wanting to go to Rock Hill where he is."" A review of the social services notes revealed 4 entries since the resident's admission on 4/21/11. The first entry was on 4/21/11 and stated that the resident was alert and verbal, signed her own papers and was scheduled to return to the (previous residential facility). The note revealed that the resident's husband was a resident at the current facility. The second entry was dated 4/25/11 and only documented that Resident #10 was moved to another room, why she was moved, and that the son was contacted related to the move. There was no mention of the resident's concerns about returning to the (previous residential facility) or her spouse's impending move to the Rock Hill facility. The third note dated 5/2/11 stated, ""Scheduled to return-lives at (previous residential facility), doing rehab (rehabilitation) for falls, with fx (fractured) ribs, had been at (rehabilitation facility), alert and oriented, verbal, feeds self, extensive assistance with other ADL(Activities of daily living) functions...no behavior issues."" The last entry was dated 5/17/11 at 2:45 PM which stated ""Up in w/c (wheel chair) today, attended rehab, sitting more upright in chair today, lived at (previous residential facility) prior to admit to (rehabilitation facility) for fx"".....the dates of new orders were listed following this entry and then stated, ""No behavior issues."" The notes did not reflect that the resident had been assessed to determine if she was appropriate to return to the (previous residential facility), or asked if she wanted to return to the previous residential facility and if not, why. Her recent separation from her husband of [AGE] years was not addressed nor ways she could talk with him or visit him explored by the social worker. Observations of resident body language were not documented and her mood, anxiety level, and potential for depression were not assessed by the social worker. On 5/17/11 at 3:30 PM the Unit Manager/Licensed Practical Nurse (LPN) #2 was interviewed and she stated she was aware that Resident #10 did not want to return to the previous residential facility, but did not know why she did not want to return. The Social Services Director was interviewed at 3:35 PM on 5/17/11 and was wearing her Identification Badge at the time which stated ""Marketing/Admissions"". She had no identification which indicated she was Social Services. She stated that she did all 3 jobs at the facility and that she was a Licensed Practical Nurse. She stated that she had had no training in the social services field. When asked about the resident, she stated that she (the resident) was to return to the previous residential facility. She was aware that the resident's husband of [AGE] years had been sent to a Rock Hill Long Term Care Facility, but did not know that the resident had cried about this. She was unaware of the resident's complaints about her care and treatment at the previous residential facility she was expected to return to. She stated no one had informed her of these issues. She stated that the resident had never told her these things and had never cried when she visited her. She asked the surveyor what she should do about the resident's concerns. During the Group Interview with 12 interviewable residents on 5/17/11 at 11:15 AM, when asked if they had a Social Worker/Social Services, 2 residents stated that the social worker resigned in 2008 and the facility had never replaced the social worker. The Group was unaware of who to go to for social service needs. In an interview with the Administrator on 5/18/11 at 10:15 AM , he confirmed he had not filled the social service slot. He stated that when the social worker resigned in 2008 he had assigned this additional job to the existing Admissions/Marketing Coordinator, who had been performing all three jobs since 2008.",2015-03-01
9560,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,280,D,0,1,JW5S11,"**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 a plan of care to ensure care needs were met for 2 of 11 resident care plans reviewed. The facility failed to review and update Resident #13's care plan related to wandering behaviors and placement of a Wanderguard and failed to review and revise Resident #10's care plan related to discharge planning. The findings included: The facility admitted Resident #13 on 10/01/10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Telephone Order dated 5/06/11 to apply a Wanderguard. The Nurse's Notes dated 5/06/11 at 3:30 PM indicated Resident #13 ""attempted x2 to go out front door. Had front door 1/2 way open before staff notified. Res. (resident) stated 'I'm going home.' Wanderguard applied...as ordered."" Review of the care plan with latest review date of 3/17/11 revealed Wandering Behaviors was not identified as a problem area. The care plan did not indicate that Resident #13 attempted to leave the facility on 5/06/11, did not indicate that a Wanderguard was placed, and did not include interventions to prevent recurrence. During an interview on 5/17/11 at approximately 4:10 PM, the Unit Manager was asked about the process used to update resident care plans. The Unit Manager stated that care plans are updated based on resident information and orders reviewed during weekly Risk Meetings, and the MDS/Care Plan Coordinators review physician telephone orders for information to be added to care plans. In addition, the Unit Manager stated that the nursing staff on the Unit can update care plans as needed when orders are received. During an interview on 5/17/11 at approximately 4:15 PM, MDS/Care Plan Coordinator #1 was asked about the process used to update resident care plans. Care Plan Coordinator #1 stated that copies of physician telephone orders are reviewed, information is obtained through staff meetings, and care plans are updated as necessary. Care Plan Coordinator #1 also stated that nursing staff on the unit can update resident care plans as needed. Care Plan Coordinator #1 stated that she was unaware Resident #13 attempted to exit the facility and was unaware of the placement of a Wanderguard. The facility admitted Resident #10 on 4/21/11 with the following [DIAGNOSES REDACTED]. The resident was recognized by the facility as interviewable and was on the facility provided Interviewable List. During an interview on 5/16/11 at 5:30 PM with the resident, the resident began to cry and stated that after her physical therapy ended she would have to return to her (previous residential facility) prior to coming to the nursing home. She further stated she did not want to return there because of the way she had been treated. She also stated that her husband of [AGE] years had recently (about 3 weeks ago) been moved out of this facility to a nursing home in Rock Hill, she missed him and worried about him. During subsequent interviews on 5/17/11 at 12:35 PM and 2:45 PM, the resident remained emotionally distraught. When asked about being included in the care plan meetings, she stated that she was unsure what that was. In a review of the resident's record on 5/16/11 and 5/17/11 nurse's notes documented the resident's concerns related to returning to the previous facility following discharge. Social service notes did not reflect that the resident had been asked about what she wished to do regarding her plans for discharge. The current care plan dated 4/27/11, was completed following the nurse's note on 4/25/11 which stated the resident had numerous concerns about returning to the (previous residential facility). The 4/27/11 Care Plan stated the problem as: "" Return to community, plan to return to (previous residential facility) when short term rehab complete "". The goal for this problem stated, ""Resident will be informed of discharge plans and assist as needed when ready for discharge"". The approach for this goal stated, ""Therapy as ordered, resident and family informed of progress, assist with discharge when short term rehab complete."" The care plan indicated that the resident had not been involved in the care planning and there was no documentation of what the resident wanted to happen upon discharge. There were no updates to reflect the resident's spouse being relocated to another town and how the resident was reacting to this change in her life. The care plan did not reflect the resident's input or concerns.",2015-03-01
9561,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,323,D,0,1,JW5S11,"On the days of the survey, based on observation, the facility failed to ensure the resident environment remains as free of accident hazards as is possible. The resident Activity Room/Chapel area on the Marion Wing was observed with broken window panes. The findings included: During random observations of the Activity Room/Chapel on the Marion Wing of the facility, broken window panes were observed in three sections of the windows around the perimeter of the room. The windows in the room were divided into a lower section and larger upper section. Two lower sections were observed with cracks in the windows panes. A large upper window section in the corner of the room was observed with numerous cracks. Observation revealed double doors lead to the room which contained a piano, various materials used for resident activities, tables and chairs, and small couches. The Activities office was located through a doorway inside the Activity Room. During an interview on 5/18/11 at approximately 1:30 PM, the Administrator stated that residents used the room for activities and visiting with family and friends. During the survey, no residents were observed in the room.",2015-03-01
9562,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,281,D,0,1,JW5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility staff failed to monitor resident vital signs, document physician's order, the starting of IV (Intravenous) fluids, or after a medication error had been identified for Resident #6. (1 of 1 residents reviewed with IV fluids/medication error.) The findings included: The facility admitted Resident #6 on 4/1/07 with [DIAGNOSES REDACTED]. Record review on 5/16/11 revealed a physician's telephone order dated 5/16/11 at 0530 for D5W 75 cc (cubic centimeters) per hour for extra [MEDICATION NAME] - BS (Blood Sugar) q (every) 4 hours. Review of the MAR (Medication Administration Record) showed this resident normally received [MEDICATION NAME] 100 units/ml - 15 units subcutaneously daily as ordered by the physician. The nurse had initialed the MAR indicated [REDACTED]. No additional information was documented on documented on the back of the MAR. However, review of the nurses notes revealed a notation dated 5/16/11 0530 BS 170 [MEDICATION NAME] 100 units SQ given. A line was drawn through the notation and the word ""error"" written and initialed. The next notation made in the nurses notes was at 1:45 PM including vital signs, skin warm and dry, IV site intact, D5W infusing at 75 cc/hour. BS 275. The next entry was at 10:30 PM (2230). The FSBS (Finger Stick Blood Sugar) for 2100 was documented as 304. The next entries 11:30 PM, 11:40, 11:41, 12:10, 12:15 AM, and 1:48 AM pertained to the IV site as being red and swollen and orders obtained to restart IV in right arm. There was no documentation that the resident's blood sugar was monitored every four hours per the physician's order. An interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing), and the Administrator on 5/16/11 at approximately 2:30 PM revealed the night nurse realized she that she had given 100 units of [MEDICATION NAME] rather than the 15 units ordered. The nurse filled out a medication error report but did not complete an incident report. The physician was notified and an order obtained to start the IV. The family was notified at 8:30 AM. The Administrator stated the nurse would be required to view the Med Pass video again, and be observed on a Med Pass before going back on the med cart. There would also be another RN (Registered Nurse) in the building with her. Additionally, the nurse would also be inserviced on documentation principles.",2015-03-01
9563,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,314,D,0,1,JW5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility staff failed to obtain timely an order for [REDACTED].# 18 was 1 of 3 residents reviewed for pressure ulcer treatments. The findings included: The facility admitted Resident # 18 on 4/20/07 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 5/6/11 the wound care notes documented the presence of skin breakdown on the coccyx, stage II ... measuring 5 x 6 cm, 2.5 x 3 cm, and 5 x 5 cm (cubic centimeter). On 5/13/11 the note stated ""Res(ident) wound is worse- now stage III on coccyx. Area measures 3x3, moderate exudate with odor noted. Dark brown areas with dark center measures 1 x 10 cm full thickness. Depth of wound is 1 cm."" Observation of a wound treatment on 5/17/11 at 2:45 PM revealed a large stage IV sacral ulcer with large amount of dark brown, foul smelling exudate coming from the wound. The nurse stated the dressing had been changed that morning which also had a large amount of foul smelling drainage. The dressing removed at this time was completely saturated and dark brown in color. The wound had large amounts of brownish drainage inside the wound bed flowing out of the wound onto the residents skin. The odor was pungent. No action had been taken by the staff or Housekeeping to decrease the odor in the semi-private room. The Unit Manager stated the odor had been noticed on 5/13/11 as verified in the wound care notes. On 5/13/11, the treatment was changed from [MEDICATION NAME]/CombiDERM dressing to clean with normal saline and apply silversorb gel to wound base and cover with ABD pad. The odor and exudate continued. On 5/16/11 at 10:15 AM an order was obtained to do a culture and sensitivity of the wound. On the evening of 5/16/11 at 4:30 PM an order was obtained for [MEDICATION NAME] 500 mg (milligrams) daily x 7 days. On 5/17/11 at 2 PM a new order was received to discontinue the silversorb dressing and apply silverantimicrobial wound dressing. On 5/18/11 at 1:45 PM the lab culture and sensitivity report sent to the Nursing Home documented the organism in the wound to be Proteus Mirabilis and that the organism was resistant to the [MEDICATION NAME] which had been ordered. Review of Skin Integrity/Wound Care Program Policy stated under Infection Control Guidelines: Cultures should be obtained on wounds that present signs/symptoms of infection (e.g. purulent drainage, foul odor, etc.)",2015-03-01
9564,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,425,D,0,1,JW5S11,"On the days of the survey, based on observation and interview, the facility failed to discard (2) 100 ml (milliliter) bags containing IV (Intravenous) Ceftriaxone which contained labels which stated to ""Discard after 5/2/11"". The findings included: Observation on 5/16/11 at 6:00 PM revealed (2) 100 ml bags containing IV Ceftriaxone in the Nursing Center Medication Room refrigerator. Further review revealed the bags were dated 4/22/11 and a label attached to the bags contained instructions to ""Discard after 5/2/11"". During an interview on 5/16/11 at 6:18 PM, Licensed Practical Nurse (LPN) #3 verified the 2 IV bags of Ceftriaxone in the medication room refrigerator had been labeled with instructions to discard the medication after 5/2/11. When asked what it meant to discard the medication, she stated that the medication should have been thrown away. During an interview on 5/16/11 at 6:22 PM, the Unit Manager stated the 2 bags of IV Ceftriaxone could not be sent back to the Pharmacy and that the nursing staff should have disposed of the medication.",2015-03-01
9565,CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2011-05-18,333,D,0,1,JW5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, a facility staff member administered an incorrect/excessive dose of insulin to Resident # 6. (1 of 1 residents reviewed with a medication error.) The findings included: The facility admitted Resident #6 on 4/1/07 with [DIAGNOSES REDACTED]. Record review on 5/16/11 revealed a physician's telephone order dated 5/16/11 at 0530 for D5W 75 cc (cubic centimeters) per hour for extra [MEDICATION NAME] - BS (Blood Sugar) q (every) 4 hours. Review of the MAR (Medication Administration Record) showed this resident normally received [MEDICATION NAME] 100 units/ml - 15 units subcutaneously daily. The nurse had initialed the MAR indicated [REDACTED]. A line was drawn through the notation and the word ""error"" written and initialed. An interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing), and the Administrator on 5/16/11 at approximately 2:30 PM revealed the night nurse had given 100 units of [MEDICATION NAME] rather than the 15 units ordered. The nurse completed a medication error report. The physician was notified and an order obtained to start an IV. The family was notified at 8:30 AM.",2015-03-01
9566,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2011-11-15,281,G,1,0,0U6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Survey, based on record review and interview of the facility staff, the facility staff failed to provide care and services in accordance with professional standards of practice for one of two residents reviewed with tracheostomies. Resident #1 did not receive [MEDICAL CONDITION] care or humidified oxygen on 9/28/2011-9/29/2011,Resident #1 was not sent to the emergency room timely for respiratory distress on 10/27/11, and Resident #1 did not have an interim care plan or comprehensive care plan that reflected the resident's care needs. The findings included: The facility admitted Resident #1 on 09/05/2011 with [DIAGNOSES REDACTED]. The resident was admitted to the hospital for treatment several times after the 9/5/11 facility admission and then finally discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Resident #1 was again discharged to the hospital on [DATE] and remained in the hospital at the time of the survey. Review of the Interim Care Plan dated 09/09/2011 (4 days after the resident was originally admitted ) revealed, ""Pulmonary Disease: suction PRN (as needed), O2 per 5 [MEDICAL CONDITION] 5 LPM (liters per minute), Humidified O2 at 28% [MEDICAL CONDITION]"" The Interim Care Plan did not include any other interventions related to the care of the resident'[MEDICAL CONDITION] any hospitalization s, Central Line Access, [MEDICAL TREATMENT] access changes and infections. The Interim Care Plan did not address the resident's complexity of care or her unstable medical conditions. No Interim Care Plan was developed for the resident's second admission back to the facility on [DATE]. During an interview on 11/15/2011 at 10:55 AM, the Care Plan Coordinator confirmed the Interim Care Plan was dated 09/09/2011 and did not include the necessary care items for Resident #1. An Admission Minimum (MDS) data set [DATE] coded the resident as having moderately impaired decision making abilities. The resident was coded as requiring total two person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. The resident was noted to receive all nutrition via a [DEVICE]. The resident was coded as receiving [MEDICAL TREATMENT] and [MEDICAL CONDITION] Care. No Comprehensive Care Plan was developed. During an interview on 11/15/11 at 10:55 AM, the Care Plan Coordinator stated that Resident #1 did not have a comprehensive care plan developed. She stated that the Admission MDS had been completed but when the resident was scheduled to have her care plan developed she had been transferred to the hospital. Review of the physician's orders [REDACTED].@ 28% [MEDICAL CONDITION], check O2 saturation every shift and as needed to keep saturations greater than 92%, #6 [MEDICATION NAME]. Review of the Nurses Notes dated 09/29/2011 revealed, ""Approximately 7:40 AM resident anxious and writer (Licensed Practical Nurse #1) pulled [MEDICATION NAME] to take in room c (with) other meds. Resident a little SOB (Short of Breath) p (after) being turned- wound care nurse going on started to suction while writer prepped for meds- when wound care nurse attempting to suction, very dry, writer aided and added a little saline out of pink [MEDICATION NAME] to provide moisture. Suctioned a little thick sputum appeared tight in trach- inner cannula removed - found to be completely filled c thick dry mucous- almost completely filled c very little area though for air- also when writer entered room, sterile water container on humidifier was empty- writer placed sterile water in to produce humidity p suctioning- inner cannula changed- med administered and respiratory treatment administered by writer... sat maintained at 95-96%... when coming out of room across hall from resident at approximately 10:15 AM, resident's roommate was standing in door way saying honey come here she needs you- writer in room noticed all electricity out, yelled for assistance, attempt to move plug to another outlet would not work- all plugs removed all equipment rolled to door and plugged in outside door into a red emergency outlet- (Maintenance) had already been paged in beginning- on scene immediately and out of room to check the breaker- during all this time wound care nurse had been giving resident air through Ambu Bag prior to electricity source being switched on... Sat 83%-84%. EMS had already been called, they arrived in approximately 8 minutes-incident started at 10:15 AM, EMS here at 10:30 AM... EMS to (Hospital)... "" At 3:30 PM, ""spoke with daughter, stated Pulmonologist at (Hospital) admitting her mom... "" The resident returned on 10/7/2011. The resident returned with a Central Line for IV Antibiotics for Endocarditis. On 10/11/2011 during the 11-7 shift, Resident #1 had a ""mod(erate) amount of white blood tinged secretions."" On 10/22/2011 during the 3-11 shift, "" suctioned x1 upon return- blood tinged thin secretions."" On 10/23/2011 during the 7-3 shift, the resident ""coughed up blood tinged secretions and noted when suctioned, notified MD via MD book."" On 10/24/2011 during the 7-3 shift "" resident in distress shortly after writer entered building... sent to ER."" The resident returned at 2:55 PM the same day. On 10/25/2011 during the 7-3 shift, ""bloody mucous inside dried to inner cannula."" During the 11-7 shift the resident was noted to cough up a ""small amount of blood tinged secretions. On 10/26/2011 during the 7-3 shift, ""trach care completed inner cannula replaced- had small amount of dried blood on wall of cannula..."" On 10/27/2011 at 12 AM, Resident #1 was ""diaphoretic, skin cool and clammy, O2 sat= 54%... Resident repositioned, PRN [MEDICATION NAME] nebulizer tx (treatment) given. [MEDICAL CONDITION] cannula changed. Sats remained in the 50's. Lung sounds diminished. Resident alert and responding to staff. Abdominal breathing noted, MD and RT paged. "" At 12:10 AM, The Respiratory Therapist returned the page and ""advised to sent resident to ER."" At 12:30 AM, ""Telephone order rec'd (received) from (Provider on Call) to send to ER. Resident's daughter notified and she asked that her mom be sent to (Hospital). EMS called for transport."" At 12:50 AM, ""Resident transported to ER via stretcher. Report called..."" Review of the Medication Administration Record [REDACTED]. Resident #1 did not [MEDICAL CONDITION] on the 11-7 shift on 09/29/2011. During an interview on 11/15/2011 at 2:30 PM, LPN #1 stated that she was assigned to the resident on 9/29/11 during the 7-3 shift. She stated that she noted the water bottle to the resident's humidifier was empty and the resident had a thick mucous plug that occluded the inner cannula. She stated that the nurses were to check the bottle frequently and refill as needed. Review of the Facility's 5 Day Report submitted to the State Agency on 10/7/2011 regarding the facility reported neglect related to [MEDICAL CONDITION] care revealed the facility substantiated neglect against Registered Nurse (RN #1). RN #1 was terminated due to her lack of care for Resident #1 on the 11-7 shirt on 09/28/2011. RN #1 failed to provide [MEDICAL CONDITION] care and failed to assure the humidifier was functioning appropriately. Review of the facility obtained statement dated 9/29 revealed ""(RN #1) stated that she went in at 1 AM to give resident her [MEDICATION NAME] and [MEDICATION NAME]. Never really went in rest of night except to hang new tube feeding bag at 5 AM. Stated she would walk by and look in. (RN#1) stated she did not remember doing [MEDICAL CONDITION] on the resident and she did not realize that the suction machine was on all night or that the water bottle on humidified air compressor to the resident'[MEDICAL CONDITION] out of water. She stated that she never really did check on the resident. She stated that she knew the resident was up all night in the geri chair but she didn't think about it because she was told that the family requested it."" Registered Nurse #1 (the nurse assigned to Resident #1 on 9/29) was not available for interview. Review of the Assignment Sheet revealed RN #1 was assigned to care for Resident #1 on the night shift of 9/28/2011-9/29/2011. Review of the Facility Corporate Training on [MEDICAL CONDITION] Care and Assessment revealed: ""...Nursing Assessment: Humidity delivered to airway... [MEDICAL CONDITION] care is provided at least every 8 hours and more often if indicated."" Review of the Respiratory Assessment Corporate Training dated 2011 revealed: ""... Assessment of respiratory function is one of the MOST important assessments...""",2015-03-01
9567,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2011-11-15,328,G,1,0,0U6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Survey, based on record review and interview, the facility failed to ensure one of two residents reviewed with tracheostomies received the necessary care and services to maintain the highest practicable wellbeing as possible. Resident #1 did not receive [MEDICAL CONDITION] care or humidified oxygen on [DATE]-[DATE]. The resident developed a mucous plug that occluded the inner cannula and was transferred to the hospital. Resident #1 also was not sent to the emergency room timely for respiratory distress on [DATE]. Resident #1's Attending Physician documented on ,[DATE] that the resident's complex care needs would be better served at an intermediate hospital. The facility admitted the resident back to the facility on [DATE] despite the physician's statement. Resident #1 coded on [DATE] and was readmitted to the hospital. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and readmitted on [DATE]. Resident #1 was again discharged to the hospital on [DATE] and remained in the hospital at the time of the survey. An Admission Minimum (MDS) data set [DATE] coded the resident as having moderately impaired decision making abilities. The resident was coded as requiring total two person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. The resident was noted to receive all nutrition via a [DEVICE]. The resident was coded as receiving [MEDICAL TREATMENT] and [MEDICAL CONDITION] Care. No Comprehensive Care Plan was developed. Review of the Interim Care Plan dated [DATE] (4 days after the resident was originally admitted ) revealed, ""Pulmonary Disease: suction PRN (as needed), O2 per 5 [MEDICAL CONDITION] 5 LPM, Humidified O2 at 28% [MEDICAL CONDITION]. The Interim Care Plan did not include any other interventions related to the care of the resident'[MEDICAL CONDITION] any hospitalization s, Central Line Access, [MEDICAL TREATMENT] access changes and infections. The Interim Care Plan did not address the resident's complexity of care or her instability of medical conditions. No Interim Care Plan was developed for the resident's second admission on [DATE]. During an interview on [DATE] at 10:55 AM, the Care Plan Coordinator stated that Resident #1 did not have a comprehensive care plan developed. She stated that the Admission MDS had been completed but when the resident was scheduled to have her care plan developed she had been transferred to the hospital. The Care Plan Coordinator confirmed the Interim Care Plan was dated [DATE] and did not include the necessary care items for Resident #1. Review of the physician's orders [REDACTED].@ 28% [MEDICAL CONDITION], check O2 saturation every shift and as needed to keep saturations greater than 92%, #6 [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED]. Resident #1 also did not [MEDICAL CONDITION] on the ,[DATE] shift on [DATE]. Review of the Nurses Notes dated [DATE] revealed, ""Approximately 7:40 AM resident anxious and writer (Licensed Practical Nurse #1) pulled [MEDICATION NAME] to take in room c (with) other meds. Resident a little SOB (Short of Breath) p (after) being turned- wound care nurse going on started to suction while writer prepped for meds- when wound care nurse attempting to suction, very dry, writer aided and added a little saline out of pink [MEDICATION NAME] to provide moisture. Suctioned a little thick sputum appeared tight in trach- inner cannula removed - found to be completely filled c thick dry mucous- almost completely filled c very little area though for air- also when writer entered room, sterile water container on humidifier was empty- writer placed sterile water in to produce humidity p suctioning- inner cannula changed- med administered and respiratory treatment administered by writer... sat maintained at ,[DATE]%... when coming out of room across hall from resident at approximately 10:15 AM, resident's roommate was standing in door way saying honey come here she needs you- writer in room noticed all electricity out, yelled for assistance, attempt to move plug to another outlet would not work- all plugs removed all equipment rolled to door and plugged in outside door into a red emergency outlet- (Maintenance) had already been paged in beginning- on scene immediately and out of room to check the breaker- during all this time would care nurse had been giving resident air through Ambu Bag prior to electricity source being switched on... Sat 83%-84%. EMS had already been called, they arrived in approximately 8 minutes-incident started at 10:15 AM, EMS here at 10:30 AM... EMS to (Hospital)... "" At 3:30 PM, ""spoke with daughter, stated Pulmonologist at (Hospital) admitting her mom... "" The resident returned on [DATE]. The resident returned with a Central Line for IV Antibiotics for Endocarditis. On [DATE] during the ,[DATE] shift, Resident #1 had a ""mod(erate) amount of white blood tinged secretions."" On [DATE] during the ,[DATE] shift, "" suctioned x1 upon return- blood tinged thin secretions."" On [DATE] during the ,[DATE] shift, the resident ""coughed up blood tinged secretions and noted when suctioned, notified MD via MD book."" On [DATE] during the ,[DATE] shift "" resident in distress shorted after writer entered building... sent to ER."" The resident returned at 2:55 PM the same day. On [DATE] during the ,[DATE] shift, ""bloody mucous inside dried to inner cannula."" During the ,[DATE] shift the resident was noted to cough up a ""small amount of blood tinged secretions. On [DATE] during the ,[DATE] shift, ""trach care completed inner cannula replaced- had small amount of dried blood on wall of cannula..."" On [DATE] at 12 AM, Resident #1 was ""diaphoretic, skin cool and clammy, O2 sat= 54%... Resident repositioned, PRN [MEDICATION NAME] nebulizer tx (treatment) given. [MEDICAL CONDITION] cannula changed. Sats remained in the 50's. Lung sounds diminished. Resident alert and responding to staff. Abdominal breathing noted, MD and RT paged. "" At 12:10 AM, The Respiratory Therapist returned the page and ""advised to sent resident to ER."" At 12:30 AM, ""Telephone order rec'd (received) from (Provider on Call) to send to ER. Resident's daughter notified and she asked that her mom be sent to (Hospital). EMS called for transport."" At 12:50 AM, ""Resident transported to ER via stretcher. Report called..."" Review of the Physician's Progress Notes revealed the resident was assessed on [DATE] due to the resident's daughter was concerned the resident was anxious ""...AP 1) SOB- probably related to anxiety, however will obtain chest x-ray secondary to history of [MEDICAL CONDITIONS] "" (CXR negative for [MEDICAL CONDITIONS]). On [DATE] the Attending Physician documented: ""(Resident #1) has very high intensity resident needs c constant risk of decompensation or respiratory and cardiovascular status. She also requires very high intensity of care from the standpoint of her size. She has had repeated trips to the hospital with problems related to to her medical conditions. The level of her care requirements are likely beyond the capacity of a typical skilled care nursing facility and will be better provided in a long term intermediate level hospital facility. "" The resident was readmitted to the facility on [DATE]. On [DATE] the resident decannulated and was sent to the emergency room . On [DATE] at 8:20 AM, Resident #1 coded and CPR was initiated. The resident was sent to the hospital and remained there during the survey. During an interview on [DATE] at 1:15 PM, the Attending Physician confirmed his note on [DATE] indicating the facility would not be able to meet the resident's care needs. He stated that the facility ""probably shouldn't have admitted the resident "" on [DATE]. He stated that the resident had multi-organ complex care needs including, [MEDICAL CONDITION], [MEDICAL TREATMENT], cardiovascular and obesity. He stated that the the resident's needs would be better served in intermediate care facility. He also stated that one LTACH denied the resident and the hospital was ready to discharge her. The Attending Physician stated that the facility would ""try again"" and she was readmitted on [DATE]. The Attending Physician stated that the time of the survey, the resident was on a ventilator in the Intensive Care Unit. The Physician once again stated that the resident's care needs could best be met in a different type of facility. The Physician stated that the resident was supposed to have humidified oxygen at all times. He stated that the resident did have problems with secretions. He stated that a lack of humidity could lead to dry mucous and mucous plugging that could lead to respiratory distress. The Attending Physician also stated that if a resident was in respiratory distress then the nursing staff should call 911 and send the resident to the emergency room . He stated that the provider should be notified but stated that he relied on nursing judgment to call 911 first if the situation was emergent. The Attending Physician stated that on [DATE] the resident should have been sent to the emergency room immediately. He stated that the nursing staff should not have waited 50 minutes before the resident was sent out. During an interview on [DATE] at 2:15 PM, the Director Of Nurses confirmed the resident had multiple care areas that exceeded the level of care abilities of the facility. She also confirmed that due to the complexities of the resident the facility wanted the resident to be admitted to a Long Term Acute Care Hospital. The DON stated that one LTACH denied the resident and the facility made the decision to accept the resident back. The DON confirmed the Attending Physician's statement stated that the facility would not be able to meet the care needs of the resident. The DON confirmed again that the resident was readmitted despite the physician's statement. During an interview on [DATE] at 2:30 PM, LPN #1 stated that she was assigned to the resident on [DATE] during the ,[DATE] shift. She stated that she noted the water bottle to the resident's humidifier was empty and the resident had a thick mucous plug that occluded the inner cannula. She stated that the nurses were to check the bottle frequently and refill as needed. Licensed Practical Nurse #2 (the nurse assigned to the resident on [DATE]) was not available for interview. Review of the 5 Day Report submitted on [DATE] revealed the facility substantiated Neglect against RN #1. RN #1 was terminated due to her lack of care for Resident #1. RN #1 failed to provide [MEDICAL CONDITION] care and failed to assure the humidifier was functioning appropriately. Review of the facility obtained statement dated ,[DATE] revealed "" (RN #1) stated that she went in at 1 AM to give resident her [MEDICATION NAME] and [MEDICATION NAME]. Never really went in rest of night except to hang new tube feeding bag at 5 AM. Stated she would walk by and look in. (RN#1) stated she did not remember doing [MEDICAL CONDITION] on the resident and she did not realize that the suction machine was on all night or that the water bottle on humidified air compressor to the resident'[MEDICAL CONDITION] out of water. She stated that she never really did check on the resident. She stated that she knew the resident was up all night in the geri chair but she didn't think about it because she was told that the family requested it. "" Registered Nurse #1 (the nurse assigned to Resident #1 on ,[DATE]) was not available for interview. Review of the Assignment Sheet revealed RN #1 was assigned to care for Resident #1 on the night shift of ,[DATE]-[DATE]. Review of the Time Care report revealed RN #1 clocked in at 10:19 PM on ,[DATE] and clocked out at 7:14 AM on [DATE]. Review of RN #1's Inservices revealed she received training with competencies on emergent [MEDICAL CONDITION] reinsertion and [MEDICAL CONDITION] care on [DATE]. Review of the Facility Corporate Training on [MEDICAL CONDITION] Care and Assessment revealed: Nursing Assessment: Humidity delivered to [MEDICAL CONDITION] care is provided at least every 8 hours and more often if indicated. "" Review of the Respiratory Assessment Corporate Training dated 2011 revealed: "" Assessment of respiratory function is one of the MOST important assessments. """,2015-03-01
9568,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2011-11-15,441,D,1,0,0U6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Survey based on observations, record review and interview, the facility failed to adhere to infection control practices for one of two sampled residents. Resident #1 coded on 11/12/2011, her room was left with suction cannisters full of an opaque liquid, tubing, oxygen delivery tracheostomy collar and opened saline exposed in the room. The findings included: The facility admitted Resident #1 on 09/05/2011 with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and readmitted on [DATE]. Resident #1 was again discharged to the hospital on [DATE] and remained in the hospital at the time of the survey. Observations on 11/15/2011 at 9:30 AM and at 2:30 PM revealed Resident #1's respiratory cart was in the room. On the cart was a suction cannister filled ? of the way with an opaque liquid and had [MEDICATION NAME] material floating near the bottom. Also on the cart, draped over the suction cannister and suction machine was the resident's corrugated tubing and tracheostomy collar left exposed. An open container of saline was also left open on the cart. During an interview on 11/15/2011 at 2:30 PM, Licensed Practical Nurse (LPN) #1 confirmed the suction cannister, tubing, tracheostomy collar and saline were left exposed in the resident's room. She stated that the nursing staff was responsible for cleaning up those items. She confirmed that the resident left the faciity on [DATE] and stated again that someone should have cleaned up the room.",2015-03-01
9569,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,283,D,0,1,G05Z11,"**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 complete a discharge summary that includes a recapitulation of the resident's stay; and a final summary of the resident's status for Resident # 18 who was discharged home. (One of three closed records reviewed) The findings included: Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. During record review of the resident's medical record, there was no discharge summary or recapitulation of her stay at the facility noted. During an interview with the Director of Nursing (DON) on 3/15/11 at 9:00 AM, the DON stated that there was no one in Medical Records in December. The facility failed to provide a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge for two of three closed records reviewed . The findings included: Resident # 16 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident's birthdate was 07/19/39. The resident was dicharged to the hospital on [DATE] after a fall resulting in a fracture to the right wrist. Record review on 03/14/11 showed no Discharge Summary had been completed for this resident. This was confirmed by an interview with the the Director of Nursing on 03/24/11 at approximately 4 PM.",2015-03-01
9570,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,364,F,0,1,G05Z11,"On the days of the survey, based on observation and interview, the facility failed to prepare food that was palatable and attractive in 3 of 3 dining rooms observed. Plastic medication cups were used to serve sauces for a meal and vegetables were overcooked and pale in color. The findings included: On 3/14/11 at 11:50 AM, during observation of lunch trayline, it was revealed that medicine cups were used for sweet and sour sauce on all trays receiving the regular and mechanical soft diets. The vegetable medley was overcooked and pale in color. On 3/14/11 at 6:00 PM a test tray was requested for the last tray on the last tray cart. The test tray was not sent on the tray cart as requested and was later brought into the conference room by the kitchen. Therefore this surveyor was unable to accurately assess the meal for proper temperature due to the kitchen sending a tray that was not observed for setup and distribution. A group Interview was conducted on 03/14/11 at 11 AM with four facility resident's which included the former Resident Council President as well as the newly elected Resident Council President. Questions were addressed to the group from the CMS ""Group Interview Form"" 806B which included questions about the facility food and dinning experience. The residents stated that the food was often cold and unappetizing and the tea was always watery before it reached the dinning area due to the ice melting and the coffee was cold at the breakfast meal . The residents also expressed concern that the bread served with meals was often hard and difficult to eat.",2015-03-01
9571,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,456,E,0,1,G05Z11,"On the days of the survey, based on observations, the facility failed to maintain an ice machine in a safe operating condition. The ice machine on Unit I was observed on all days of the survey in The findings included: On Initial Tour on 03/13/11 at 10:45 AM and on all days of the survey, the ice machine on Unit I across from the elevators was observed with a slimy build up over and under the drainage area. The observations were shared on 3/15/11 with the Administrator, Director of Nursing and Clinical Consultant and not disputed.",2015-03-01
9572,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,250,D,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide social services interventions for 2 of 18 residents reviewed for social services. Resident #10 was hospitalized in a Geriatric-Psychiatric unit and determined to be at risk to self. The concern was not addressed by Social Services. Resident #17 was ordered to have a Hospice Consult. Social Services did not address Hospice or end of life care for the resident. The findings included: Resident #17 was readmitted on [DATE] with [DIAGNOSES REDACTED]. During record review on [DATE], there was a physician's orders [REDACTED]. The last documented social services note was dated ,[DATE] and also dated [DATE] (same social services note). There were no social services notes depicting a decline in condition, need of hospice services nor end of life interventions. The resident expired on [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 9:00 AM, she stated that the Social Services Director had been out on Medical Leave. The facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. Based on record review and interview, the facility failed to identify and provide medically-related social services. Review of the hospital History and Physical (H&P) on [DATE] at 1:30 PM revealed that the resident had exhibited delusional behavior with increasing anxiety in the late afternoons. She exhibited inappropriate behavior toward others, including verbal aggression and wandering, impulsive attempts to ambulate without assistance, and was at risk for self harm. Review of the Interim Plan of Care in the medical record revealed no references to the resident's cognitive state or these behaviors. The only behavior noted was: ""Obsessed with bathroom even when just been. Don't frequently use when taken but frequently ask."" During an interview on [DATE] at 4:35 PM, the Unit Three Manager stated that she was unaware of the resident's behavior noted in the H&P because she had gotten no information from the hospital in a verbal report. She reviewed and verified the Interim Plan of Care at this time. When asked about the CNA (Certified Nursing Assistant) Care Plan, she provided a copy and verified that it was ""blank"". Review of Social Service Progress Notes revealed no reference to the self harm risk. During an interview on [DATE] at 1:05 PM, Social Services stated that she ""must not have read that the resident was at risk for self harm or I would have included it in my notes"". When asked to review the medical record and get back with any additional information, none was provided by Social Services.",2015-03-01
9573,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,252,E,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and resident, family, and staff interviews, the facility failed to provide an environment free of institutional odors. During two days of the survey, although the facility appeared clean, two of three units in the facility had a pervasive unpleasant odor. The findings included: Upon entry to the facility on [DATE] at approximately 10:45 AM, the survey team noted an unpleasant stale odor. During Initial Tour on 3-13-11, multiple residents on Units 2 and 3 were noted to be still in bed. The heaviest odors were noted on the front hall between the two nursing stations on the first floor. These odors persisted through day two of the survey. During the Initial Tour with Licensed Practical Nurse #1, there were obvious attempts noted to mask the odors with a ""baby powder"" scent, especially in the area of the soiled utility room on Unit 3. During a resident interview on 3-14-11 at 9:10 AM, when asked about odors in the facility, the resident stated, ""There's a urine and BM (bowel movement) smell seven days a week, 365."" This resident was noted as ""interviewable"" during the Initial Tour with Registered Nurse #1. Review of the Central Information Tool and 12-10-10 Social Service Progress Notes on 3-14-11 at 9:15 AM revealed that this resident was alert and oriented to person, place, and time. During an interview on 3-14-11 at 6:15 PM, a family member stated that there was a urine smell in the building ""all the time, especially in the hall from the front door"" to Unit 3. The family stated that he/she felt that this was due to incontinent care not being provided as needed and that the residents' chairs were not being cleaned when they had been incontinent in them. During an interview with the Clinical Consultant, the Housekeeping/Laundry Supervisor and his District Manager on 3-15-11 at 11:15 AM, the malodor was attributed to a resident who urinated on the floor. They stated that the tile would possibly need to be replaced. On 3/13/11, during initial tour of Unit 2 between 11:05 AM and 12:00 PM, musty, urine odors were observed throughout the tour. At 12:00 PM on 3/13/11, room 113 had a strong musty urine odor. During a resident interview on 3/13/2011, the resident stated there were odors all in the hallway. The resident stated that there was always an odor in his/her room. The resident thought the odor ""comes from the bathroom."" At the time of the interview the resident's room was observed to have had a musty odor.",2015-03-01
9574,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,323,E,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to maintain a safe environment, free of accident hazards for 5 of 15 residents observed for safe environment. Resident's #1, #10, #19 with fall prevention alarms, did not have alarms on as ordered. Resident #14's bed alarm did not function. Resident #8's oxygen tubing was on the floor across the doorway entrance. The findings included: The facility admitted Resident #8 on 3/11/11 with [DIAGNOSES REDACTED]. On 3/14/11 at 5:30 PM, the resident was observed sitting by his bed. The oxygen concentrator was in the room between the resident and the door of the resident's room. His oxygen tubing was observed on the floor by the concentrator and looped around into the doorway at the edge of the main hallway, causing a trip hazard. Residents were observed walking in the hallway. The facility admitted Resident #1 on 2-27-07 with [DIAGNOSES REDACTED]. Record review on 3-13-11 at 1:30 PM revealed a current physician's orders [REDACTED]."" The Care Plan noted the resident was ""at risk for falling R/T (related to) SDAT (Senile Dementia-Alzheimer's Type) + late loss ADL's (activities of daily living)"". Interventions included ""bed alarm at all times while in bed"". At 4:30 PM on 3-13-11 and at the same time on 3-14-11, the resident was observed in a low bed with a mat, but with no alarm in place as ordered. During an interview and observation on 3-14-11 at 4:45 PM, Licensed Practical Nurse (LPN) #3 checked the resident and verified that the bed alarm was not in place as ordered. A pressure alarm was located in the resident's gerichair. The LPN stated she thought the alarm was to be used in the chair only. Review of the 2-11 and 3-11 Treatments Flowsheets revealed that the alarm had been initialed every shift as applied as ordered. Review of the Central Information Tool (Certified Nursing Assistant (CNA) Care Plan) revealed instructions for use of a ""Bed & canary alarm, C-pad alarm"". The Care Plan was last noted as updated in 1-09. During an interview on 3-14-11 at approximately 9 AM, the Unit Manager stated that canary alarms were clip-type alarms and that they were no longer used. She could not explain what a C-pad alarm was. When questioned on 3-14-11 at 5:30 PM about how she knew what care was needed for specific residents, CNA #1 stated she referred to the PCR (Patient Care Record) Book at the desk or got the information from other CNAs. During an interview on 3-15-11 at 9:30 AM, CNA #2 stated she got her information in the same manner, but also added that she would ask the charge nurse if she noted that some new item of care had been implemented. During an interview on 3-14-11 at 6:15 PM, a family member stated that Resident #1 has unexpectedly gotten up and walked in the past. The facility admitted Resident #10 on 2-28-11 with [DIAGNOSES REDACTED]. Review of the hospital History and Physical (H&P) on 3-13-11 at approximately 1:30 PM revealed that the resident had exhibited delusional behavior with increasing anxiety in the late afternoons. She exhibited wandering and impulsive attempts to ambulate without assistance. Review of a 3-1-11 Fall Risk Evaluation revealed that the resident scored ""13"" which indicated she was ""at risk for falls"". Interventions initiated at that time, according to the back of the form, included ""bed and chair alarm"". Further review revealed 3-11 physician's orders [REDACTED]. During the Initial Tour on 3-13-11 with Registered Nurse #1, the resident's pressure pad was noted to be on an unoccupied bed with the alarm/audible unit lying on the bedside table with the back off and the attached battery lying on top of the table. A lap buddy was laying on the bed. As the tour progressed, the resident was observed being returned to her room by a staff member in a wheelchair without an alarm in place. At 1:20 PM and 3:15 PM on 3-13-11 and on 3-14-11 at 3 PM, the resident was observed in a low bed without an alarm in place. Each time, the pressure alarm was located attached to her wheelchair. Review of the Interim Plan of Care in the medical record revealed safety devices to be used included ""chair & bed alarms"". However, the CNA Care Plan for Resident #10 included no information on resident care needs, no instructions for care to be administered. When questioned on 3-14-11 at 5:30 PM about how she knew what care was needed for specific residents, CNA #1 stated she referred to the PCR Book at the desk or got the information from other CNAs. During an interview on 3-15-11 at 9:30 AM, CNA #2 stated she got her information in the same manner, but also added that she would ask the charge nurse if she noted that some new item of care had been implemented. During an interview on 3-15-11 at 11:45 PM, when asked about the CNA Care Plan, the Unit Three Manager verified that it was ""blank"". She verified that the resident was at high risk for falls per the assessment, confirmed the physician's orders [REDACTED]. The facility admitted Resident #19 on 8-29-05 with [DIAGNOSES REDACTED]. Record review on 3-14-11 at approximately 4:30 PM revealed a 3-11 physician's orders [REDACTED]. The chair alarm was listed as an intervention for the listed problem of ""Resident at risk for falls as evidence(d) by: late loss ADL's; cognitive impairment; anemia; res(ident) will try to get OOB (out of bed) unassisted."" The CNA Care Plan (last updated 1-09) noted that the resident was to have a ""bed pad alarm, canary alarm"". During an interview on 3-14-11 at approximately 9 AM, the Unit Manager stated that canary alarms were clip-type alarms and that they were no longer used. Observations on 3-14-11 at 2 PM, 4:30 PM, and 5:30 PM revealed the resident seated at a table in the Dining/Day Room without an alarm in place as ordered. At 5:30 PM, the surveyor asked CNA #1 to check the resident in the Dining/Day Room. She verified that there was no alarm on the chair. She immediately checked the resident's room, removed the pressure pad alarm from the resident's made up bed, and placed it under the resident in the chair. When questioned on 3-14-11 at 5:30 PM about how she knew what care was needed for specific residents, CNA #1 stated she referred to the PCR Book at the desk or got the information from other CNAs. At this time, the CNA Care Plan was reviewed and the CNA verified that it stated that a canary alarm was to be used. CNA #1 stated that the facility only used the pressure type alarms. During the Initial Tour with Registered Nurse #1 on 3-13-11 beginning at 10:50 AM, Resident #14 was observed in bed with a pressure pad alarm unit on the floor. The back of the unit was off and the attached battery was lying on the floor. When asked to check the function of the alarm, RN #1 picked the unit up and found that the cord was detached from the plug site. She verified that the resident was supposed to have the alarm on and that it should have been plugged in for the alarm to work. Resident # 14 was last admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. On 3/14/11 at 3:10 PM, per review of the physician orders, it revealed that the resident was ordered to be placed in a geri-chair when out of bed. The nursing notes dated 2/15/11 indicated Resident #14 was at risk for falls related to impaired mobility, SDAT (Senile Dementia Alzheimer Type) and anxiety. Resident #14 had a fall on 1/19/11 resulting in a skin tear to the right leg. The resident's care plan dated 2/15/11 for falls stated the resident was to be placed in a gerichair, contour mattress on bed, and no briefs while in bed. Per review of the Comprehensive Care Plan dated 2/15/11 the resident was not care planned for a bed alarm. On 3/14/11 at 3:30 PM, Resident #14 was observed in her bed with a bed alarm on next to her head. On 3/14/11 at 3:35 PM an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated that the resident does have a bed alarm and is usually in a geri-chair due to her fall risk. On 3/14/11 at 3:42 PM an interview was conducted with the Unit Manager. She stated that the resident is ordered to have a bed alarm. The unit manager was unable to find an order for [REDACTED].#14's last fall was from the bed. On 3/14/11 at 4:35 PM an interview was conducted with the Assistant Director of Nursing (ADON). She stated that the facility did not have a policy for bed alarms. On 3/15/11 at 10:30 AM, during a random observation, Resident #14 was observed in her bed with the bed alarm under the bed which was not turned on. On 3/15/11 at 11:30 AM, during a review of the CNA (Certified Nursing Assistant) Care Plan dated 1/15/09 it was revealed that the resident was care planned for a bed alarm.",2015-03-01
9575,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,332,D,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations and record reviews, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.1%. There were 3 errors out of 41 opportunities for error. The findings included: Error #1: On 3/14/11 at 8:15 AM, during observation of medication pass on Unit 2, RN (Registered Nurse) #1 was observed to administer liquid tears, one drop in both eyes. During reconciliation of the medication pass with the physician's orders [REDACTED]. Review of the Drug facts of the eye drops administered, the active ingredient was listed as [MEDICATION NAME] Alcohol. No [MEDICATION NAME] ointment was given. Error #2 and #3: On 3/14/11 at 8:35 AM, during observation of medication pass on Unit 3, RN #2 was observed to administer one Magnesium 500 milligram (mgm) tablet, Tylenol Arthritis 650 mgm one caplet, Liquid Tears eye drops, one drop each eye, Actos 45 mgm, one tablet, ASA (Aspirin) 81 mgm, [MEDICATION NAME] coated tablet, [MEDICATION NAME] sulfate 325 mgm tablet, [MEDICATION NAME] 100 mgm tablet, Senna 8.6, two tablets, and Tums two tabs. During reconciliation of the medication pass, review of the current physician's orders [REDACTED]. The resident only received one Tylenol Arthritis. The ASA that was administered was not the chewable tablet but [MEDICATION NAME] coated. [MEDICATION NAME] coated tablets dissolve at a slower rated than the chewable tablets.",2015-03-01
9576,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,514,D,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and staff interviews, the facility failed to maintain and complete accurate medical records for 2 of 19 records reviewed. Resident #17 and #18 were discharged and their medical record had not been closed in a timely manner. The findings included: Resident #17 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The medical record was reviewed on [DATE]. The medical record was difficult to follow and did not give a picture of the resident and her needs. On [DATE] there was a physician's orders [REDACTED]. There is no indication in the medical record that the consult was obtained. physician progress notes [REDACTED]. At that time there was no indication of considering Hospice or end of life. Review of the nurses notes revealed the last ""Daily Skilled Nurse's Note"" was dated for [DATE]. The note stated that the resident continued with therapy. No signs and symptoms of distress, total care with ADL's...... There were no notes regarding a deteriorating condition or concern or changes in condition that should have been reported to physician. On [DATE] there was a nurses note timed for 8:00 AM. ""Dr. --- here for routine visit, new order to d/c (discontinue) [MEDICATION NAME] TD ---notified."" The next nurses note on [DATE] at 9:10 AM, stated, ""Res (resident) has O2 (oxygen) 2L/m (liters a minute)...... There were no nurses notes from [DATE] until [DATE]. The resident expired on [DATE] The last documented social services note was dated for ,[DATE] and dated [DATE] (same social services note). There were no social services notes depicting decline in condition, need of hospice services nor end of life interventions. There was no way to know from the medical record if the resident received a hospice consult or if she was in need of a hospice consult. There was no documentation to show change in condition. On [DATE] at 4:45 PM, the DON (Director of Nursing) , ADON (assistant Director of Nursing) and Clinical Services Director were shown the chart and asked for explanation or if they could locate additional information. The ADON stated that she thought the son had rejected the hospice services, but she was unable to find any information in the medical record to support the statement. The resident expired on [DATE]. However, during the days of the survey the medical record had not been closed. Resident # 18 was admitted on [DATE] with [DIAGNOSES REDACTED]. On the days of the survey, the medical record had not been closed.",2015-03-01
9577,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,280,D,0,1,G05Z11,"**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 update resident care plans after documented changes in care and treatment had been identified. The care plan was not updated for Resident #2 related to documentation of a fungal wound that later was identified to be a pressure ulcer. Resident #1 and Resident #5's (Certified Nursing Assistant) CNA Care Plan was not updated to reflect the residents current needs and abilities based on 3 of 11 residents reviewed for care plans. The findings included: On 3/14/11 at 11:03 AM, review of the Weekly Wound Tracking Worksheet dated 3/2/11, it revealed Resident #2 had a Stage II pressure ulcer on the right buttocks. Review of the Weekly Wound Tracking Worksheet dated 3/9/11 documented that Resident #2 had a Stage III pressure ulcer on the left buttocks. The Wound Treatment and Progress Record for March 2011 revealed that Resident #2 had ordered to clean right buttock with wound cleanser. The resident's care plan dated 2/24/11 stated that the resident had fungal wounds to left buttock, right buttock, and right inner thigh and did not address the documented pressure ulcers. On 3/14/11 at 4:42 PM, an interview with the Minimum Data Set (MDS) Coordinator was conducted. She stated that she documented that the resident had fungal wounds because she did not have documentation stating the wound was a pressure ulcer. The facility admitted Resident #5 on 4-1-05 with [DIAGNOSES REDACTED]. status with direct care needs. On all days of the survey, the resident was observed in a gerichair in the Day/Dining Room with no fall prevention alarms in place. Contractures were noted to both upper extremities. Review of the Annual Minimum Data Set Assessment (Assessment Reference Date: 12-24-10) on 3-14-11 at 9:15 AM revealed that, under Section G, the resident was noted as non-ambulatory, requiring extensive assistance for transfers. Review of the Central Information Tool on 3-14-11 at 11:10 AM revealed that the information provided to CNAs related to care was noted as ""Updated 1/09"". Instructions included (1) participation in the ""walk to dine"" program, (2) use of a wheelchair, and (3) use of a chair pad alarm when out of bed."" On 3-14-11 at 4:15 PM, the Unit Manager stated that it was the unit nurse who was responsible for updating the information on the CNA Care Plan as the resident's condition changed. She stated she was unaware of the resident ever participating in the ""walk to dine"" program. The nurse also stated that Resident #5 had been in a gerichair for an extended (unspecific) period of time and that he did not use any type of fall prevention alarms. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 3-13-11 at 1:20 PM revealed current physician's orders [REDACTED]. Orders were also noted for a ""Regular diet; Pureed texture"" initiated on the same date. Multiple observations (3-13-11 at 1:15 PM and 4:30 PM; 3-14-11 at 4:30 PM) were made and no fall prevention alarms were noted to be in place. All meals observed were of pureed texture. Review of the Central Information Tool on 3-14-11 at 8:20 AM revealed that the information provided to CNAs related to care was noted as ""Updated 1/09"". The tool noted that the resident was to have ""Bed + canary alarm, C-pad alarm"" and was on a ""mech(anical) soft, lg (large) portions"" diet. On 3-14-11 at approximately 8:30 AM, the Unit Manager verified the information on the CNA Care Plan. She explained that canary alarms were the ""clip-on"" type and were no longer used. She did not know what the c-pad alarm was. On 3-14-11 at 4:15 PM, the Unit Manager stated that it was the unit nurse who was responsible for updating the information on the CNA Care Plan as the resident's condition changed.",2015-03-01
9578,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,371,F,0,1,G05Z11,"On the days of the survey, based on observation, interview, and review of the facility policy and procedure for "" Indication for Glove Use"" dated 10/2009, the facility failed to store, prepare, and serve food under sanitary conditions. The findings included: On 3/14/11 at 11:50 AM, during lunch tray line observation, it was observed that the cook used gloved hands to place chicken onto plates. The cook then used the same glove to pick up a piece of cooked beef and proceeded to chop the meat with one hand while holding the meat. The cook continued to place chicken and egg rolls on residents plates using her gloved hand and did not change gloves at anytime throughout meal service. The egg rolls were chopped for the mechanical soft diets and placed on top of the steam table throughout the meal service. It was also observed that a tray of thickened liquids and pureed desserts was placed on the ledge of the 3 compartment sink next to clean utensils that were drying. On 3/14/11 at 2:20 PM, a tour of the kitchen was conducted with the Food Service Director. It was observed that the ice machine had a rusty nail on the inside guard which was confirmed by the Food Service Director. On 3/14/11 at 6:00 PM, during supper tray line observation, it was observed that the cook used gloved hands to place french fries on each plate. The cook then proceed to pick up a bag of fries and poured them into the fryer using her gloved hands to touch the bag and the handles of the fryer. The cook then continued to plate french fries without changing her gloves. The cook touched hamburger meat with her gloved hands and then continue to use her gloved hands to place french fries onto the plates. A tray of thickened liquids and pureed desserts was again on the 3 compartment sink where dishes were drying. It was noted that the sanitizer well was completely full at the time. On 3/15/11 at 9:00 AM, an interview with the Food Service Director was conducted. She stated that food trays should not be placed on the 3 compartment sink Per review of the facility provided Nutrition Policies and Procedures ""Indication for Glove Use"" dated 10/2009, which stated ""Changes gloves whenever an un-sanitized item or surface is touched. Change gloves when they become soiled or torn and before beginning a different task..."".",2015-03-01
9579,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,372,F,0,1,G05Z11,"On the days of the survey, based on observation and interview, the facility failed to dispose of refuse properly based on grease on ground around the grease trap. The findings included: On 3/13/11 at 10:50 AM, during initial tour of the kitchen, it was revealed that the grease trap had grease on the ground around the front of the container. On 3/14/11 at 2:20 PM, during tour with the Food Service Director, it was observed that the grease trap continued to have grease on the ground around the outside of the container. During an interview with the Food Service Director, on 3/14/11 at 2:20 PM, she stated that the grease trap must have a leak and verified that there was grease on the ground outside of the container.",2015-03-01
9580,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,167,C,0,1,G05Z11,"On the days of the survey, based on observation and interviews, the facility failed to post results of complaint surveys which had been conducted since the last standard survey. The findings included: During Initial Tour of the facility on 3-13-11 and on 3-14-11, the notebook containing the survey was noted in a communication box in the entryway of the facility near the Admissions Office. Upon inspection, it was noted that the last survey available for review by residents was the Federal Comparative survey dated 2-12-10. On 3-14-11 at 3:50 PM, the Admissions/Marketing Coordinator verified that the subsequent complaint survey results (1-14-11, 7-8-10) with accompanying deficiencies were not included in the survey book and notified the Administrator. During the pre-exit management meeting on 3-15-11 at 1:45 PM, the Administrator stated he had placed the CMS-2567 Statements of Deficiencies and Plans of Correction for the complaint surveys in the book.",2015-03-01
9581,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,279,D,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to develop an Interim Care Plan to reflect the immediate care needs of one of three newly admitted residents reviewed. Resident #10's Interim Plan of Care did not address interventions related to assistance with activities of daily living, pressure ulcer risk, weight loss, pain, wandering, or risk of self harm. The findings included: The facility admitted Resident #10 on 2-28-11 with [DIAGNOSES REDACTED]. Review of the hospital History and Physical (H&P) on 3-13-11 at 1:30 PM revealed that the resident had exhibited delusional behavior with increasing anxiety in the late afternoons. She exhibited inappropriate behavior toward others, including verbal aggression and wandering, impulsive attempts to ambulate without assistance, and was at risk for self harm. Review of the Interim Plan of Care in the medical record revealed no references to the resident's cognitive state or these behaviors. The only behavior noted was: ""Obsessed with bathroom even when just been. Don't frequently use when taken but frequently ask."" Further review of the hospital H&P (history and physical) revealed that the resident weighed 103.6 pounds (#) and had been refusing food. Upon admission to the facility, the Weight Record noted that the resident was 5 feet 4 inches tall and weighed 94#, a 9.6# loss from 2-15-11 to 3-1-11. Review of the Interim Plan of Care in the medical record revealed no references to the resident's weight loss or interventions. This section was marked ""N/A (not applicable)"". Review of the admission nursing assessment (Nursing Data Collection Tool) revealed that the resident was incontinent of bladder and wheelchair dependent which were not reflected on the Braden Scale completed on the same day. The Skin Risk Analysis also did not reflect the resident's incontinence, weight loss, or Dementia which were noted as primary risk factors for impaired skin integrity. Review of the Interim Plan of Care in the medical record revealed no reference to the resident's pressure ulcer risk. The section on pressure sores was also marked ""N/A (not applicable)"". Continued record review revealed 3-3-11 physician's orders [REDACTED]. Review of the Interim Plan of Care in the medical record revealed no references for the need for pain management. When questioned on 3-14-11 at 5:30 PM about how she knew what care was needed for specific residents, Certified Nursing Assistant (CNA) #1 stated she referred to the PCR (Patient Care Record) Book at the desk or got the information from other CNAs. During an interview on 3-15-11 at 9:30 AM, CNA #2 stated she got her information in the same manner, but also added that she would ask the charge nurse if she noted that some new item of care had been implemented. Review of the Central Information Tool (CNA Care Plan) for Resident #10 revealed that it included no information on resident care needs. The only information on the care plan included name, date of birth, age, and admitted . There was no information regarding how much assistance was required with activities of daily living or any special instructions related to cognitive status/behaviors, bowel and bladder status, weight loss, or identified risks (falls, pressure ulcers). During an interview on 3-14-11 at 4:35 PM, the Unit Three Manager stated that she was unaware of the resident's behavior noted in the H&P because she had gotten no information from the hospital in verbal report. She reviewed and verified the Interim Plan of Care at this time. When asked about the CNA Care Plan, she provided a copy and verified that it was ""blank"". On 3-14-11 at 4:15 PM, the Unit Manager stated that it was the admitting nurse who was responsible for completing the information on the CNA Care Plan. During an interview on 3-15-11 at 9:20 AM, the Unit Manager confirmed the resident was underweight and stated that the family was concerned about the fact that the resident had lost a lot of weight at home and in the hospital.",2015-03-01
9582,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,318,D,0,1,G05Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to provide services to prevent further decline in range of motion for one of three sampled residents reviewed with contractures. Resident #5, with noted contractures of both upper extremities, had no evidence of ongoing services to prevent further decline in range of motion (ROM). A left arm splint and right hand device was not observed in use per the physician's orders [REDACTED]. The findings included: The facility admitted Resident #5 on 4-1-05 with [DIAGNOSES REDACTED]. Observation on 3-14-11 during the breakfast meal revealed that the resident had contractures of both upper extremities. The resident was unable to use the left arm or hand. He was able to use only the thumb and index finger of his right hand to feed himself. Review of the 1-12-10 and 12-24-10 Annual Minimum Data Set Assessments on 3-14-11 at 9:15 AM revealed that the resident had functional limitations of both upper and lower extremities. Continued record review revealed physician's orders [REDACTED]. The CNA (Certified Nursing Assistant) Care Plan did not include this information, but did indicate that he was to have a splint. No current order for the splint could be located. When this was brought to the Unit Manager's attention, she located an 8-30-10 Occupational Therapy Discharge note which stated that the resident was to have a left arm splint applied daily up to eight hours. The Unit Manager reviewed the medical record and verified that the splint order had not been brought forward on the monthly orders. Multiple observations were made of the resident in the Day/Dining Room (on 3-13-11 at approximately 11:45 AM and 1:15 PM; on 3-14-11 at 11:30 AM) without the left arm splint or right hand device in place. During an interview on 3-14-11 at 11:30 AM, the Unit Manager stated that the resident was supposed to wear a splint on the left arm and that either the aides or the nurses were responsible for the application. After observing the resident in the day area without it in place, she spoke to the CNA assigned to the resident. The CNA stated that she did not know how to apply the splint. Further record review revealed that a Restorative Plan of Care was initiated on 8-27-10 ""to maintain current ROM"" to lower extremities for a period of 90 days. There was no evidence of provision of maintenance services/ROM after 11-10. On 12-1-10, after the resident expressed interest in ""exercise for UE's (upper extremities)"", the Physical Therapist recommended ""referral back to restorative program"". However, no further restorative program participation could be found. During an interview on 3-15-11 at 9 AM, the Unit 3 Manager and therapy staff verified that there was no restorative program in place for this resident. The Unit Manager stated that the Assistant Director of Nurses (ADON) was responsible for overseeing the restorative program. During an interview on 3-15-11 at 9:45 AM, the ADON stated that she was just learning the restorative program. She stated she had audited the records to determine who had orders for restorative services, but that there was no process improvement plan in place at this time.",2015-03-01
9583,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,464,E,0,1,G05Z11,"On the days of the survey, based on observations, the facility failed to provide dining areas which were adequately furnished during the days of the survey. Residents were observed eating off from overbed tables and tables removed from other resident rooms which were not cleaned prior to use. The findings included: On 3-13-11 at the noon meal, multiple residents were noted eating off of overbed tables in the Dining/Day Room on Unit 3. On 3-14-11 at 8:15 AM, a Certified Nursing Assistant was observed to remove two soiled overbed tables from Room 120 (male room) and place them in front of two female residents in the Unit 3 Dining/Day Room. Staff delivered and set up breakfast trays and proceeded to assist the residents with their meals without cleansing the tables. During dining observation on Unit 3, on 3/14/11 at 12:30 PM, it was observed that 6 residents were eating their meals using bedside tables. On 3/14/11 at 6:28 PM, during supper meal observation on Unit 1 it was revealed that 12 residents were sitting in a circle in wheelchairs and gerichairs,eating their meals using bedside tables. During dining observation on unit 3, on 3/14/11 at 12:30 PM, it was observed that 6 residents were eating their meals using bedside tables. On 3/14/11 at 6:28 PM, during supper meal observation on unit 1 it was revealed that 12 residents were sitting in a circle in wheelchairs and gerichairs,eating their meals using bedside tables. On 03/14/11 during an observation of the lunch and supper meal on Unit I, twelve residents were observed eating off of over bed tables in the activity/dining room.The residents were noted to be very crowded.",2015-03-01
9584,KINGSTREE NURSING FACILITY,425117,401 NELSON BOULEVARD,KINGSTREE,SC,29556,2010-10-13,156,B,0,1,M1ZN11,"On the days of the survey, based on record review and interview, the facility failed to provide documentation of the timely notification of Medicare Provider Non-Coverage (CMS Form ) for 1 of 3 residents reviewed (Resident A). In addition, the facility failed to provide the required Liability Notice to 2 of 3 residents reviewed (Resident A and Resident #4). The findings included: Review of Notices of Medicare Non-Coverage for Resident A on 10/12/10 revealed the Centers for Medicare and Medicaid Services (CMS) Form indicated that current Skilled Services would end on 8/26/10. Review of the form revealed no resident or representative (RP) signature and no documentation to indicate when/how the resident or RP was notified of this change. In addition, CMS dated 8/16/10 was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. Review of Resident #4's Notice of Medicare Non-Coverage revealed CMS was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. During an interview on 10/13/10 at approximately 10:30 AM, a member of the facility's business staff reviewed the forms for Resident A and Resident #4 and confirmed the above findings.",2015-03-01
9585,KINGSTREE NURSING FACILITY,425117,401 NELSON BOULEVARD,KINGSTREE,SC,29556,2010-10-13,502,D,0,1,M1ZN11,"**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 ensure that laboratory test results were available for clinical management in a timely manner for 1 of 2 residents receiving [MEDICATION NAME] (Resident #2). The findings included: The facility admitted Resident #2 on 7/11/07 with [DIAGNOSES REDACTED]. Review of the medical record on 10/11/10 revealed Resident #2 received [MEDICATION NAME] 125 mg/5cc (miligrams/cubic centimeters) every 8 hours. Further record review indicated the current cumulative physician's orders [REDACTED]. LPN #1 was asked to review the laboratory results section of the medical record and confirmed that the May 2010 [MEDICATION NAME] Level was not on the record. When asked about the procedure for tracking when labs are due, LPN #1 stated that the Unit Manager posts a list of due/draw dates at each unit. During an interview on 10/13/10 at approximately 11:00 AM, RN #1 stated that the Unit Manager maintains a log for each resident that indicates when labs are due. RN #1 stated that lab results are faxed to the facility, sorted by the Unit Managers, and filed in the medical records after the physician signs the test results. RN #1 stated that when lab results are received, he/she documents the log with the date the lab was drawn. Review of the laboratory log for Resident #1 revealed the space to document the May 2010 [MEDICATION NAME] Level was blank.",2015-03-01
9586,SOUTHLAND HEALTH CARE CENTER,425157,722 SOUTH DARGAN STREET,FLORENCE,SC,29506,2011-04-05,425,D,0,1,701511,"On the days of the survey, based on observations, interviews, and review of the facility policy titled ""Disposal/Destruction of Expired or Discontinued Medication"", the facility failed to follow a procedure to ensure expired medications were removed from medication storage in 2 of 3 medication supply rooms. (Hall 100 and Hall 200) The findings included: On 04-05-11, at approximately 12:30 PM, observation of the Crash Cart in the Hall 200 Medication Room revealed two Heparin Lock Flushes, 100 units per milliliter (ml), Lot # 73-355-DK, with expiration date of January 01, 2011, two Sterile Waters, 20 ml, Single Dose Vial, NDC # -185-20, with expiration date of October 2010, and one 1000 ml bag of 5 percent (%) Dextrose and 0.45 % Sodium Chloride Injection, Lot # C 3, with expiration date of October 2010. Further observation of the Hall 200 Medication Room revealed one 10 ml Single dose 0.9 % Sodium Chloride Injection, Lot # 68-430-DK, NDC # 0409-4888-10, with expiration date of 08-01-2010. During an interview at 1:00 PM with the 200 Hall Ward Clerk, she stated, ""We try to check at least every month"". During an interview at approximately 1:00 PM with Registered Nurse (RN) #1, she stated, ""We just got cited by Licensure recently. Everything had been checked"". RN #1 proceeded to take the expired products to dispose of them. During an interview at approximately 1:00 PM with Licensed Practical Nurse (LPN) #1, she stated, ""The evening nurses usually check the supplies"". On 04-05-11, at approximately 2:00 PM, observation of the 100 Hall Medication Room revealed thirty 0.9 Gram packs of Dymarex Triple Antibiotic Ointment, Lot # , with expiration date of February 2011. During an interview at 2:40 PM with RN #2, she stated, ""The Ward Clerk usually checks them weekly. I'll take and dispose of them"". Review on 04-05-11 of the facility policy titled ""Disposal/Destruction of Expired or Discontinued Medication"" with revised date of 05-01-10, revealed Procedure: 4. stated, ""Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction"".",2015-03-01
9587,ROLLING GREEN VILLAGE,425160,1 HOKE SMITH BOULEVARD,GREENVILLE,SC,29615,2011-08-03,333,D,0,1,LVKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to ensure that a resident observed during medication pass (Resident A) was free of a significant medication error. The findings included: On 8/2/11 at approximately 4:04 PM, during observation of medication pass, Licensed Practical Nurse (LPN) #1 was observed to administer [MEDICATION NAME] 6.25 milligram (mg) tablet and five other medications to Resident A. After administering the medications LPN #1 returned to the medication cart and began to record the medications on the Medication Administration Record [REDACTED] On 8/2/11 at approximately 4:22 PM, through interview LPN #1 verified that the [MEDICATION NAME] 6.25 mg tablet was not administered according to the physcian's order. ""I did not take pulse, normally medical nurses have it before we get on the floor."" On 8/2/11 at approximately 4:30 PM review of the current physician's orders [REDACTED].",2015-03-01
9588,ROLLING GREEN VILLAGE,425160,1 HOKE SMITH BOULEVARD,GREENVILLE,SC,29615,2011-08-03,425,D,0,1,LVKY11,"On the days of the survey, based on observation and interview, the facility failed to discard one expired 5 milliliter (ml) Heparin Lock Flush Solution 10 units/ml which was stored in the medication room. The findings included: On 8/2/11 at approximately 2 PM, inspection of the medication storage room revealed a 5 ml Heparin Lock Flush Solution 10 units/ml with an expiration date of June 2011 available for use. Interview with Registered Nurse #1 at approximately 2:30 PM, confirmed the Heparin Lock Flush Solution was expired..",2015-03-01
9589,ROLLING GREEN VILLAGE,425160,1 HOKE SMITH BOULEVARD,GREENVILLE,SC,29615,2011-08-03,441,D,0,1,LVKY11,"**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 discard one box of expired Exuderm Odor Shield with Hydropolymer dressings and one Med Mark Inc. dressing change tray that were stored and available for use in the Medication Room. The findings included: On [DATE] at approximately 2 PM while in the medication room the following observations were made: 1. A box of ten Exuderm Odor Shield with Hydropolymer Dressings 2 inch x 2 inch with the expiration date of [DATE]. 2. One Med Mark Inc. Dressing Change Tray with the following contents: mask, measuring tape, waste bag, 2 x 2 inch gauze sponge, 4 x 4 inch gauze sponge, chlora prep 1 step applicator, chlora prep 1 step insert, non adherent dressing, transparent dressing, and one label. The expiration date was [DATE]. The expired items were in unopened and undamaged packaging and were for single use only. During an interview on [DATE] at approximately 2:30 PM, Registered Nurse (RN) #1 confirmed the expired items in the medication room. RN #1 stated, ""Nurses take turns every week checking the med room and pharmacy comes one a month to check for expired meds.""",2015-03-01
9590,ROLLING GREEN VILLAGE,425160,1 HOKE SMITH BOULEVARD,GREENVILLE,SC,29615,2011-08-03,225,D,0,1,LVKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to report and investigate an allegation of misappropriation of a resident's property to the State Survey and Certification Agency. ( 1 of 7 sampled resident reviewed) Resident #3 informed the facility that ""someone stole his money"". There was no report or investigation submitted to the State Survey and Certification Agency. The findings included: The facility admitted Resident #3 on 5/31/11 with [DIAGNOSES REDACTED]. Record review revealed a nurse note dated 6/04/11 that indicated the resident was alert with no confusion and was able to make his needs known. The nurse note further indicated the resident came to the nurse station with his wallet in his hand and stated ""he had almost $100.00 in his wallet yesterday and now there is only $4 in his wallet states he think someone stole his money"". An interview on 8/02/11 at approximately 1:32 PM with the resident revealed he felt someone stole money from his wallet and he had reported the incident to the facility staff. The resident further stated ""I still have not heard any about the stolen money and I wish they would let me know something."" An interview on 8/02/11 at approximately 2 PM with the Social Services Director revealed the facility was aware of the report and the report was taken a grievance and the facility staff spoke with the ""boyfriend"" of the resident's daughter and not the resident. An interview on 8/03/11 at approximately 8:30 AM with the DON (Director of Nursing) confirmed the report was taken as a grievance. The DON further stated the facility did not report the allegation to the State Survey and Certification agency as a misappropriation of property.",2015-03-01
9591,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,285,D,0,1,HEEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review and interview, the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for Resident #3 who was admitted with a [DIAGNOSES REDACTED].#5. (2 of 14 Residents reviewed for PASRRS) The findings included: Resident # 3 was admitted to the facility 1/7/11 with [DIAGNOSES REDACTED]. Interview with Social Service Staff #2 on 2/1/11 at 1:05PM confirmed a PASRR had not been completed for the resident. The facility admitted Resident #5 on 2/2/10 and readmitted the resident on 2/25/10 with [DIAGNOSES REDACTED]. Review of the PASARR- Level I Screening Form dated 3/1/10 on 2/1/11 at approximately 12:00 Noon revealed ""Section V. Pertinent Information"" had not been filled out related to the Signature and title of assessor. During an interview on 2/1/10 at 12:05 PM, Social Worker #3 verified the signature and title of the assessor had not been completed. . During an interview on 2/1/11 at 4:30 PM, Social Worker #4 verified Resident #5 had been admitted on [DATE] and that the PASARR for Resident #5 had not been filled out until 3/1/10. She thought the family had not been available at the time. She also verified the signature and title of the assessor on the back of the form had not been completed, and that she had just signed it ""today"".",2015-03-01
9592,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,367,D,0,1,HEEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, random observations, and interview Residents # 7 and #14 with a physician's order for a NAS ( No Added Salt ) diet received salt packets on meal trays. Resident #13 with a physician's order for Honey Thickened Liquids received Nectar Thicken Liquids on meal tray. ( 3 of 14 sampled residents reviewed for therapeutic diets.) The findings included: The facility admitted Resident #7 on 12/06/10 and readmitted on [DATE] and 1/26/11 with [DIAGNOSES REDACTED]. Record Review on 1/31/11 revealed Resident #7 to have a physician's order dated 1/27/11 to change diet to Regular, RCS (Reduced Concentrated Sweets), NAS (No Added Salt). During the supper meal served at 6:15 PM, the resident's tray had salt packets on the tray. The tray card did not have NAS listed on the card. On 2/01/11 at the lunch meal at 1:10 PM, salt packets were again observed on the meal tray. An interview on 2/1/11 at 9:55 AM with the RD (Registered Dietician) and the Food Service Manager revealed that a Diet Order and Communication Form had not been received from nursing when the resident returned from the hospital with the change in diet. The facility admitted Resident #14 on 1/6/11 with [DIAGNOSES REDACTED]. Record Review on 1/31/11 revealed a physician's order dated 1/18/11 to add NAS (No Added Salt ) to diet. During the supper meal served 1/31/11 at 5:30 PM, salt packets were observed on the meal tray. The tray card was not marked for NAS diet. On 2/1/11 at 12:30 PM observation was made of the lunch tray served to the resident and salt packets were again on the tray. During an interview on 2/1/11 at at 9:55 AM, both the RD and the Food service Manager confirmed the Kitchen had not received the Diet Order and Communication Form from Nursing to show the order change by the physician. Resident #13 was admitted to the facility 6/1/07 with [DIAGNOSES REDACTED]. Observation of the resident's lunch on 02/1/11 at 1:00 PM revealed 2 containers of nectar thickened liquids. In addition, the CNA assisting the resident stated she mixed a packet of thickener with coffee to make it nectar thick. Interview with the Food Service Supervisor on 2/1/11 at approximately 3:00 PM revealed there had been a communication form sent from nursing changing the consistency of the liquids from nectar thickened to honey thickened liquids on 12/1/11. The computerized diet slip had the correct type of thickened liquids. It was also noted during record review that the Registered Dietitian's progress notes for 12/3/10 and 1/25/11 documented that the resident was on nectar thickened liquids.",2015-03-01
9593,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,333,D,0,1,HEEE11,"**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 ensure that a resident observed during medication pass was free of a significant medication error. (Resident A) The findings included: On 2/2/11 at 9:36 AM, during observation of medication pass, Licensed Practical Nurse (LPN) #2 was observed to administer one [MEDICATION NAME] 6.25 milligram (mg) tablet and 8 other medications to Resident A. Review of the current physician's orders [REDACTED].#A revealed an order for [REDACTED]. LPN #2 was not observed to take Resident A's blood pressure prior to administering the [MEDICATION NAME] to the resident. During an interview on 2/2/11 at 9:48 AM, LPN #2 confirmed that she had not taken the resident's blood pressure, that it was not recorded on the blood pressure sheet on the medication cart and that she did not know what the resident's blood pressure was when the [MEDICATION NAME] was administered to the resident. LPN #2 stated that the Certified Nursing Assistant (CNA #1) assigned to Resident A may have taken the resident's blood pressure that morning and recorded it on the vital signs sheet at the Nurses Station. Review of the vital signs sheet at the Nurses Station revealed no blood pressure recorded for Resident A. During an interview on 2/2/11 at 10:25 AM, CNA #1 stated that she had not taken Resident A's blood pressure that morning, but she thought LPN #2 had taken it.",2015-03-01
9594,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,425,E,0,1,HEEE11,"On the days of the survey, based on observations, interviews, and the Drug Facts and Comparisons book (updated monthly), the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 2 of the facility's 3 medication rooms. The findings included: On 2/1/11 at 11:43 AM, observation of the 200 Unit medication room revealed one 5 ml (milliliter) vial (50 tests) Tuberculin Purified Protein Derivative, opened with a puncture date of 12/28/10. The Drug Facts and Comparisons book (updated monthly), page 2001, states (in reference to Tuberculin Purified Protein Derivative): ""Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency."" During an interview on 2/1/11 at 11:58 AM, the Director of Nursing (DON) revealed that the Infection Control Nurse and the Unit Manager check the medication room once a month for expired products and that Pharmacy also comes once a month and checks the medication room. On 2/1/11 at 12:01 PM, observation of the 100 Unit medication room revealed one 5 ml vial (50 tests) Tuberculin Purified Protein Derivative (PPD), opened with no date of puncture. During an interview on 2/1/11 at 12:52 PM, The Unit Manager stated that she (the Unit Manager) checks the medication room for expired products. She stated that she did not know who opened the vial of PPD but would find who did. On 2/1/11 at 3:10 PM, the Unit Manager stated that Licensed Practical Nurse (LPN) #3 had given the PPD shot to Certified Nursing Assistant (CNA) #2 yesterday (1/31/11) but confirmed that the vial of PPD had not been dated when it was punctured.",2015-03-01
9595,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,328,D,0,1,HEEE11,"**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 ensure that Resident #1, with a [MEDICAL CONDITION], receive proper specialized care. Oxygen filters were observed to be heavily soiled on two days of the survey. (1 of 1 sampled residents with a [MEDICAL CONDITION].) The findings included: The facility admitted Resident #1 on 12/24/10 with the [DIAGNOSES REDACTED]. The record review on 01/31/11 revealed current Physician order [REDACTED]. material at each observation. On 2/1/11 the resident's wife was present in the room when the surveyor checked the filters and she commented she did not recall anyone checking the filters before. On 2/1/11 at 4:05 PM the Unit Secretary accompanied the surveyor to the resident's room and was shown the filters. She agreed they needed to be cleaned and immediately washed both filters.",2015-03-01
9596,SPRINGDALE HEALTHCARE CENTER,425169,146 BATTLESHIP ROAD,CAMDEN,SC,29020,2011-02-02,314,D,0,1,HEEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to ensure that 1 of 4 residents observed for wound care (Resident #2) received necessary treatment and services to promote healing. The findings included: The facility admitted Resident #2 on 7/22/10 with [DIAGNOSES REDACTED]. Observation on 2/1/11 at 2:20 PM of wound care on an unstageable sacral ulcer revealed the Unit Manager holding Resident #2 on her right side Registered Nurse (RN) #1, who was performing the wound care, sprayed wound cleanser on the sacral ulcer allowing the cleanser to flow by gravity across and through the wound. She then used 4 x 4's to dab all around the inside surfaces of the wound, potentially cross contaminating the wound. She then used another 4 x 4 to dry the wound, again dabbing around the inside surfaces of the wound . After washing her hands and re-gloving, the nurse then squeezed Santyl ointment onto her gloved hand, and used her gloved hand to dab the ointment over the yellow/white portion of the wound. When finished with the treatment, the nurse initialed the treatment as being completed. According to the treatment record that had been initialed, the nurse was to have applied the Santyl Ointment ""nickel thick"". When asked what ""nickel thick"" meant, the nurse stated the size of a nickel. The Unit Manager, who was also present, gestured the size of a nickel with her fingers and stated that is how thick the ointment should be applied. During an interview on 2/1/11 at approximately 3:45 PM, RN #1 verified she had sprayed the wound cleanser over the wound and had cleaned and dried the wound by dabbing the wound with 4 X 4's, and had not cleaned from inner to outer surfaces of the wound. When the surveyors observations were shared that she had not applied the Santyl ointment per the physicians orders of ""Apply Santyl ointment- nickle thick layer"" to sacral ulcer, RN# 1 stated she had thought she had done so.",2015-03-01
9597,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,252,D,1,1,P7F311,"On the days of the survey based on observations and interview, the facility failed to provide a clean, comfortable and homelike environment for 2 of 2 dining rooms with tablecloths. Soiled/stained tablecloths were noted in the Indigo and Magnolia dining rooms. The findings included: On 5/3/11 at 10:45 AM, two stained tablecloths were noted in the Indigo dining room. On 5/4/11 at 3:45 PM, stained tablecloths were again observed. On 5/3/11 at 11:15 AM, three soiled/stained tablecloths were observed in the Magnolia dining room. On 5/4/11 at 4:30 PM, five soiled/stained tablecloths were observed. On 5/5/11 at 12:05 PM, the Administrator observed the Magnolia dining room and confirmed the soiled/stained tablecloths. On 5/5/11 at 6:00 PM, the Housekeeping Supervisor stated that the tablecloths were changed after lunch and dinner and taken to the laundry.",2015-03-01
9598,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,323,D,1,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey and complaint inspection, based on record reviews, interviews, and review of facility fall investigative documents, the facility failed to ensure residents were provided with adequate supervision and assistance devices for 1 of 4 residents reviewed who had falls that resulted in fractures (#6). Resident #6 had two falls at the facility during which her safety alarms were not in place and/or armed. The findings included: Resident #6 with [DIAGNOSES REDACTED]. Review of information from the hospital revealed the resident fell at home in late February and fractured her left humerus in two places. She had a bipolar left hemiarthroplasty, went to rehabilitation, and then went home where she fell again causing a wound dehiscence. The resident received antibiotic treatment for [REDACTED]. Review of the resident's admission Minimum (MDS) data set [DATE] revealed she was alert and oriented with no communication problems. The resident was not ambulatory and required extensive assistance with transfer, dressing, hygiene, and toilet use. Review of the Multidisciplinary Review dated 4/1/11 by physical therapy and speech therapy, and 4/2/11 by occupational therapy, showed an entry in the category of COMPREHENSION/SAFETY stating the resident had had a previous fall and was recommended to have a bed and wheelchair body alarms. Review of the resident's care plan and the Kardex revealed the resident needed a personal safety alarm while in bed and while in the chair. Review of the Interdisciplinary Progress Notes showed an entry on 4/5/11 at 1800 (6 PM) stating the resident fell from her wheelchair while trying to toilet herself unassisted. ""...Alarm was not sounding nor was it in place to W/C (wheelchair)."" There was no evidence of injury to the resident from the fall. On 4/18/11, the Interdisciplinary Progress Notes documented another fall at 1855 (6:55 PM). The nurse heard a loud noise and found the resident on the floor in the hallway leaning against the wall on her left side, bleeding from her wound. The staff called 911 and the resident went to the hospital where a fractured left shoulder was diagnosed . ""This nurse noted alarm to W/C was turned off."" An interview with the Unit Manager on 5/4/11 at 4:45 PM revealed personal safety alarms were supposed to be checked by the Certified Nursing Assistants (CNAs) during rounds at the change of every shift. The Unit Manager stated the CNAs' compliance with checking the alarms was not always perfect, and they seemed to be better checking the tab alarms than the pressure pad alarms. During the Initial Tour of the facility on the 300 Hall with Licensed Practical Nurse (LPN) #2 beginning at 6:40 PM on 5-2-11, two residents who were in bed were randomly selected for review related to falls. Both had fall prevention measures in place. At 7 PM, Resident #15 was observed sitting up in bed feeding herself. Half siderails were in place and an alarm mat was noted on the floor at the bedside with an overbed table positioned on the mat. When asked to check the mat's function, the LPN noted that it was not turned on. At 7:45 PM, Resident #12 was noted in a bed with one side against the wall and a half rail up on the other side. A bed alarm unit was noted to be attached to the headboard. When checked, the alarm was noted to be in the ""off"" position. This was verified at the time by LPN #2. The LPN stated,""The alarms should be turned on when the residents are in bed.""",2015-03-01
9599,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,312,D,0,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to provide hygiene and nail care as required for one of one sampled residents reviewed with a noted need for nail care. Resident #2, was noted with thick, yellow fingernails, one inch or more in length past the fingertips, curving into the palm of his contracted hand. The Resident's hand was noted with a foul odor. The findings included: The facility admitted Resident #2 on 12-11-09 with [DIAGNOSES REDACTED]. Observation on 5-4-11 at 8:45 AM revealed that the resident's fingernails were thick, yellow, and curved inward toward the palm of his contracted hand. During an interview on 5-4-11 at 9:15 AM, Licensed Practical Nurse (LPN) # 1 confirmed that the resident's nails were thick, yellow and in need of attention. When she opened the resident's contracted hand to examine his nails, a foul odor was present. When asked what the smell was, she stated, ""Some sort of body odor."" She stated that the podiatrist looked at them and ""cannot do anything with them."" Record Review on 5-4-11 at 9:30 AM revealed 4-18-11 Discharge Instructions from the wound center on that included a physician's orders [REDACTED]. During an interview with the Director of Nursing (DON ) on 5-5-11 at approximately 2:15 PM, she confirmed that there was no documentation in the chart regarding follow-up from the physician's orders [REDACTED].",2015-03-01
9600,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,156,D,1,1,P7F311,"**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 afford one of twenty-one sampled residents reviewed for code status the opportunity to formulate his/her own advanced directives. The findings included: The facility admitted Resident #13 on 05-04-10 with [DIAGNOSES REDACTED]. Record review on 5-3-11 at 5:30 PM revealed an Emergency Medical Services Do Not Resuscitate Order signed by a family member on 5-20-10. Review of the Level of Comprehension form revealed it was signed on 5-13-10 by one Physician, and signed on 5-20-10 by a second physician, certifying that Resident #13 ""was not able to make healthcare decisions (including Advance Directives)"". 5-5-10 Dietary Progress Notes stated ""Resident is alert and oriented and able to make his needs known."" 12-23-11 Social Progress Notes stated that Resident #13 ""was cognitively competent with a score of 15 on the Brief Interview for Mental Status (BIMS)."" On 3-24-11 Social Services noted a BIMS of 14 (cognitively intact). Review of the 3-23-11 and 12-22-10 Minimum Data Set (MDS) assessments revealed that the resident was cognitively intact. During an interview with the Social Worker on 5-4-11 at approximately 5:30 PM, she stated that she let the family sign if the resident requested them to do so and she would document this on the Social Service Progress Notes. Review of the Social Service Progress Notes revealed no documentation of this. She also stated that if a resident's cognitive status improved after admission, she did not go back and discuss advance directives with the resident. She had no tracking mechanism in place and it was not reviewed with the Care Plan on a quarterly basis.",2015-03-01
9601,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,318,D,0,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to provide services to prevent further decline in range of motion for one of three residents sampled with contractures. Resident #2 with noted contractures of both upper extremities, had no hand rolls or arm splint in place as ordered by the Physician. The findings included: The facility admitted Resident #2 on 12-11-09 with [DIAGNOSES REDACTED]. Observation on 5-3-11 at 12:00 PM revealed that Resident #2 had contractures of both hands and left arm. The right arm/hand had significant [MEDICAL CONDITION] present. Record review on 5-3-11 at 10:20 AM revealed physician's orders [REDACTED]. During an interview on 5-4-11 at 9:15 AM, Licensed Nurse (LPN) # 1 stated she had ""not seen any hand rolls or splint for a while."" An interview with the Rehabilitation Program Manager on 5-5-11 at 11:30 AM confirmed that hand rolls and left elbow splint were ordered and agreed that they should be in place to provide comfort, prevent further contractures, and prevent fingernails from digging into palms of hands. Upon entering the resident's room, the surveyor noted the Unit Coordinator at the bedside. She and the Rehabilitation Program Manager confirmed that the hand rolls and splint were not on the resident as ordered. After searching the room, they located one hand roll in the resident's bedside table. The Unit Coordinator stated she ""did not know if it should be on him (the resident) or not."" They both also confirmed that significant [MEDICAL CONDITION] was present to the resident's right arm and hand.",2015-03-01
9602,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,328,D,0,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to administer oxygen (O2) at the prescribed rate to 1 of 4 residents reviewed on oxygen therapy. Resident #13 had a physician's orders [REDACTED]. The findings included: The facility admitted Resident #13 on 5-4-10 with [DIAGNOSES REDACTED]. Observations on 5-2-11 during the Initial Tour, on 5-3-11 at 10:05 AM, 3:20 PM, and 6:35 PM, on 5-4-11 at 8:50 AM, 9:10 AM, and 5:20 PM, and on 5-5-11 at 9:25 AM revealed Resident #13 receiving O2 at 3 LPM Review of the physician's orders [REDACTED]. During an interview on 5-4-11 at 9:10 AM, Licensed Practica Nurse (LPN) #1 checked the O2 concentrator and confirmed the settings at 3 LPM. The nurse checked the O2 saturation of the resident which was 94%. During an interview on 5-5-11 at 9:15 AM, the Director of Nursing and the Nurse Consultant confirmed the physician's orders [REDACTED]. After verifying the wrong setting on the concentrator, the Nurse Consultant stated that she had corrected it.",2015-03-01
9603,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,367,D,0,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation and interviews, the facility failed to provide the diet as ordered by the physician for one of eight residents reviewed for therapeutic diets. Resident # 13 was provided a regular diet instead of a carbohydrate controlled diet as ordered by the physician during two meal observations. The findings included: The facility admitted Resident #13 on 5-4-10 with [DIAGNOSES REDACTED]. Record review on 5-4-11 at 9:50 AM revealed a physician's orders [REDACTED]."" Observation on 5-3-11 at 12:15 PM revealed the resident's lunch tray had a card indicating that the resident received ""Regular Diet, Mechanical Soft, Chopped Meat with Extra Protein."" The food noted on the tray consisted of rice and shrimp (not chopped), fried okra, corn bread, pudding, butter, one salt packet, two sugar packets, ice tea, 2 percent milk, and one can of tomato juice. The resident stated, ""I am not supposed to have sugar because I am a diabetic."" Observation of the supper tray on 5-3-11 at 6:30 PM revealed the resident received the same diet as lunch. The food on the tray consisted of spaghetti with meat sauce, squash, a bread roll, tomato juice, tea, 2 percent milk, fruit cocktail, and 2 sugar packets. During an interview on 5-5-11 at 3:55 PM, the Dietary Manager stated she compared the physician's orders [REDACTED]. During an interview on 5-5-11 at 3:50 PM, the Ward Secretary stated that after the Physician writes a diet order, it is placed on a Diet Communication Form and sent to the Dietary Manager who kept a copy in a notebook. The Ward Secretary could not locate her copy of the Diet Communication Form. She provided a copy of the original physician's orders [REDACTED].""",2015-03-01
9604,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2011-05-05,441,E,0,1,P7F311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record reviews, the facility failed to appropriately implement contact precautions for one of one sampled residents reviewed on transmission-based precautions. Resident #2 had contact precautions in place without a Physicians Order, and was then removed after a physician's orders [REDACTED]. There was no documentation in the chart relating to the resident being on any type of precautions, even though the resident had a known multi-drug resistant organism (MDRO) in the sputum. The findings included: The facility admitted Resident #2 on 12-11-09 with a [DIAGNOSES REDACTED]. During Initial Tour of the facility on 5-2-11 on 6:30 PM , a cart containing isolation personal protective equipment (PPE) was observed in the corridor outside the resident's room. A sign was on the door indicating he was on contact precautions. The accompanying nurse stated that the resident was on precautions for extended-spectrum beta-lactamases ( ESBL) and asked the surveyor if she ""would like to dress out"" to enter the room. They both entered the resident's room in protective gear based on facility policy as stated by the nurse. . Observations on 5-3-11 at 10:00 AM revealed that the isolation cart and sign had been removed. Record review on 5-3-11 at 10:20 AM revealed a physician's orders [REDACTED]."" No record could be found related to when precautions had been implemented. Review of Infection Control Logs on 5-5-11 revealed no record of the resident being placed on transmission-based precautions. Review of laboratory reports on 5-3-11 at 10:20 AM revealed a 12-9-10 sputum culture positive for ""[DIAGNOSES REDACTED] Pneumoniae -ESBL producer....This organism has been confirmed as having resistance due to...ESBL. It should therefore be considered clinically resistant to therapy..."" During an interview on 5-5-11 at 11:55 AM, the Director of Nursing (DON), stated that when she was doing rounds, she noted the cart in the hall and sign on the door and removed them because she knew the resident was not on precautions. She also stated, ""Someone probably put it there to use the items off the cart if needed when doing tracheostomy care."" After the DON reviewed the chart, she said ""When the resident finished his antibiotics, he was considered colonized and precautions should have been discontinued."" She verified that there was no order to start the resident on contact precautions. When asked for documentation regarding the resident being colonized,the DON presented a Consultation Record completed while the resident was hospitalized on [DATE], which stated in the Assessment and Plan section; ""The ESBL is most likely a colonizer."" Policy and procedures on precautions required for residents with ESBL were requested, but the DON stated the facility had none.",2015-03-01
9605,CAPSTONE HEALTH & REHAB OF EASLEY,425298,1850 CRESTVIEW ROAD,EASLEY,SC,29642,2011-09-21,328,D,0,1,4W3811,"**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 obtain an order for [REDACTED]. The findings included: The facility admitted Resident # 6 with [DIAGNOSES REDACTED]. Multiple observations on 9/19/11 at 11:45 AM and 6:45 PM and 9/21/11 at 9:25 AM and 12:55 PM, revealed Resident #6 received oxygen at 2 lpm (liters per minute) via nasal cannula throughout the days of the survey. At 3:30 PM on 9/19/11, review of the Discharge Summary from the hospital, the admission physician's orders [REDACTED]. Record review of the Nurse's Notes at 4:05 PM revealed multiple entries that oxygen continued at 2 lpm via NC. The Initial Nursing Summary dated 9/10/11 indicated the resident was receiving oxygen therapy but did not indicate the flow rate. During an interview on 9/21/11 at 9:15 AM, the Director of Nursing (DON) confirmed there was no order for oxygen until 9/20/11. She stated that when the surveyor requested copies from the record, she reviewed the chart on 9/20/11 and found there were no orders for oxygen or an administration rate. A clarification order was obtained at that time, 10 days after admission. The Director of Nursing stated that the Assistant Director of Nursing (ADON) usually completed the clinical admission assessment but that Resident #6 was admitted on the weekend and the ADON was not at work at that time. The DON also stated that she usually reviewed admission charts within 24-48 hours but confirmed that she had not reviewed the record for Resident #6 until 9/20/11 after copies had been requested.",2015-03-01
9606,CAPSTONE HEALTH & REHAB OF EASLEY,425298,1850 CRESTVIEW ROAD,EASLEY,SC,29642,2011-09-21,425,D,0,1,4W3811,"On the days of survey, based on observation and interview, the facility failed to ensure that two (2) 1ml vials of Tuberculin Purified Protein Derivative (PPD) (Mantoux) located in one (1) of one (1) medication rooms were not expired. The findings included: On 9/19/2011 at 2:45pm, inspection of the medication room refrigerator revealed two (2) used PPD vials. A opened date of 08/07/2011 was written on one vial and a opened date of 8/17/2011 was written on the other vial. The label listed on each box stated ""30 day expiration after bottle first opened"". During an interview on 9/19/2011 at 3:30pm with Registered Nurse (RN) #1, confirmed that the vials of PPD were expired. RN #1 then left the medication room to find out who is responsible for checking for expired medications. Upon her returned she stated that the weekend third shift nurses were responsible, however all nurses check the medication prior to administration. RN #1 revealed that she was not sure if the pharmacist checks the medication room or not during their visit.",2015-03-01
9607,CAPSTONE HEALTH & REHAB OF EASLEY,425298,1850 CRESTVIEW ROAD,EASLEY,SC,29642,2011-09-21,160,E,0,1,4W3811,"**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 convey funds timely for 4 of 5 resident accounts reviewed for disbursement of funds. The findings included: Review of the ""Detail Admission/Discharge Report"" on [DATE] revealed Resident A had expired on [DATE]. According to the ""Resident Fund Management Service Closed Account Summary"", Resident A had $934.89 in her account on [DATE] when it was closed. Review of the Check Listing Report revealed a check date of [DATE]. After review, the Business Office Manager (BOM) stated that [DATE] was the date the check had been printed. She verified that the funds had not been conveyed within 30 days of the resident's death. Review of the ""Detail Admission/Discharge Report"" on [DATE] revealed Resident B had expired on [DATE]. According to the ""Resident Fund Management Service Closed Account Summary"", Resident B had $.48 in her account on [DATE] when it was closed. Review of the Check Listing Report revealed a check date of [DATE]. After review, the BOM stated that [DATE] was the date the check had been printed. She verified that the funds had not been conveyed within 30 days of the resident's death. Review of the ""Detail Admission/Discharge Report"" on [DATE] revealed Resident C had expired on [DATE]. According to the ""Resident Fund Management Service Closed Account Summary"", Resident C had $1270.09 in her account on [DATE] when it was closed. Review of a copy of the check showing disbursement of funds revealed a check date of [DATE]. The BOM verified the funds had not been conveyed within 30 days of the resident's death. Review of the ""Detail Admission/Discharge Report"" on [DATE] revealed Resident D had expired on [DATE]. According to the ""Resident Fund Management Service Closed Account Summary"", Resident D had $1040.67 in her account on [DATE] when it was closed. Review of a copy of the check showing disbursement of funds revealed a check date of [DATE]. The BOM verified the funds had not been conveyed within 30 days of the resident's death. During an interview on [DATE], the BOM stated that she couldn't believe she overlooked those accounts. She stated the process was to make a request to the corporate office for the account to be closed and the money transferred so she could disburse the funds. She thought that the money had not been refunded within the 30 days because money was still owed on the accounts. She stated there was no way to know when she had requested the funds be disbursed.",2015-03-01
9608,CAPSTONE HEALTH & REHAB OF EASLEY,425298,1850 CRESTVIEW ROAD,EASLEY,SC,29642,2011-09-21,323,D,0,1,4W3811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide adequate supervision and/or assistance devices for one of three residents reviewed for falls. Nursing staff were not aware of a recommendation from therapy for a bed alarm for Resident #2. The findings included: The facility admitted Resident #2 on 5/6/11 with [DIAGNOSES REDACTED]. Observations on 9/19/11 at 2:43 PM and 9/20/11 at 9:10 AM and 11:05 AM revealed Resident #2 lying in bed with her eyes closed. There was no bed alarm in place. Review of Nurses Notes on 9/19/11 and 9/21/11 revealed the following entries: ""5-6-11 11:30 (AM), Resident is a [AGE] year old female who has been living at home with her son when she fell and bruised her chest and rt (right) shoulder on Sunday, May 1. Resident admitted to room ..."". ""5/9/11 7:45 P(M), CNA (Certified Nursing Assistant) called this nurse to room. Res (Resident) found sitting in floor....(No) injury noted...Res stated ""I was trying to get in bed.""..."". ""6/17/11 12:45 AM, No distress from fall..."". ""7/15/11 8:30 AM, Resident in bathroom on floor, states ""I slipped + fell + hit my head over there"" pointing to tub. ROM (Range of Motion) complete, no signs injury. Bump noted on r(ight) side of head (with) discoloration (purple)..."". ""7/15/11 9:15 AM, NP (Nurse Practitioner) returned call r/t (related to) fall, send Resident out to ER (emergency room ). Resident c/o (complaint of) fell ing ""sleepy""..."". ""7/24/11 11:30 PM, Resident noted to be sitting on floor in front of w/c (wheelchair) in an upright position...No injury noted-...Res stated ""I slipped""- Res has had (increased) confusion since foley cath(eter) was put in-..."". ""8/10/11 8:50 PM, Resident noted sitting on bottom in bathroom. When asked what happened resident stated ""I slipped coming back from the bathroom...Educated on purpose and use of call light. Resident voiced understanding"". ""8/20/11 1:46 AM, Resident sitting on floor by bathroom door. Resident states, ""I was going to the bathroom and fell lightly. I'm OK."" (No) complaints of pain..."". Review of ""Incident Report(s)"" revealed Resident #2 had falls on 5/9/11, 6/16/11, 7/15/11, 7/24/11, 8/10/11, and 8/20/11. The report revealed there had been no safety devices in place at the time of the falls. Review of the Care Plan revealed a ""Problem Onset"" date of 5/9/11 for ""I am at risk for falls due to gait disturbances, poor safety awareness, and muscle weakness"". Approaches included ""Remind me to ask for assist for all ambulation, Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician...Refer me to restorative nursing program as needed, PT/OT (Physical Therapy, Occupational Therapy) to eval(uate) and tx (treat) as ordered..."". Approaches that had been handwritten on the Care Plan included ""7/25/11- Non-slip shoes, 8-11-11 Therapy to eval(uate), 8-17-11 Restorative as ordered, 8-20-11 enc(ourage) to call for assist(ance) prior to transfers"". There were no interventions listed for the falls on 6/16/11, or 7/15/11. Review of the Admission and Quarterly Minimum Data Set (MDS) Assessments with Assessment Reference Dates of 5/15/11 and 8/6/11 respectively revealed in section J1800 that no falls had been coded since admission or since the prior assessment. Review of the ""Fall Risk Assessment"" dated 8/9/11 revealed a ""Fall Risk Score"" of 22-42 which was ""Med(ium)"". According to the facility MDS consultant, the answers to the ""Fall Risk Assessment"" generated numbers that when totaled, determined the ""Fall Risk Score"". Two of the questions included in the assessment were ""Hx (History) of falls in last month?, Hx of more than 1 fall in the last 6 months?"". Both questions had not been checked as having been true of Resident #2, which in turn generated a ""0"" score for those questions. During interviews on 9/20/11 and 9/21/11, MDS Nurse #1 verified the Admission and Quarterly MDS assessments above had not been coded correctly in relation to the number of falls and stated it was an oversight. She also verified the ""Fall Risk Assessment"" had not been coded correctly and the score would have been higher if scored for falls the resident had. During an interview on 9/20/11 at 4:32 PM, the Director of Nurses (DON) and MDS Nurse #1 were present. They reviewed and verified the above Care Plan interventions. When asked if she knew what the recommendations from therapy were from the August screen related to falls, the DON stated she would have to look at the notes. Review of the Interdisciplinary Therapy Screening Form dated 8/15/11 revealed the resident had recent falls. The therapist had noted under ""Recommendations"" that Skilled Therapy Services were not indicated and the resident should be referred to Restorative Nursing for ambulation. Review of Physician's Telephone Orders dated 8/17/11 revealed an order for [REDACTED]. Under ""Comments"", therapy had documented ""No decline noted in bed mob(ility)/transfers- I -S/P (status [REDACTED]. During an interview on 9/20/11 at 5:00 PM, the DON stated she did not know if a bed alarm at night had been discussed for the resident. During an interview on 9/20/11 at 5:03 PM, MDS Nurse #1 did not remember discussing the bed alarm for the resident and was not aware of the recommendations from therapy for the bed alarm. During an interview on 9/21/11 at 9:35 AM, the DON stated she had not been aware of the recommendation for the bed alarm, but that from then on therapy screens would come to her first before being put on the chart. She stated had she known, the bed alarm would have been discussed. She stated that therapy's recommendation for Restorative Nursing for ambulation had been completed and that interventions had been put into place after each fall. When asked how the recommendation for Restorative Nursing got implemented and not the bed alarm, the DON stated that therapy wrote the order for Restorative Nursing.",2015-03-01
9609,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-11-29,280,D,1,0,159X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review and interview, the facility failed to assure 1 of 3 residents reviewed for assistive devices had their care plans reviewed and revised to reflect the current needs of each resident. Resident #1 was not care planned for a physician ordered sippy cup for all liquids. The findings included: The facility admitted Resident #1 on 6/15/2011 with [DIAGNOSES REDACTED]. Review of the October 2011 Cumulative Physician order [REDACTED]."" Review of the Resident's Care Plan that was reviewed 8/2/2011 and 10/20/2011 revealed the assistive device and no straw order were not included on the care plan. Review of the Central Information Tool, used by Certified Nursing Assistants to guide care, revealed the resident's ordered assistive device and an order for [REDACTED]. During an interview on 11/29/2011 at 2 PM, the Unit Manager and the Social Worker both confirmed that Resident #1's care plan and CNA care guide did not have the residents ordered sippy cup or the order for no straws. Both confirmed that the care plans should have included the assistive devices.",2015-03-01
9610,EXALTED HEALTH & REHAB OF IVA,425317,406 WEST BROAD STREET,IVA,SC,29655,2011-08-30,332,E,0,1,P2MH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and record reviews, the facility failed to ensure that it is free of medication error rates of five percent or greater. The medication error rate was 10.6%. There were 5 errors out of 47 opportunities for error. The findings included: Error #1: At 5:48 PM on 8/28/11 RN #1 was observed during medication pass. RN #1 withdrew 0.5 ml (milliliters) of [MEDICATION NAME] into a syringe. The medication was then placed into a medication cup. After knocking and awakening Resident A, RN #1 then poured the medication into the resident's mouth and followed the medication with water. She did not attempt to place the medication under the resident's tongue. On 8/29/11 review of the Medication Administration Record [REDACTED].) On 8/29/11 at approximately 4:55 PM, the Director of Nursing (DON) confirmed the medication should have been given SL as ordered. Error #2: On 8/28/11 at 6:00 PM during observation of the medication pass, LPN (Licensed Practical Nurse) #1 retrieved (1) [MEDICATION NAME] 5 mg. (milligram) tablet, (1) [MEDICATION NAME] 20 mg. tablet, (1) [MEDICATION NAME] 500 mg. tablet, (1) [MEDICATION NAME] 600 mg. tablet, (1) [MEDICATION NAME] 25 mg tablet and (1) [MEDICATION NAME] 10 mg. tablet and placed them into a medication cup. Upon entering the room, LPN #1 handed the medication cup to Resident B. The resident poured the medications onto the over-bed table and picked up the [MEDICATION NAME] which he proceeded to drop. LPN #1 retrieved the medication from the floor and discarded it. LPN #1 returned to the medication cart to replace the [MEDICATION NAME] and realized the medication had been completed with the 9:00 AM dose that morning and did not replace the medication. All other medication were administered. Review of the August monthly physician's orders [REDACTED]. On 8/29/11 at 8:53 AM, RN #2 confirmed Resident B should not have received the [MEDICATION NAME]. During an interview at 4:44 PM, LPN #1 confirmed that she gave the [MEDICATION NAME] and the DON stated the Nurse who initiated the order should have indicated the last dose on the MAR indicated [REDACTED]. Error #3: On 8/29/11 at 9:00 AM, LPN #2 was observed during the medication pass. LPN #2 placed an 81 mg. [MEDICATION NAME] Coated Aspirin into a medication souffle cup with 3 other pills and crushed them. She then placed the crushed medication into apple sauce in a plastic medication cup. After checking the pulse of Resident C, LPN #2 opened a capsule of medication and added it to the applesauce and mixed the mixture. She then administered the applesauce and medication mixture to the resident. During an interview after the administration of the medication, LPN #2 stated that if a medication should not be crushed, it is usually stated on the MAR. She verified that she did crush the [MEDICATION NAME] Coated Aspirin and confirmed that [MEDICATION NAME] coated medications should not be crushed. Review of the Medication Administration Record [REDACTED]."" On 8/29/11 at approximately 4:55 PM, the DON stated the nurse should have used the chewable form. Error #4 and #5: On 8/29/11 at 9:39 Am LPN # 3 was observed during the AM medication pass. LPN #3 placed (1) Glipized 5 mg. tablet, (1) [MEDICATION NAME] 200 mcg. (microgram) tablet, (1) [MEDICATION NAME] 75 mg. tablet, (1) 5 mg. [MEDICATION NAME] tablet, (1) [MEDICATION NAME] 5 mg tablet, (1) [MEDICATION NAME] 1000 mg tablet, and (1) [MEDICATION NAME] 100 mg. tablet into a medication cup. She then placed (1) [MEDICATION NAME] 25 mg 3/4 tablet and (1) [MEDICATION NAME] 10 mg tablet into a second medication cup. The number of medications were counted by the surveyor and the nurse, there were 7 pills in the first cup and 2 blood pressure pills in the second medication cup. After obtaining the pulse of Resident D, LPN #3 started to administer the medications. At 9:49 AM, after the surveyor questioned LPN #3, she confirmed that she had omitted the Multivitamin tablet. Review of the August monthly physician's orders [REDACTED]., 1 tab PO (by mouth) daily."" At approximately 10:10 AM, LPN #3 also confirmed that the stock bottle of [MEDICATION NAME] ([MEDICATION NAME]) contained 75 mg. tablets and that she had given only 1 tablet. She also verified the order was for 150 mg.",2015-03-01
9611,EXALTED HEALTH & REHAB OF IVA,425317,406 WEST BROAD STREET,IVA,SC,29655,2011-08-30,425,D,0,1,P2MH11,"On the days of the survey, based on observations and interview, the facility failed to ensure that expired medications were removed from storage in one of one treatment cart where other medications were stored and available for resident use. The findings included: On 8/28/11 at approximately 4:55 PM, observation of the facility's Treatment Cart revealed one 30 ml (milliliter) bottle of ""C/Trimazole/Betam"" with an expiration date of October, 2010. In addition, a tube of Dollar General Muscle Rub containing Menthol 10% and Methyl Salicylate 15% with an expiration date of 02/08 was found in the Treatment cart. During an interview on 8/28/11 at 5:17 PM, Licensed Practical Nurse (LPN) #4 confirmed that the medications were expired and should have been discarded. During an interview on 8/29/11, the Director of Nursing stated the Muscle Rub was probably brought in by a resident's family but that it should have been discarded when it was noted to be expired.",2015-03-01
9612,EXALTED HEALTH & REHAB OF IVA,425317,406 WEST BROAD STREET,IVA,SC,29655,2011-08-30,502,D,0,1,P2MH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on observation and interview, the facility failed to ensure that expired laboratory supplies were removed from storage in one of one medication rooms where other laboratory supplies were stored and available for resident use. The findings included: On [DATE] at approximately 4:55 PM, inspection of the medication room revealed 11 green top BD Vacutainer Blood Collection Tubes labeled ""PST (Plasma Separator Tube) Gel and [MEDICATION NAME]"" in the storage cabinet with expiration dates of ,[DATE]. During an interview on on [DATE] at 5:17 PM, Licensed Practical Nurse (LPN) #4 confirmed that the Vacutainer were labeled with expiration dates of ,[DATE].",2015-03-01
9613,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2011-11-21,156,C,0,1,CVQE11,"On the days of the survey, based on observation and interview, the facility failed to prominently display a posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups as required. The findings included: During the Initial Tour of the facility on 11/20/11 at approximately 11: 30 AM, the postings of names, addresses, and telephone numbers of the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit were not observed. This finding remained the same throughout the day on 11/20/11. During the Group Interview with nine interviewable residents on 11/21/11 at approximately 9:30 AM, the residents were asked if they were aware of the location of the postings for advocacy agencies, the State certification and licensure office, and Medicare/Medicaid agencies. None of the residents were aware of where this information was posted. Following the Group Interview, the surveyor located this information posted in three frames on the wall leading to the Activity Room. Observation revealed the surveyor was unable to read the information in the frame at the top and middle while standing in front of the postings. At that time, the surveyor asked a resident in a wheelchair to observe the postings. When asked if she could read the information in the three frames, the resident replied that she was unable to read the information. On 11/21/11 at approximately 11:25 AM, the surveyor informed the Administrator that none of the residents in the Group Interview were aware of the location of the required postings, and the surveyor had been unable to locate the postings until after the Group Interview and that the surveyor could not read the posted information in the top two frames. The Administrator did not dispute this finding. During an interview with the Social Services Director on 11-21-11 at approximately 8:15 AM, she confirmed that the postings related to the Medicare and Advocacy Agencies were covered up by sign related to ongoing activities. The sign was in front of the postings for 2 days of the survey, until the surveyor brought it to the attention of the Social Services Director.",2015-03-01
9614,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2011-11-21,463,E,0,1,CVQE11,"On the days of the survey, based on observation and interview, the facility failed to ensure that the resident communication system was fully functioning in multiple resident rooms, resident bathrooms, and the resident central shower room. On the B Hall, the call light system was not properly working in the following areas: Room 182B, bathrooms in Room 184A and Room 188A, and the Central Shower Room. On the A Hall, the call light system was not properly working in the following areas: Room 166A, Room 167A, Room 170A, Room 168B, Room 162B, Room 167B, Room 163A, and Room 165A. The findings included: During the Initial Tour of the B Hall on 11/20/11 at approximately 11:25 AM, random call lights were checked in resident rooms and bathrooms with the assistance of facility staff. The following concerns related to the call light system were identified at that time: (1) Room 182B had no call light working above the doorway or audible sound at the Nurses Station. (2) The bathrooms in Room 184 and Room 188 had no call light working above the doorway or audible sound at the Nurses Station. (3) The call light above the Shower Room door was constantly on and could not be turned off. (3) Room 183A, Room 184A, and Room 188A had no call bell cord at the bedside. Staff offered no explanation at this time. These areas were re-checked on 11/20/11 at approximately 12:00 PM with Licensed Practical Nurse (LPN) #1, and the above concerns remained the same. At this time, LPN #1 informed the surveyor that Room 183A, Room 184A, and Room 188A had a doorbell for the resident to use in the room and a device with light and sounding mechanism plugged into outlets in the hallway. These doorbells were tested and were operational at that time. The call bell system in rooms, bathrooms, and shower room was re-checked with Administrator and Maintenance Supervisor on 11/21/11 at approximately 12:30 PM. The light above the Shower Room door continued to remain turned on. At that time, the Administrator was asked if staff had attempted to repair the light above the Shower Room door at any time prior to the survey and if staff had a schedule for checking call bells and call lights in the facility. No information related to this process was received prior to exit from the facility. During initial tour of the facility on 11-20-11 at approximately 11:00 AM, when this surveyor checked the call light in the shower stall in the shower room on B hall, there was not an immediate response from the staff. Certified Nursing Assistant (CNA) # 1 went past the shower room twice, before checking inside the shower room. CNA # 1 stated that the light over the shower room had not been working for ""quite a while"" therefore, she didn't know where the call light was activated. Further checking of the call bell system on the A hall revealed the following: In room 170, Bed A the call button produced a light but did not sound, In room 168, Bed B the call button produced a light but did not sound, In room 166, Bed A the call button did not light and did not sound, In room 162, Bed B the call button produced a light but did not sound, In room 167, Bed A had a door bell that did not produce a light or sound, In room 167, Bed B the call button produced a light but did not sound, In room 165, Bed A had a door bell that did not produce a light, In room 163, Bed A had a call button produced a light that did not sound. A recheck of the call bell system with the Administrator and the Maintenance Supervisor at 12:30 PM on 11-21-11, revealed that the blue light above the door in the shower room on B hall, was on continuously, and that when the call light was activated in the 2 shower stalls and the commode stall, no additional lights came on above the door. Recheck of the call lights on A Hall which were not functioning on 11-20-11 revealed the following problems: The call button in room 163 Bed A was ringing and lighting up as Bed B. The call button in room 163 Bed B was ringing and lighting up as Bed A on the switchboard. The door bell for room 165 did sound but did not light up. Before the surveyors left the facility all residents who had a door bell as an alarm system also had a manual dinner bell which could be used in case of a power outage. The door bell for room 165 was replaced with a door bell which lit up as well as sounded. The call buttons on room 163 bed A and B were correctly identified on the switch board, and the shower light was repaired. The Administrator provided a purchase requisition which included a new call system for the building dated 7-6-11 and stated that the system was on order, but wasn't sure how soon it could be installed because of the wiring system which was required.",2015-03-01
9615,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2011-11-21,155,D,0,1,CVQE11,"**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 respect resident rights related to formulatting advanced directives for 1 of 10 records reviewed for code status. There was no evidence that an advance directive was formulated for Resident #1 and his medical record reflected conflicting information regarding code status. The findings included: The facility admitted Resident #1 on 10/27/11 with [DIAGNOSES REDACTED]. Review of the 11/3/11 Admission Minimum Data Set assessment on 11/21/11 at 10:25 AM revealed Resident #1 scored ""05"" on the Brief Interview Mental Status (BIMS). A score of 0-7 indicated the resident's cognitive status was severely impaired. Record review on 11/21/11 at 11:00 AM revealed a physician's orders [REDACTED]. Further review of Resident #1's record revealed no evidence of advanced directives. There was no documentation that two physicians had evaluated him to determine his capacity to make health care decisions or that advanced directives were discussed with family. Review of the Nursing Home Admission History and Physical Worksheet on 11/21/11 at 1:00 PM revealed no information to reflect a code status. Review of the Interim Plan of Care on 11/21/11 at 1:10 PM noted Resident #1 as a Full Code. During an interview on 11/21/11 at 1:30 PM with the Director of Nursing (DON), she reviewed the resident's record and stated that Resident #1 was a DNR. After further review, she verified Resident #1 should be a ""Full Code"" due to no formulation of advance directives.",2015-03-01
9616,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2011-12-07,371,F,0,1,2G3S11,"On the days of the survey, based on observation and interview, the facility failed to prepare, and serve food under sanitary conditions. Dietary staff was observed not wearing beard guards; the thermometer used for obtaining temperatures was not sanitized between food items; food items were not held at appropriate temperatures; inappropriate handling of raw food items was observed; dietary staff was observed chewing gum and the microwave was observed in poor repair. The findings included: On 12/5/11 at 6:30 PM, observation of the dinner meal was conducted. Two male staff were observed with facial hair prepping food, not wearing a beard guard. On 12/6/11 at 12:00 PM, observation of the lunch tray line was observed in Orchard View kitchen. Dietary Aid #2 was observed taking the temperature of food using a wet paper towel. Dietary Aid #2 went from vegetable to puree meat to ground meat to desserts, without properly sanitizing the thermometer. The temperature of the turkey was 125 degrees Fahrenheit, Boston Creme Pie was 80 degrees Fahrenheit, and puree Boston Creme Pie was 62 degrees Fahrenheit. All desserts were observed in pans on the counter not being kept cool. Food was plated at the start of the tray line and was going to be served to residents. Staff was asked to stop trayline until food was brought to the proper temperature. A pan of noodles and a pan of gravy were both observed not in the steam table during meal service. On 12/6/11 at 12:40 PM, in the main kitchen, Dietary Aid #3 was observed chewing gum while prepping food. The microwave was observed with grim all around the outside plastic on the door and the paint on the inside door was missing making it an uncleanable surface. On 12/7/11 at 8:17 AM, observation of temperatures and trayline were conducted in Overlook Point kitchen. Two fried eggs were observed being held above the steam table and two pancakes were held above the steam table. On 12/7/11 at 9:45 AM, an interview was conducted with the Certified Dietary Manager (CDM) and he confirmed all findings. On 12/5/11 at 6:34 PM, during a general dining observation of Orchard View dining room, Dietary Aid #1 was observed removing lettuce from a stainless steel container and placing it on plates for 2 residents using her bare hands. Certified Dietary Manager (CDM) #1 entered the kitchen area on Orchard View and talked to the Dietary Aid. At that time, the Dietary Aid donned gloves without washing her hands prior to putting on the gloves. During an interview at 9:21 AM on 12/7/11, CDM #1 confirmed that he had observed the Dietary Aid plating food with her bare hands. He stated that staff should be wearing gloves when handling ready-to-eat foods. Review of the ServSafe Essentials policy provided by the CDM as the facility's policy revealed ""Foodhandlers should change their gloves...before handling cooked or ready-to-eat food.""",2015-03-01
9617,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2011-12-07,441,D,0,1,2G3S11,"On the days of the survey, based on observation, interview and review of the facility's policy, the facility failed to utilize procedures to prevent the development and transmission of disease and infection. The Registered Nurse (RN) failed to clean a multi-use glucometer before and after obtaining a Finger Stick Blood Sugar (FSBS) for Resident A, 1 of 4 residents observed for Finger Stick Blood Sugars. The findings included: During the observation of the Medication Pass on the Orchard View unit on 12/6/11 at 11:13 AM, RN #1 obtained a FSBS with a glucometer used for multiple residents. After administering the resident's IM antibiotic, the RN removed her gloves washed her hands and donned clean gloves. She then inserted the test strip into the glucometer and proceeded to perform the finger stick. She did not clean the glucometer before using. After the blood sugar result was obtained, RN #1 then placed the glucometer back into the basket with the alcohol and chlorine wipes and lancets without cleaning the glucometer. During an interview on 12/6/11 at 1:56 PM, RN #1 confirmed she did not clean the glucometer. Review of a Lutheran Homes of South Carolina policy, ""POLICY / PROCEDURE NO. NSG____"" revealed ""General Guidelines: The glucometer is to be disinfected before and after each use with 1:10 bleach solution."" the section titled Procedure stated ""If no visible soilage is present, disinfect after each use, the exterior surfaces with a diluted bleach of 1:10 solution. Bleach wipes are available in Central Supply.""",2015-03-01
9618,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,157,E,0,1,WXRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to notify the physician and/or family of changes in the resident's condition potentially requiring physician intervention for one of six sampled residents reviewed for notification. Resident #1 had three documented instances of [MEDICAL CONDITION] symptoms without evidence of physician and/or family notification. The findings included: The facility admitted Resident #1 on 10-8-07 with [DIAGNOSES REDACTED]. Record review on 7-5-11 at 2:45 PM revealed physician's orders [REDACTED]. Take 2 tablets by mouth in the morning"" and ""...1 tablet...at bedtime"" for ""convulsions/agitation"". Review of Nurse's Notes at 3:30 PM revealed that on 4-15-11 at 10:20 AM the resident had an ""Onset of general [MEDICAL CONDITION], res(ident) up in gerichair c (with) noted tonic-clonic muscle convulsions to upper/lower extremities, every 2-3 seconds, pupils bilat(really) dilated c (with) fixed stare, skin warm c some clammy texture, resp(iratory) rate labored sporadically. Symptoms lasted 15 min(utes)...returned to relaxed state..."" Vital signs were recorded as within normal limits and no oxygen (O2) saturation (sat) level was monitored. There was no evidence in the record that the physician or family were notified of the incident. Further review of Nurse's Notes revealed that the last previously documented [MEDICAL CONDITION] was on 1-26-11. An entry in the Nurse's Notes on 6-9-11 recorded: ""@ (At) approx 10:30a(m) Resident began having episodes of convulsions...(Family) notified and MD (medical doctor) notified via MD Book."" Vital signs were noted to be essentially normal at that time and no O2 sat was documented. Further review revealed no evidence in the record that the physician had been made aware of the incident. On 6-14-11 at 9 AM, the Nurse's Notes recorded: ""Res sitting at table c a blank stare - spaced out appearance. Occasional jerking noted every few seconds...slow to respond...O2 sat 79%..."" After O2 was started at 2 liters per nasal cannula, the O2 sat increased to 98% and ""jerking ceased"". Vital signs were recorded as within normal limits. Review of the Plan of Care (last updated on 5-20-11) revealed an intervention of ""Report all [MEDICAL CONDITION] to MD promptly"" for a noted problem of ""Risk for injury during [MEDICAL CONDITION] has monaclonic jerks"". During an interview on 7-6-11 at 12:50 PM, Registered Nurse (RN) #1 and the Director of Nurses (DON) reviewed the entries in the Nurse's Notes and confirmed that there was no evidence that the physician and/or family had been notified of the changes in the resident's condition as noted above. Both stated that the oxygen was started on 6-14-11 per standing orders. RN #1 stated that the physician came to the facility 2-3 times per week, but both she and the DON reviewed the physician's Progress Notes and could find no reference to the MD's awareness of the 4-15-11 [MEDICAL CONDITION]. The last Progress Note in the record was dated 5-9-11. There was no documentation which indicated the physician had been made aware or evaluated the resident following the two [MEDICAL CONDITION] incidents in June.",2015-03-01
9619,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,365,E,0,1,WXRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, and interviews, the facility failed to provide liquids in the proper thickness for intake as ordered by the physician and for use as needed at the bedsides of six of six sampled residents reviewed for thickened liquids. Residents #1, #7, #11, #12, #13, and #14 had both nectar- and honey-thickened liquids at their bedsides. The findings included: During the Initial Tour of the facility with Certified Nursing Assistant (CNA) #1 beginning on 7-5-11 at 10:45 AM, Residents #7, #11, #12, #13, and #14 were noted with both nectar- and honey-thickened liquids in coolers at their bedsides. Resident #1 had honey-thickened liquids at the bedside when nectar-thickened was ordered. Record review on 7-5-11 at approximately 1 PM revealed that Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Nurse's Notes at 3:30 PM revealed an entry on 6-14-11 at 12 PM: ""...Extensive tactile stimulation required to assist res(ident) with eating meals + chewing (unable to read) food is in mouth. Excessive coughing noted frequently throughout meal..."" A physician's orders [REDACTED]. Therapy screened the resident on 6-22-11 and found no diet changes needed since she was tolerating the nectar-thickened liquids and had had no further choking episodes. During the Initial Tour on 7-5-11 at approximately 11 AM, five containers of honey-thickened liquids were noted at Resident #1's bedside in a cooler. CNA #1 verified this and stated that the resident was ""on nectar"". On 7-5-11 at 12:55 PM, 4:40 PM, and 6 PM, and on 7-6-11 at 9:05 AM, six containers of honey-thickened liquids were noted in the cooler at the resident's bedside. The facility admitted Resident #7 on 5-2-05 with [DIAGNOSES REDACTED]. During the Initial Tour with CNA #1 on 7-5-11 at approximately 11:30 AM, three containers of honey-thickened liquids and three of nectar-thickened liquids were noted at Resident #7's bedside in a cooler. CNA #1 verified this, stated that the resident was ""on honey"", and removed the nectar-thickened liquids. Record review on 7-6-11 revealed current physician's orders [REDACTED]. The facility admitted Resident #11 on 5-2-08 with [DIAGNOSES REDACTED]. During the Initial Tour with CNA #1 on 7-5-11 at approximately 11:30 AM, four containers of honey thickened liquids and two of nectar thickened liquids were noted at Resident #11's bedside in a cooler. CNA #1 verified this, stated that the resident was ""on nectar"". At 6:05 PM on 7-5-11, four containers of honey-thickened liquids and two of nectar-thickened liquids remained at the bedside. On 7-6-11 at 9:10 AM, four containers of honey-thickened liquids were observed in the cooler. Record review on 7-6-11 at 12:30 PM revealed current physician's orders [REDACTED]. The facility admitted Resident #12 on 3-28-11 with [DIAGNOSES REDACTED]. During the Initial Tour with CNA #1 on 7-5-11 at approximately 11:15 AM, both honey- and nectar-thickened liquids were noted at Resident #12's bedside in a cooler. CNA #1 verified this and stated that the resident was ""on nectar"". At 6:05 PM on 7-5-11, two containers of honey-thickened liquids and three of nectar-thickened liquids were still noted at the bedside. Record review on 7-6-11 at 12:30 PM revealed current physician's orders [REDACTED]. The facility admitted Resident #13 on 5-27-09 with [DIAGNOSES REDACTED]. During the Initial Tour with CNA #1 on 7-5-11 at approximately 11 AM, two containers of honey-thickened liquids and three of nectar-thickened liquids were noted at Resident #13's bedside in a cooler. Record review on 7-6-11 at 12:50 PM revealed current physician's orders [REDACTED]. The facility admitted Resident #14 on 2-3-10 with [DIAGNOSES REDACTED]. During the Initial Tour with CNA #1 on 7-5-11 at approximately 11 AM, two containers each of honey- and nectar-thickened liquids were noted at Resident #14's bedside in a cooler. CNA #1 verified this, stated that the resident was ""on nectar"". Record review on 7-6-11 at 12:50 PM revealed current physician's orders [REDACTED]. During an interview on 7-6-11 at 12:45 PM, CNA #2 stated that the thickened liquids came from the kitchen in the ice-packed coolers and that the nursing staff ""added or took them out as needed"". During an interview on 7-6-11 at 4:15 PM, the Director of Nurses stated that dietary staff was responsible for replacing the coolers daily with the correct physician-ordered thickened liquids.",2015-03-01
9620,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,309,D,0,1,WXRM11,"**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 initiate a Hospice referral per physician recommendation for one (Resident #1) of three residents reviewed for provision of Hospice services. The findings included: The facility admitted Resident #1 on 10-8-07 with [DIAGNOSES REDACTED]. Record review on 7-5-11 at 1 PM revealed a 3-30-11 Physician's Progress Note which indicated that the resident had ""end stage"" [MEDICAL CONDITION]. He noted a persistent ""slow weight loss"" with the resident being uncooperative with feeding, ""holds mouth shut"". Following the written assessment, the physician wrote, ""Would recommend hospice."" Further record review revealed no evidence that the family had been contacted to discuss this or that Hospice had been contacted to evaluate the resident for provision of services. During an interview on 7-6-11 at 12:50 PM with Registered Nurse #1 and the Director of Nurses (DON), it was initially stated that Hospice had evaluated the resident and found that she was not appropriate for services. However, the DON reviewed the medical records and returned with the information that this recommendation by the physician had not been written as an order and that there had been no follow through with regard to the recommendation. On 7-6-11 at 3:50 PM, RN #1 reviewed and verified the Progress Notes. She stated, ""No follow-up is done unless the physician writes an order.""",2015-03-01
9621,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,371,E,0,1,WXRM11,"On the days of the survey, based on observation and interviews, the facility failed to follow a procedure to ensure appropriate storage of food items and failed to ensure that expired food items were not stored in the refrigerator for use by residents. Magic Cups were found in the refrigerator instead of the freezer and expired milk was observed in the refrigerator on one of two resident care units. The findings included: During the Initial Tour of the facility with Certified Nursing Assistant (CNA) #1, at approximately 11:45 AM on 7-5-11, three 8 ounce cartons of milk were noted to be expired in the 300 Hall Skilled Unit refrigerator. Two cartons had expiration dates of 7-1-11 and one had an expiration date of 7-3-11. The CNA verified this and disposed of them. Also, eleven melted Magic Cups (like fortified ice cream) were stored in the refrigerator instead of the freezer. The CNA stated that they were to have been passed out that morning. During an interview on 7-6-11 at 3:50 PM, Registered Nurse #1 stated that the 11PM-7AM shift nursing staff was responsible for checking the refrigerator temperature and removing expired food items. She referred to the Refrigerator Compliance Check form taped to the front of the unit. During an interview with the Director of Nurses at 4:15 PM, she noted that the 11PM-7AM shift CNA was supposed to check the refrigerator nightly and remove expired items.",2015-03-01
9622,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,156,C,0,1,WXRM11,"On the days of the survey, based on observations and interview, the facility failed to display all required postings of current names and telephone numbers of pertinent State client advocacy groups. The findings included: On all days of the survey, review of postings within the Bernardin building revealed that Medicare information, Protection and Advocacy information, how to file a complaint with the State survey agency, and how to apply for a refund were not displayed within the building. Review of postings in the Skilled building revealed information on Protection and Advocacy information was not displayed. On 7/6/11, the Director of Nursing (DON) was asked to view both buildings with the surveyor for the required postings. After viewing both buildings, the DON confirmed that the required postings were not displayed. She stated that the Bernardin building had undergone renovations and that the required postings had not been replaced after the renovations.",2015-03-01
9623,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,312,E,0,1,WXRM11,"On the days of the survey, based on observations and interview, the facility failed to provide necessary Activities of Daily Living (ADL) care and services to maintain good nutrition for 3 of 3 randomly observed residents requiring dining assistance during 1 of 2 meals observed. Residents A, B, and C with limited feeding ability, were not provided assistance with eating and/or positioning, which caused excessive spillage and poor intake. The findings included: During the initial dining room observation on 7-5-11 at approximately 6:30 PM, Resident A was observed with other residents seated at a table in her Geri chair. Resident A's divided tray was set up in front of her. However, she was positioned poorly by not being upright and not in close reach to her plate. The resident was observed feeding herself, stretching to reach the tray with her spoon which caused spillage of food. Resident #1 attempted to feed herself again but then stopped eating and leaned back to rest. After eating 1 of 3 sections of food on the plate, the resident attempted unsuccessfully to reposition the plate to eat another food item. Showing signs of frustration, Resident A reached for the cup with nectar thick liquids but was unable to reach it. She then picked up a Magic Cup and dropped it in her lap which caused spillage. At approximately 7:00 PM Resident A asked Certified Nursing Assistant (CNA) #1 for help. The CNA did not respond. At 7:10 PM Resident A reached for applesauce on her tray, unsuccessfully trying to remove the clear wrap. At 7:13 PM CNA #1 asked Resident A if she needed any assistance and opened the applesauce for her. Resident A was then observed feeding herself from her lap. The CNA told the resident to put the applesauce on the table, ""You're spilling it."" At 7:20 PM Resident A asked, ""Will you please feed me?"" Two CNA's within two feet of the resident did not respond. At approximately 7:25 PM, when the resident asked for assistance the third time, the Director of Nursing (DON) assisted Resident A to consume her meal. Resident B was observed in the dining room on 7-5-11 at approximately 6:30 PM eating peas and oranges with her fingers. The Resident stopped eating and began to stand. With the encouragement of another resident Resident B did not get up. Resident B showed no interest in the meal. She stopped eating and began to stand for the second time and the chair alarm went off. Resident B expressed she wanted a sandwich to eat. At approximately 6:50 PM, the CNA brought Resident B an egg salad sandwich. Resident B moved the sandwich around and did not attempt to eat. She looked at the sandwich, picked it up, then laid it on top of the other uneaten food on the plate, and covered it with her clothing protector. The resident then attempted to get up from table once again. At 7:05 PM, a CNA assisted the resident from the table without offering assistance or encouraging the resident to eat. Observation of Resident B's tray revealed her total meal intake was less than 25 %. During dinner observation on 7-5-11 at approximately 6:30 PM, Resident C was observed mixing all of her food into her beverage. A CNA noticed and removed Resident C's cup. Resident C was then observed taking Resident A's cup and began to put more food in the cup. CNA's were observed in the area.picking up trays and cleaning tables. Staff was not observed to assist Resident C nor bring another meal for her to eat. Resident C was also noted to consume less than 25% of her dinner. Per interview with the Director of Nursing on 7-6-11 at approximately 4:15 PM, she stated she expected residents to attempt to feed themselves first and then be assisted by staff as needed.",2015-03-01
9624,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,323,D,0,1,WXRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to implement fall prevention measures as ordered by the physician for 1of 1 sampled resident, (Resident #1) reviewed for the use of bed/chair alarms. On both days of the survey, Resident #1 was observed without a chair alarm in place. The findings included: The facility admitted Resident #1 on 10-8-07 with [DIAGNOSES REDACTED]. Record review on 7-5-11 at approximately 2:45 PM, revealed a Care Plan (last updated 5-20-11) for ""Risk for falls/injury mobility devices in geri chair."" Review of the Plan of Care revealed that Resident #1 required a geri chair to be reclined to prevent rising at times. Review of the physician's orders [REDACTED]."" Observations made during Initial Tour with Certified Nursing Assistant (CNA) #1 on 7-5-11 approximately at 11 AM, revealed the resident sitting outside of her room door with no alarm in place. At approximately 2:30 PM, 4:40 PM, and 6 PM, Resident #1 was also observed in a geri chair with no alarm in place to signal staff if resident attempted to get up. During an interview on 7-6-11 at approximately 1:30 PM, CNA #2 verified that there was no chair alarm in place for Resident #1. When asked how she knew if any residents needed special care items (alarm), CNA #2 referred to a Pocket Worksheet. Review of the Pocket Worksheet revealed Resident #1 was noted as a ""Fall Risk and must have alarm in bed and chair."" Following the interview with CNA #2, Resident #1 was again observed at approximately 3 PM, at the activity/meal table without the chair alarm in place as ordered.",2015-03-01
9625,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,226,J,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey, based on observations, record review, interview and review of the facility's policy on Abuse and Neglect, Substandard Quality of Care and Immediate Jeopardy was identified on 11/08/2011 related to the facility's failure to ensure one of one allegation of neglect was thoroughly investigated. The facility was unable to provide evidence of a thorough investigation of the family's concern that Resident #16 received an unprescribed Benzodiazepine medication. Resident #16's family found the resident unresponsive at the facility on 9/17/2011 and asked that she be admitted to the hospital. The family asked the emergency room (ER) physician to perform a Toxicology Screen on 9/17/2011 during the ER visit. The Urine Toxicology Screen showed a Benzodiazepine medication that was not prescribed for Resident #16. On 9/19/2011 the family voiced their concerns to the facility related to the drug screen. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Resident #16's closed medical record was reviewed due to a complaint that a Benzodiazepine medication was found during a Toxicology Screen at a hospital on [DATE]. In an interview on 10/31/2011 at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive urine sample and that the resident was not prescribed any Benzodiazepines. The DON stated that the Licensed Practical Nurse (LPN) #3) on duty the night of the incident, denied during interview, administering ""anything that was not prescribed to the resident."" The DON further stated that LPN #3 had other medication errors and was re-educated. During the ""re-education"", LPN #3 apparently made another error and was then placed on PRN (as needed) staffing. The DON stated that LPN #3 had not worked since. The DON stated the facility did not obtain proof of the positive toxicology screen, reported by the resident's family. Review of an undated, written statement provided by the DON, she documented, ""On 9/19/11, (Resident #16's family member) came in and told me about his experience with LPN #3, second shift nurse. He explained that... after she was admitted , her bed sheets were dirty. Stating they were bloodstained and when LPN #3 was informed she cut off paper/plastic bracelets from the hospital and stated that the bracelets cut her arm. She in fact had no cuts on her... On Saturday, (Resident #16) was visiting with 2 family members and she became unresponsive. They placed her into a wheelchair and moved to bed. (LPN #3) informed the family that she could have had a TIA ([MEDICAL CONDITION]) or stroke and they asked about her vital signs. Her vital signs came back normal and after a little while (Resident #16's son) asked for his mother to be sent to the ER (emergency room ). He further stated that (LPN #3) was verbally rude to him when he asked what medications she had given his mother and when EMS (emergency medical service) arrived (LPN #3) said she needed to talk to them and he needed to leave. At the ER he had his mother tested for medications and the results came back with Benzodiazepines in her system. (Resident #16's son) agreed to give a summary of the events and a copy of the drug results. He said that at some point (LPN #3) said to him that it was his word against hers and she would be fine and he just needed to leave. All the above information was also shared with (the Administrator) by (Resident #16's son.)"" No other investigative material was provided at the time of the survey. During a follow up interview on 10/31/2011, the DON, confirmed her written statement and stated that she did not have any other documentation related to the investigation. She stated that the resident's son did not provide the toxicology screen therefore she did not have proof the error occurred. The DON stated that she did not attempt to obtain the toxicology screen from the hospital. The DON stated that she knew LPN #3 had made other errors in the past. She also confirmed that she did not have any documentation related to LPN #3's re-education or evidence that errors were made on the med pass observation. The DON confirmed that LPN #3 worked with residents until 10/8/2011. She stated that LPN #3 was working under the supervision of another nurse. However, there was no evidence LPN #3 worked with another nurse. The DON also confirmed that Resident #16's roommate was prescribed [MEDICATION NAME] (a Benzodiazepines). The DON confirmed again that a formal investigation had not been initiated related to the Responsible Party's complaint. During an interview on 11/7/2011 at 4:15 PM, a family member stated that on 9/17/11 Resident #16 was unresponsive. The family member stated that on arrival at the facility around 5 PM, the resident was in her room. LPN #3 informed the family that the resident could have had a TIA. She told the family she had not administered anything other than Tylenol. The family stated that LPN #3 became defensive and uncooperative. The family then requested that Resident #16 be transported to the hospital where a drug screen was ordered and the resident was positive for Benzodiazepines. The family stated that on Monday, 9/19/11, the DON was told of the concerns related to the drug screen and LPN #3; the DON requested the Administrator join the conference. Review of the Clean Catch Urine Toxicology Screen dated 9/17/2011 at 9:49 PM, revealed Resident #16 was ""POS"" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED].#16 was not prescribed Benzodiazepines. Review of the facility's policy on Abuse and Neglect revealed: ""Investigation: 1) A complete and thorough investigation will be conducted to identify the cause of all injuries. 2) The investigation will be conducted with the resident's safety as the foremost concern in order to protect the resident from future harm. 3) If abuse or neglect is suspected, the individual suspected of abusing or neglecting the resident will be placed on suspension pending the outcome of the investigation. If Administration is unable to determine that there is a clear suspect, all staff assigned to the resident prior to the incident/injury will be interviewed in an effort to identify who may be responsible. 4) If after interviewing all staff, Administration is still unable to conclude that a staff member is responsible, Administration will increase observation and surveillance of the hall or unit. Administration will implement any procedures deemed appropriate and necessary at the time, i.e. change in staff assignments, nursing administrative rounds, etc. 5) Administration will continue to make daily checks on any and all residents who have ""cause unknown"" injuries or who have may been abused to ensure that injuries are not still occurring."" Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility staffs' failure to properly administer medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one resident received Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to the investigation of an allegation of neglect and the administration of controlled substances. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Substandard Quality of Care and the Immediate Jeopardy citation at F-226 was lowered in scope and severity from ""J"" to ""D"".",2015-03-01
9626,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,281,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey, based on observations, record review, interview and review of the facility's policy on Medication Administration, Immediate Jeopardy was identified on 11/08/2011 related to the facility staff's failure to administer medications per the physician's orders [REDACTED].#16 received a Benzodiazepine without a physician's orders [REDACTED].#19, #20, #21, #22, #23, and #24 failed to receive controlled substances as ordered; Resident #7 documented to receive the wrong dose of medication on the Medication Administration Record. In addition, the facility failed to adhere to accepted standards of practice for two of two sampled residents reviewed with Sliding Scale Insulin. Nursing Staff failed to administer the physician ordered amount of Sliding Scale Insulin as per Finger Stick Blood Sugar results for Residents #2 and #7. (2 of 2 sampled residents reviewed for professional standards related to administration of sliding scale insulin) The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Resident #16's closed medical record was reviewed due to a complaint received by the Department of Health and Environmental Control, that a Benzodiazepine medication was found during a Toxicology Screen at a hospital on [DATE]. In an interview on 10/31/2011 at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive Toxicology Screen and that the resident was not prescribed any Benzodiazepines. The facility did not have or attempt to obtain proof of the toxicology report. Review of the Clean Catch Urine Toxicology Screen dated 9/17/2011 at 9:49 PM revealed Resident #16 was ""POS"" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED].#16 was not prescribed Benzodiazepines. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of Resident #17's Admission Physician order [REDACTED]. In addition, Resident #17 was prescribed [MEDICATION NAME] 5/325 mg three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log for [MEDICATION NAME] 5/325 revealed the medication label on the Narcotic Log sheet stated, ""[MEDICATION NAME]-[MEDICATION NAME] 5-325 ([MEDICATION NAME]) mg TA 180 EA (each) QTY (quantity) REM (remaining) 900... C 23..."" Handwritten on the Narcotic Log indicated ""Date Received 9/28/2011; Qty Received 120; Qty Dispensed 120. The medication label did not match the handwritten information on the Narcotic Log. Resident #17 should have received a minimum of 47 doses of [MEDICATION NAME] 5/325 mg between 10/14 at 8 PM and 10/31 at 8 AM. Per the Narcotic Log, Resident #17 received 19 of the 47 doses. Review of the Narcotic Logs for [MEDICATION NAME] revealed the medication label on the Narcotic Log sheet stated, ""[MEDICATION NAME] ([MEDICATION NAME]) 1 mg Tablet 30... C 56..."" Handwritten on the Narcotic Log ""[MEDICATION NAME] 0.5 mg give q (every) A.M. The 0.5 mg was crossed off and 1 mg written and initialed. There was no date received, no quantity received. Handwritten showed ""QTY Dispensed 20 - 1/2 tabs"". Between 10/18 and 10/31, Resident #17 should have received 13 doses of the 0.5 mg tablet, however Resident #17 only received 11 doses. Resident #17 should have received 12 doses of the 1 mg [MEDICATION NAME] between 10/18 and 10/30, however the resident only received 7 doses. Review of the Medication Administration Record dated October 2011 revealed Resident #17's [MEDICATION NAME] was initialed as given three times daily with the exception of 2 doses in which the resident refused on 10/23 and 10/27. In addition, [MEDICATION NAME] was initialed as given every morning and every evening. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Order dated 8/19/2011 revealed [MEDICATION NAME] 0.25 ml (0.5 mg) twice daily was prescribed. Review of the Narcotic Logs for [MEDICATION NAME] ([MEDICATION NAME]) revealed four (4) sheets. Sheet one (1) start date on 8/9/2011 with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME] 2MG/1MG ORAL CO 30 ML QTY REM:0... 07/20/11... Take 0.25ML (0.5MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR AGITATION ... REFILL AFTER 08/06/11... C 10..."". Sheet two (2) begin date 9/9/11 was handwritten ""... [MEDICATION NAME] 2 mg/ml 0.25 ml po (by mouth) BID (twice a day) for agitation. Sheet three (3) begin date 9/25/11 handwritten ""[MEDICATION NAME] liquid 0.25 ml"". Sheet four (4) begin date 10/14/2011 handwritten ""... [MEDICATION NAME] liquid 0.25 ml"". [MEDICATION NAME] 0.25 ml twice daily prn was prescribed prior to 8/19/2011. On 8/19/2011 the resident was switched to a scheduled dose twice daily. Resident #19 was prescribed a total of 0.5 milliliters of [MEDICATION NAME] a day. A 30 ml bottle was dispensed to the facility and two doses were given prior to 8/19/11 leaving 29.5 ml. Resident #19's [MEDICATION NAME] bottle should have been completed on 10/17/11. A total of 29 missed doses were noted or 7.25 ml accounting for 15 days worth of medication. Review of the Medication Administration Record documentation for October 2011 revealed Resident #19's [MEDICATION NAME] was initialed as given twice daily except for the following date 10/2/2011 at 6 PM, when the resident refused; 10/11/2011 when the resident refused and was combative with increased agitation; 10/27/2011 when the resident refused. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the Narcotic Log sheet for [MEDICATION NAME] (Klonopin) revealed two (2) sheets. Sheet one (1) start date on 9/27/2011 with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME] 0.5 MG TABLETS 75 EA (each) QTY REM:375... 09/20/11... TAKE 2 AND 1/2 TABS (1.25 MG) BY MOUTH AT BEDTIME FOR ANXIETY...REFILL AFTER 10/16/11... C 95... handwritten Qty. Dispensed 60 whole tabs"". Eleven (11) tablets remained on this sheet on 10/31/2011. Sheet two (2) begin date 9/27/2011 was handwritten ""... [MEDICATION NAME] 0.25 mg give 1 1/2 tab along with (2) whole 0.5 tabs... QTY 30 1/2 tabs"". Both logs were started on 9/27/11 at 8 PM. On 9/28 the resident received 0.5 mg only. On 9/29/2011 and 9/30/2011 - Resident #20 received 1 mg. No Klonopin was given between 10/1/2011 and 10/3/2011. On 10/4/2011 Resident #20 received 1 mg. On 10/10/2011 she received 0.25 mg. On 10/11/2011 she was given 0.5 mg; on 10/15/2011 and 10/16/2011 she received 0.25 mg only. On 10/28/2011 the resident received 0.5 mg. No Klonopin was given on 10/29/2011. On 10/30/2011 the resident received 0.5 mg. During an interview on 10/31/2011, Registered Nurse (RN) #3 stated that she had been administering 2 - 0.25 mg tablets to Resident #20 instead of the prescribed 1.25 mg dose. RN #1 stated that she ""didn't know"" what the correct combination of tablets was to be administered to the resident. RN #3 also stated that during medication pass, the nurse was to check the medication administration record and the actual medication, dispense the tablet and initial the Medication Administration Record (MAR) as given. For controlled substances, the nurses were to sign the Narcotic Log at the time the drug was administered. RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks on the Narcotic Log for 10/31/2011 and stated that she had not signed for her shift as of 2 PM (10/31/2011). The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 9/21/2011 revealed Resident #21 was prescribed Narco 5/325 mg by mouth three times daily, scheduled at 8 AM, 2 PM and 8 PM and three times daily as needed for pain. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 5-325 ([MEDICATION NAME]) revealed three (3) sheets. Sheet one (1) start date on 10/01/2011 with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 90 EA (each) QTY REM:990... 09/22/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER 10/05/11... C 43... handwritten Qty. Dispensed 90"". Sheet two (2) a continuation of sheet one documenting medication dispensed from 10/10/2011 through 10/31/2011. Sheet three (3) stat date on 10/12/2011 with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 90 EA (each) QTY REM:900... 10/08/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER 10/21/11... C 43... handwritten Qty. Dispensed 90"". Scheduled and as needed medications were documented on the same Narcotic Log sheet. Resident #21 failed to receive one (1) dose of [MEDICATION NAME] on 10/7/2011, 10/10/2011, and 10/16/2011; she failed to receive two (2) doses of [MEDICATION NAME] on 10/12/2011. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 10/19/2011 revealed Resident #22 was prescribed [MEDICATION NAME] 10 mg ER (Extended Release), three times daily scheduled at 6 AM, 2 PM and 10 PM. Resident #22 did not have an as needed dose of [MEDICATION NAME] ordered. Review of the Narcotic Log sheet for [MEDICATION NAME] REFORMULATED 10MG TAB SR ([MEDICATION NAME] Sustained Release) revealed one (1) sheet start date on 10/19/2011 with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME] REFORMULATED 10MG TAB SR 90 EA (each) QTY REM:0... 10/19/11... TAKE 1 TAB BY MOUTH THREE TIMES DAILY FOR PAIN **DO NOT CRUSH OR CHEW** ...REFILL AFTER 11/14/11... N 47... handwritten Qty. Dispensed 90"". No date was recorded when the tablets were received. The log was started on 10/19/2011. On 10/21/11, Resident #22 received the scheduled 10 PM dose. Then on 10/22/11 at 12 AM, the resident received another dose of [MEDICATION NAME]. The resident also received the 6 AM dose and then received an 8 PM dose (two hours before the scheduled time). On 10/24, Resident #22 received an 8 PM dose instead of a 10 PM dose of [MEDICATION NAME]. On 10/30, the 6 AM dose was not received. Resident #22 should have received 32 doses of [MEDICATION NAME] between 10/19 at 9 PM and 10/31 at 6 AM. The resident did not receive 2 scheduled doses and had 4 wrong administration times. Review of the MAR dated October 2011 revealed Resident #22's [MEDICATION NAME] SR was initialed as given three times daily at 6 AM, 2 PM and 10 PM. The facility admitted Resident #23 with [DIAGNOSES REDACTED].#7 Fracture, [MEDICAL CONDITION] and Dementia. Review of the Physician's Telephone Orders dated 10/18/2011 revealed Resident #23 was prescribed [MEDICATION NAME]/[MEDICATION NAME] 1 mg every night and [MEDICATION NAME] 2.5/500 mg every 8 hours scheduled at 6 AM, 2 PM and 10 PM. Review of the Narcotic Log sheet for [MEDICATION NAME] 1MG TABLET ([MEDICATION NAME]) revealed one (1) sheet with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME] 1MG TABLET 30 EA (each) QTY REM:30... 10/20/11... TAKE 1 TAB BY MOUTH AT BEDTIME FOR ANXIETY/AGITATION ...REFILL AFTER 11/15/11... C 68... handwritten Qty. Dispensed 30"". No date was recorded when the medication was received, however the Narcotic Log sheet was started on 10/20/11 (2 days after the order was written). The resident did not receive a dose of [MEDICATION NAME] on 10/24/2011. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 2.5-500MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] 2.5-500MG 90 EA QTY REM:90... 10/20/2011... TAKE 1 TAB BY MOUTH EVERY 8 HOURS FOR NECK OR JOINT PAIN ...REFIL AFTER 11/15/11... C 64... handwritten QTY. Dispensed 90"". No date was recorded when the medication was received, however the card was started on 10/20/11 (2 days after the order was written). Resident #23 should have received 30 doses of [MEDICATION NAME] between 10/19 and 10/31/2011; he only received 21 tablets. Review of the MAR for October 2011 revealed the resident refused the 2 PM dose of [MEDICATION NAME] on 10/20, 10/22, 10/23, 10/24 and 10/25. (Only the 10/22 dose was wasted per the Narcotic Log). 10/26 was left blank. All other scheduled doses were recorded as given. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the Admission physician's orders [REDACTED]. On 9/28/2011 the order for [MEDICATION NAME] was changed to [MEDICATION NAME] 0.5 mg at bedtime. Review of MAR for 10/1/2011 through 10/31/2011 documented the resident received ""[MEDICATION NAME] 0.5MG TABLET (for [MEDICATION NAME]) TAKE 1/2 TAB BY MOUTH AT BEDTIME"". Review of the Narcotic Log Sheet for [MEDICATION NAME] 0.5MG TABLET revealed, ""[MEDICATION NAME] 0.5MG TABLET 30 EA QTY REM:150... 9/28/11... REFIL AFTER 10/24/2011... C 07... handwritten Qty. Dispensed 30 ...Date Received 9/28/11"". The nursing staff document on the October 2011 MAR that Resident #7 received [MEDICATION NAME] .25MG instead of the ordered [MEDICATION NAME] .5MG tablet at bedtime. Resident #7 received per documentation on the Narcotic Log sheet [MEDICATION NAME] .5MG at bedtime. Earlier record review on 10/10/2011 at approximately 5:20 PM revealed a September 2011 Documentation Record which included an entry for FSBS (Finger stick blood sugar) AC (Before Meals) + HS (Bedtime) (with) SSI (sliding scale insulin) , [MEDICATION NAME], 175-249= 1 unit..."" According to the Documentation Record, Resident #7 had (2) Blood Sugar results that required 1 unit of Insulin coverage with no documentation that the coverage was provided by the nursing staff. The following are those results: 9/22/2011 4:30 PM Blood Sugar 176 9/27/2011 9:00 PM Blood Sugar 244. During an interview on 10/10/2011 at 5:35 PM, Licensed Practical Nurse (LPN #2) verified the above findings after reviewing the record. The facility admitted Resident #24 on 10/11/11 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated 10/12/2011 revealed the resident was prescribed [MEDICATION NAME] 5/325 three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 5-325MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] 5-325MG TA 45 EA QTY REM:1035 SUB FOR [MEDICATION NAME] 10/21/2011... *DOSE CHANGE* TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED FOR PAIN ...REFIL AFTER 11/03/11... C 36... handwritten QTY. Dispensed 45"". The card was started on 10/24/11. No [MEDICATION NAME] was given on 10/25 or 10/26. The resident received a 2 AM as needed dose of [MEDICATION NAME] on 10/27. No scheduled doses were given. No other [MEDICATION NAME] had been given since 10/27/11. Resident #24 received 1 out of 17 scheduled doses of [MEDICATION NAME] between 10/23 and 10/31/11. Review of the MAR for October 2011 revealed the resident's [MEDICATION NAME] was initialed as given three times daily at the scheduled times. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/10/2011 at 12:28 PM revealed a Documentation Record for October 2011 that included an entry for ""[MEDICATION NAME] FSBS (Fingerstick Blood Sugar) before meals and Bedtime. If (less than) 70= 0 units, 70-150= 0 units, 151-200= 2 units..."". According to the Documentation Record, Resident #2 had (4) Blood Sugar results that required 2 units of Insulin coverage with no documentation that the coverage was provided by the nursing staff. The following are those results: 10/2/2011 12:00 Noon Blood Sugar 174 10/3/2011 8:00 PM Blood Sugar 158 10/5/2011 12:00 Noon Blood Sugar 161 10/6/2011 12:00 Noon Blood Sugar 163 During an interview on 10/10/11 at 12:40 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the record. On 10/31/2011 between 2 PM and 4 PM, the Director of Nurses (DON) confirmed the above Narcotic Logs, MARs and physician's orders [REDACTED]. Even though the Narcotic Log sheets and the actual drug counts were correct, there was a noted excess of controlled substances for the above residents. The DON confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON confirmed again that Resident #20 was not receiving the ordered dose of Klonopin. The DON also confirmed that Resident #19's bottle of liquid [MEDICATION NAME] should have been completed in the beginning of October 2011. The DON confirmed that the facility staff was signing the MARs indicating that the medications were given, however, the narcotic sheets indicated no medication had been dispensed. Review of the facility's policy on Pharmacy Services and Procedures Manual revealed: ""Prior to Medication Administration: Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route at the correct rate, at the correct time for the correct resident. Facility staff should confirm that the MAR reflects the most recent medication order... Medication Administration: Facility staff should: Identify the resident; administer medications within timeframes specified by Facility policy; document the administration of controlled substances in accordance with applicable law... After Medication Administration: Facility should: document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms; dispose of unused medications in accordance with Facility policy..."" Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to assure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-281 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9627,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,333,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey, based on record review, interview, and review of the policy provided by the facility entitled ""Documentation Standards"", Substandard Quality of Care and Immediate Jeopardy was identified on [DATE] related to the administration of controlled substances for 7 of 8 residents on scheduled controlled substances and 1 of 1 resident that received a controlled medication in error. Resident #16 received a Benzodiazepine without a physician's orders [REDACTED].#19, #20, #21, #22, #23, and #24's controlled substances were not administered per the physician's orders [REDACTED]. Resident #2 did not receive [MEDICATION NAME] as ordered. There was also no documentation of a pulse having been checked prior to the administration of [MEDICATION NAME] with orders which stated the medication ""lower(s) HR (Heart Rate) may hold if below 40"", Resident #7 did not receive [MEDICATION NAME] as ordered and there was no documentation of Blood Pressure checks prior to the administration of a Blood Pressure medication for Resident #4 with orders to hold for certain parameters. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Review of the Nurse's Notes revealed on [DATE] (no time given), Licensed Practical Nurse (LPN) #3 documented ""Resident went to hospital per transport per request of family members. BP ,[DATE], P 76, R 18, T 97.2. Skin W+D (warm and dry). (Patient) did not c/o (complain) until family came at 5 PM. Tylenol tabs 2 given to pt prior to family visit per request of pt (patient) per request of back pain."" LPN #3 was noted to work ,[DATE] PM shift. Review of the Clean Catch Urine Toxicology Screen dated [DATE] at 9:49 PM revealed Resident #16 was ""POS"" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED].#16 was not prescribed Benzodiazepines. During an interview on [DATE] at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive urine toxicology sample. She also confirmed that Resident #16 was not prescribed any Benzodiazepines. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of Resident #17's Admission Physician order [REDACTED]. In addition, Resident #17 was prescribed [MEDICATION NAME] ,[DATE] mg three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log for [MEDICATION NAME] ,[DATE] revealed the medication label on the Narcotic Log sheet stated, ""[MEDICATION NAME]-[MEDICATION NAME] ,[DATE] ([MEDICATION NAME]) mg TA 180 EA (each) QTY (quantity) REM (remaining) 900... C 23..."" Handwritten on the Narcotic Log indicated ""Date Received [DATE]; Qty Received 120; Qty Dispensed 120. The medication label did not match the handwritten information on the Narcotic Log. Resident #17 should have received a minimum of 47 doses of [MEDICATION NAME] ,[DATE] mg between ,[DATE] at 8 PM and ,[DATE] at 8 AM. Per the Narcotic Log, Resident #17 received 19 of the 47 doses. Review of the Narcotic Logs for [MEDICATION NAME] revealed the medication label on the Narcotic Log sheet stated, ""[MEDICATION NAME] ([MEDICATION NAME]) 1 mg Tablet 30... C 56..."" Handwritten on the Narcotic Log ""[MEDICATION NAME] 0.5 mg give q (every) A.M. The 0.5 mg was crossed off and 1 mg written and initialed. There was no date received, no quantity received. Handwritten showed ""QTY Dispensed 20 - ,[DATE] tabs"". Between ,[DATE] and ,[DATE], Resident #17 should have received 13 doses of the 0.5 mg tablet, however Resident #17 only received 11 doses. Resident #17 should have received 12 doses of the 1 mg [MEDICATION NAME] between ,[DATE] and ,[DATE], however the resident only received 7 doses. Review of the Medication Administration Record dated [DATE] revealed Resident #17's [MEDICATION NAME] was initialed as given three times daily with the exception of 2 doses in which the resident refused on ,[DATE] and ,[DATE]. In addition, [MEDICATION NAME] was initialed as given every morning and every evening. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Order dated [DATE] revealed [MEDICATION NAME] 0.25 ml (0.5 mg) twice daily was prescribed. Review of the Narcotic Logs for [MEDICATION NAME] ([MEDICATION NAME]) revealed four (4) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME] 2MG/1MG ORAL CO 30 ML QTY REM:0... [DATE]... Take 0.25ML (0.5MG) BY MOUTH EVERY 4 HOURS AS NEEDED FOR AGITATION ... REFILL AFTER [DATE]... C 10..."". Sheet two (2) begin date [DATE] was handwritten ""... [MEDICATION NAME] Intonsol 2mg/ml 0.25 ml po (by mouth) BID (twice a day) for agitation. Sheet three (3) begin date [DATE] handwritten ""[MEDICATION NAME] liquid 0.25 ml"". Sheet four (4) begin date [DATE] handwritten ""... [MEDICATION NAME] liquid 0.25 ml"". [MEDICATION NAME] 0.25 ml twice daily prn was prescribed prior to [DATE]. On [DATE] the resident was switched to a scheduled dose twice daily. Resident #19 was prescribed a total of 0.5 milliliters of [MEDICATION NAME] a day. A 30 ml bottle was dispensed to the facility and two doses were given prior to [DATE] leaving 29.5 ml. Resident #19's [MEDICATION NAME] bottle should have been completed on [DATE]. A total of 29 missed doses were noted or 7.25 ml accounting for 15 days worth of medication. Review of the Medication Administration Record (MAR) documentation for [DATE] revealed Resident #19's [MEDICATION NAME] was initialed as given twice daily except for the following date [DATE] at 6 PM, when the resident refused; [DATE] when the resident refused and was combative with increased agitation; [DATE] when the resident refused. Review of the Nurses Notes revealed on ,[DATE] the resident was noted with ""increased agitation... resident yelling at staff and hitting them."" There was no documentation related to the resident's increased agitation on ,[DATE] per the MAR. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. Review of the Narcotic Log sheet for [MEDICATION NAME] (Klonopin) revealed two (2) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME] 0.5MG TABLETS 75 EA (each) QTY REM:375... [DATE]... TAKE 2 AND ,[DATE] TABS (1.25MG) BY MOUTH AT BEDTIME FOR ANXIETY...REFILL AFTER [DATE]... C 95... handwritten Qty. Dispensed 60 whole tabs"". Eleven (11) tablets remained on this sheet on [DATE]. Sheet two (2) begin date [DATE] was handwritten ""... [MEDICATION NAME] 0.25mg give 1 ,[DATE] tab along with (2) whole 0.5 tabs... QTY 30 ,[DATE] tabs"". Both logs were started on [DATE] at 8 PM. On ,[DATE] the resident received 0.5 mg only. On [DATE] and [DATE] - Resident #20 received 1 mg. No Klonopin was given between [DATE] and [DATE]. On [DATE] Resident #20 received 1 mg. On [DATE] she received 0.25 mg. On [DATE] she was given 0.5 mg; on [DATE] and [DATE] she received 0.25 mg only. On [DATE] the resident received 0.5 mg. No Klonopin was given on [DATE]. On [DATE] the resident received 0.5 mg. During an interview on [DATE], Registered Nurse (RN) #3 stated that she had been administering 2 - 0.25 mg tablets to Resident #20 instead of the prescribed 1.25 mg dose. RN #3 stated that she ""didn't know"" what the correct combination of tablets was to be administered to the resident. RN #3 also stated that during medication pass, the nurse was to check the medication administration record and the actual medication, dispense the tablet and initial the Medication Administration Record (MAR) as given. For controlled substances, the nurses were to sign the Narcotic Log at the time the drug was administered. RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks on the Narcotic Log for [DATE] and stated that she had not signed for her shift as of 2 PM ([DATE]). Review of the Nurses Notes revealed on ,[DATE] the resident was ""observed removing food from other residents..."" On ,[DATE], ""resident is sitting at nurses station yelling, trying to hit and kick staff."" On ,[DATE], the resident was ""up in wheelchair with hand raised to the sky calling for God to make her whole and that she wanted to be with her husband."" On ,[DATE], ""resident yelling that she wanted to see her deceased husband. [MEDICATION NAME] 125 mg given for increased agitation. Resident was awake all night."" During an interview on [DATE] the DON, confirmed that Resident #20 had increased agitation during the month of October. She stated that last Saturday she was working and had to administer [MEDICATION NAME] to the resident for increased agitation. The DON also confirmed that no nurses notes were documented during the month of [DATE]. The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated [DATE] revealed Resident #21 was prescribed [MEDICATION NAME] ,[DATE] mg by mouth three times daily, scheduled at 8 AM, 2 PM and 8 PM and three times daily as needed for pain. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] ([MEDICATION NAME]) revealed three (3) sheets. Sheet one (1) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 90 EA (each) QTY REM:990... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER [DATE]... C 43... handwritten Qty. Dispensed 90"". Sheet two (2) a continuation of sheet one documenting medication dispensed from [DATE] through [DATE]. Sheet three (3) start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 90 EA (each) QTY REM:900... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED ...REFILL AFTER [DATE]... C 43... handwritten Qty. Dispensed 90"". Scheduled and as needed medications were documented on the same Narcotic Log sheet. Resident #21 failed to receive one (1) dose of [MEDICATION NAME] on [DATE], [DATE], and [DATE]; she failed to receive two (2) doses of [MEDICATION NAME] on [DATE]. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated [DATE] revealed Resident #22 was prescribed [MEDICATION NAME] 10 mg ER (Extended Release), three times daily scheduled at 6 AM, 2 PM and 10 PM. Resident #22 did not have an as needed dose of [MEDICATION NAME] ordered. Review of the Narcotic Log sheet for [MEDICATION NAME] REFORMULATED 10MG TAB SR ([MEDICATION NAME] Sustained Release) revealed one (1) sheet start date on [DATE] with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME] REFORMULATED 10MG TAB SR 90 EA (each) QTY REM:0... [DATE]... TAKE 1 TAB BY MOUTH THREE TIMES DAILY FOR PAIN **DO NOT CRUSH OR CHEW** ...REFILL AFTER [DATE]... N 47... handwritten Qty. Dispensed 90"". No date was recorded when the tablets were received. The log was started on [DATE]. On [DATE], Resident #22 received the scheduled 10 PM dose. Then on [DATE] at 12 AM, the resident received another dose of [MEDICATION NAME]. The resident also received the 6 AM dose and then received an 8 PM dose (two hours before the scheduled time). On ,[DATE], Resident #22 received an 8 PM dose instead of a 10 PM dose of [MEDICATION NAME]. On ,[DATE], the 6 AM dose was not received. Resident #22 should have received 32 doses of [MEDICATION NAME] between ,[DATE] at 9 PM and ,[DATE] at 6 AM. The resident did not receive 2 scheduled doses and had 4 wrong administration times. Review of the MAR dated [DATE] revealed Resident #22's [MEDICATION NAME] SR was initialed as given three times daily at 6 AM, 2 PM and 10 PM. The facility admitted Resident #23 with [DIAGNOSES REDACTED].#7 Fracture, [MEDICAL CONDITION] and Dementia. Review of the Physician's Telephone Orders dated [DATE] revealed Resident #23 was prescribed [MEDICATION NAME]/[MEDICATION NAME] 1 mg every night and [MEDICATION NAME] 2XXX,[DATE] mg every 8 hours scheduled at 6 AM, 2 PM and 10 PM. Review of the Narcotic Log sheet for [MEDICATION NAME] 1MG TABLET ([MEDICATION NAME]) revealed one (1) sheet with a typed medication label on the Narcotic Log sheet that stated, ""... [MEDICATION NAME] 1MG TABLET 30 EA (each) QTY REM:30... [DATE]... TAKE 1 TAB BY MOUTH AT BEDTIME FOR ANXIETY/AGITATION ...REFILL AFTER [DATE]... C 68... handwritten Qty. Dispensed 30"". No date was recorded when the medication was received, however the Narcotic Log sheet was started on [DATE] (2 days after the order was written). The resident did not receive a dose of [MEDICATION NAME] on [DATE]. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] 2XXX,[DATE]MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] 2XXX,[DATE]MG 90 EA QTY REM:90... [DATE]... TAKE 1 TAB BY MOUTH EVERY 8 HOURS FOR NECK OR JOINT PAIN ...REFIL AFTER [DATE]... C 64... handwritten QTY. Dispensed 90"". No date was recorded when the medication was received, however the card was started on [DATE] (2 days after the order was written). Resident #23 should have received 30 doses of [MEDICATION NAME] between ,[DATE] and [DATE]; he only received 21 tablets. Review of the MAR for [DATE] revealed the resident refused the 2 PM dose of [MEDICATION NAME] on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. (Only the ,[DATE] dose was wasted per the Narcotic Log). ,[DATE] was left blank. All other scheduled doses were recorded as given. Review of the Nurses Notes revealed on ,[DATE] the resident was ""belligerent"" and kept removing the cervical spine collar. On ,[DATE] and ,[DATE] the resident's ""dementia was apparent."" On ,[DATE] the resident complained of elbow pain and ""a PRN was given."" However, no as needed medication was initialed as given on the MAR or recorded on the Narcotic Log. On ,[DATE] the resident again complained of pain and Tylenol 325 mg was given at 7 AM. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders dated [DATE] revealed the resident was prescribed [MEDICATION NAME] ,[DATE] three times daily scheduled at 8 AM, 2 PM and 8 PM. Review of the Narcotic Log sheet for [MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG ([MEDICATION NAME]) revealed one (1) sheet with a typed label on the Narcotic Log sheet that stated, ""[MEDICATION NAME]-[MEDICATION NAME] ,[DATE]MG TA 45 EA QTY REM:1035 SUB FOR [MEDICATION NAME] [DATE]... *DOSE CHANGE* TAKE 1 TAB BY MOUTH THREE TIMES DAILY AND TAKE 1 TAB BY MOUTH THREE TIMES DAILY AS NEEDED FOR PAIN ...REFIL AFTER [DATE]... C 36... handwritten QTY. Dispensed 45"". The card was started on [DATE]. No [MEDICATION NAME] was given on ,[DATE] or ,[DATE]. The resident received a 2 AM as needed dose of [MEDICATION NAME] on ,[DATE]. No scheduled doses were given. No other [MEDICATION NAME] had been given since [DATE]. Resident #24 received 1 out of 17 scheduled doses of [MEDICATION NAME] between ,[DATE] and [DATE]. Review of the MAR for [DATE] revealed the resident's [MEDICATION NAME] was initialed as given three times daily at the scheduled times. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 12:00 Noon revealed a Discharge Summary from the hospital dated [DATE] with a Discharge Medication List which included ""[MEDICATION NAME] 0.1 mg (milligrams) q (every) 8 hours prn (as needed) systolic blood pressure greater than 180"". Review of the ""Active Inpatient Medications"" list from the hospital revealed a typed entry for [MEDICATION NAME] HCL 0.1 mg (1 tablet) PO (By Mouth) every 12 hours. Under the frequency of ""every 12 hours"" was handwritten ""PRN syst(olic) (greater than) 180"". The box to ""Continue"" the medication had been checked. Review of Physician's admission orders [REDACTED]= (1) tab (tablet) q 12 (hours)"". There was no further documentation to indicate the medication had been ordered PRN (as needed) and there were no times listed for the medication to be given. Review of the [DATE] Documentation Record revealed the same entry for [MEDICATION NAME] as listed previously with nothing to indicate the medication was PRN or any time frames for the medication to be given. According to the Documentation Record, the [MEDICATION NAME] had not been administered at all from [DATE] through [DATE]. Review of physician's orders [REDACTED]. Review of the October Documentation Record revealed [MEDICATION NAME] 0.1 mg had been given twice daily from [DATE] through the morning dose on [DATE] (except for a circled morning dose [DATE]). There was no documentation of blood pressures having been taken prior to giving the [MEDICATION NAME]. Review of Physician's Telephone Orders for September and [DATE] revealed there were no other orders relative to [MEDICATION NAME] administration. During an interview on [DATE] at 12:40 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the records with the surveyor. When asked, she stated it looked like the [MEDICATION NAME] should have been given for a Systolic Blood Pressure greater than 180. Review of Daily Skilled Nurse's Note(s) along with the Vital Signs Record for September and [DATE] revealed no indication that the resident's blood pressure had been greater than 180 systolic. During a phone interview on [DATE] at 1:20 PM, the above record review information was relayed to the Nurse Practitioner for the facility. She was asked what she thought the Physician intended as far as what the correct order for the [MEDICATION NAME] should have been upon admission. She stated that since [MEDICATION NAME] was a rapid acting blood pressure medication, she thought that it would not have been ordered as a scheduled medication. During a phone interview on [DATE] at 2:05 PM, the above record review information was relayed to the resident's Physician. When asked which order was correct and what had been intended for the order, the Physician stated that the [MEDICATION NAME] should have been given PRN. He stated that as long as there was no order from him to change the [MEDICATION NAME] to scheduled, it should have been PRN. Resident #2 did not have a pulse checked prior to the administration of [MEDICATION NAME] with orders that the medication may be held if the heart rate was below 40. Review of Admission physician's orders [REDACTED].= 0.5 of 25 mg (1) q 12 (hours)"". Next to the entry was handwritten ""lower(s) HR may hold if below 40"". Review of the Documentation Record for [DATE] revealed the medication had been given 12 times in September without any documentation of a pulse having been checked prior to administration. Review of the [DATE] cumulative physician's orders [REDACTED]. There was nothing on the orders to indicate the medication should be held for a heart rate less than 40. Review of the Documentation Record for [DATE] also revealed no indication that the medication should be held for a heart rate less than 40. There was no documentation of a pulse having been checked prior to the administration of [MEDICATION NAME] for 18 doses in October. During an interview on [DATE] at 12:45 PM, LPN #1 verified the above findings after reviewing the record. She stated she knew to take the pulse prior to giving the [MEDICATION NAME]. She stated she did not document this. She stated that usually the medication was held for a pulse less than 60. She verified a pulse had not been documented prior to giving the medications. On [DATE] the Director of Nursing (DON) stated there was no particular facility policy related to checking for a pulse or blood pressure prior to administering medications. She provided a policy entitled ""Documentation Standards"" which stated that ...""Vital Signs (Temp, Pulse, Resp, B/P) will be documented daily within the body of the Medicare charting and the vital signs flow sheet. Licensed staff will refer to the medical record to insure that the physician orders [REDACTED]. During a phone interview on [DATE] at approximately 1:15 PM, the facility Nurse Practitioner was asked what it meant when the order said ""may hold"" if heart rate is less than 40. She stated she expected that pulse would be taken prior to giving the medication and if it was less than 40 the medication would be held. She was told that the order to ""may hold"" was on the September admission orders [REDACTED]. She stated that she thinks that sometimes when the orders are transcribed by the Pharmacy, that they sometimes drop parts of the order. During a phone interview on [DATE] at approximately 2:05 PM, the resident's Physician was asked about the order that the [MEDICATION NAME] may be held if the heart rate was less than 40. He stated he would expect that a pulse would be checked prior to the administration of the medication. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 8:30 AM revealed Admission Physician order [REDACTED]. Continued review of physician's orders [REDACTED]. Review of Daily Skilled Nurse's Note(s) revealed an entry dated [DATE] at 1:30 AM which stated ""Pharmacy called R/T (related to) allergies [REDACTED]. MD (Physician) will be called in AM"". Review of the Documentation Record for [DATE] on [DATE] revealed the nurse's initials for the medication [MEDICATION NAME] had been circled indicating the medication had not been given for 12 doses from the evening of [DATE] until [DATE]. There were also 3 blanks for that time period where the nurse did not initial for the medication at all. On the back of the Documentation Record were 3 notations that referenced the [MEDICATION NAME]. One dated [DATE] at 10:00 AM stated ""[MEDICATION NAME]----Clarification faxed to pharmacy r/t (no) true allergy"". A second dated [DATE] at 8:00 AM stated ""[MEDICATION NAME]-not in see above [DATE]"". The third was dated [DATE], which stated ""Faxed stat order for [MEDICATION NAME] 12.5. Did not send"". The Documentation Record revealed that the medication had been initialed as having been given starting [DATE] with the evening dose and also showed that while at times the medication was circled for the morning dose, the evening dose had been initialed as having been given. Review of Nurses Notes for [DATE] and the backs of the Documentation Record did not indicate why the Nurses initials had been circled except as noted above for 3 doses. The Director of Nursing verified the circles and blanks on the Documentation Record on [DATE] at 8:45 AM. She stated that the Pharmacy had initially sent only (15) ,[DATE] tablets of the [MEDICATION NAME] and that she had to sign that she would pay for the medication. She stated the Pharmacy would not accept the order from the nurse. The DON was asked to provide any invoices for the medication and any communication between the Pharmacy and the facility related to the [MEDICATION NAME] or allergies [REDACTED]. When asked if [MEDICATION NAME] was available in the stat/emergency box, the DON stated it used to be. Observation on [DATE] at 12:40 PM of the stat box in the medication room revealed it contained [MEDICATION NAME] 3.125 mg tablets #6. Review on [DATE] at 9:45 AM of the Pharmacy Invoice for medications supplied to the facility from [DATE] thru [DATE] revealed Resident #7's [MEDICATION NAME] was shipped on [DATE] and delivered [DATE] at 12:18 AM. During a phone interview on [DATE] at 1:07 PM the Pharmacy Manager asked what the issue was and said he would call the corporate office to get permission to release the information. He called back and stated he was unable to speak with the surveyor about the issue with Resident #7 due to privacy regulations. He stated if he received a signed written request for information along with a business card he could obtain the information and then speak with the surveyor. The facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] Fibrillation) Record review on [DATE] at 1:00 PM of the Physician order [REDACTED].<_ 120 and diastolic blood pressure <_ 80"". Review of the September and [DATE] Medication Administration Record (MAR) revealed only two documentation of blood pressure checks prior to medication administration. During an interview on [DATE] at 4:05 PM, with Registered Nurse (RN) #1 stated they use the daily ""Vital Sign Sheet"" obtained by the Certified Nursing Assistants (CNA) on the ,[DATE] shift for vital signs. During observation of the ""Vital Sign Sheet"" for [DATE], ,[DATE] shift, the residents blood pressure was documented ,[DATE]. RN #1 confirmed the blood pressure out of parameters, no documentation on the MAR for the blood pressure check and that the medication was administered given. Upon further review of the ""Vital Signs and Weight Record"" in the residents chart revealed that most of the blood pressure checks for the ,[DATE], ,[DATE] shift was out of parameters for the medication to be given, however the medication was administered on those days. Upon review of the facilities policy ""Documentation Standards"", on [DATE] at 1:50 PM, revealed ""Vital Signs (Temp, Pulse, Resp, B/P) will be documented daily within the body of the Medicare charting and the vital signs flow sheet. Licensed staff will refer to the medical record to insure that the physician orders [REDACTED]. On [DATE] between 2 PM and 4 PM, the Director of Nurses (D)N) confirmed the above Narcotic Logs, MARs and physician's orders [REDACTED]. Even though the Narcotic Log and the actual drug counts were correct, there was a noted excess of controlled substances for the above residents. The DON confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON also could not provide any evidence of investigation, re-education or termination for any nurse involved in potential drug errors. The DON stated that there was not an Action Plan initiated related to medication errors or controlled substances. She also stated that she was unaware of any concerns with controlled substances and had not been notified by the Pharmacy Consultant of any concerns. Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #16 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on [DATE] at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On [DATE] all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning [DATE] related to the grievance policy. On [DATE] ""...All medication records were audited on [DATE] versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on [DATE]. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on [DATE] by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On [DATE] prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-333 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9628,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,428,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review, interview and review of the Pharmacy Reports, Immediate Jeopardy was identified on 11/08/2011 related to the facility's failure to assure controlled substances were reconciled monthly. The Pharmacy Consultant failed to assure 7 of 8 residents (#17, #19, #20, #21, #22, #23 and #24) receiving scheduled controlled medications received them as ordered. The findings included: Review of the October 2011, Drug Count Verification Sheet revealed blanks where both nurses did not sign at change of shift narcotic count. During an interview on 10/31/2011 at approximately 2 PM, RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks and stated that she had not signed for her shift as of 2 PM. During an interview on 10/31/2011 at 5:30 PM, Consultant Pharmacist #1 stated that she was not assigned to the facility but was aware of what the procedure entailed. She stated that during the monthly medication review controlled substances should be reconciled by checking the narcotic sheets to the actual count. Comparing routine medications and as needed medications, risk assessments, blanks on the Medication Administration Record [REDACTED]. She stated that if there was an excess of medication she would look to see if the resident was refusing the medication. She stated that she would also train staff on administration and documentation. During an interview on 10/31/2011 at 5:45 PM, the Director of Nurses stated that she was not aware of any concerns related to controlled substances. She stated that on 10/24/11, the Quarterly Quality Assurance Review was conducted by Pharmacy. She stated that no concerns were found during the review related to controlled substance administration. She also stated that the pharmacist did not inform her of any concerns during the monthly review related to controlled substance administration. Review of the Quarterly Quality Assurance Review dated 10/24/11 revealed the Pharmacist identified the shift to shift narcotic counts were not signed by both nurses for each shift. No other concerns were noted related to controlled substances. During an interview on 11/7/2011 at 5:30 PM, Consultant Pharmacist #2 stated that she was assigned to the facility. She stated that during her monthly review that she ""in general"" looked at the controlled substances. She stated that she checked the narcotic counts and MARs for accuracy. She stated that no concerns related to narcotic administration ""jumped out at her."" During another interview on 11/8/2011 at 2:10 PM, Consultant Pharmacist #2 stated that during her monthly reviews she had noted for one resident the MAR indicated [REDACTED]. However, during the next month's follow up, the resident had been discharged . She stated that she did not find any more concerns related to that issue. Consultant Pharmacist #2 stated that other concerns she had identified were related to facility staff using different cards and narcotic logs. She stated that it was ""mostly documentation."" She stated that she did not notice any trends related to controlled substance administration. Consultant Pharmacist #2 stated that she did a 20% detailed medication review every month and had not noticed any concerns or trends related to controlled substance administration. Review of the Facility's policy on Pharmacy Services revealed: ""Upon delivery by pharmacy: A facility nurse or other licensed facility staff member should sign the delivery manifest, note the time of arrival, and take responsibility for the receipt, proper storage and distribution of the delivered medications... facility staff should immediately log controlled substances into the facility's controlled drug inventory system and should store such controlled substances in compliance with applicable law... The facility should maintain separate individual controlled substance records on all Schedule II drugs in the form of a declining inventory, Resident name, prescriber name, prescription number, drug name, strength, dosage form, dosage, date and time of administration and signature of person administering the drug...The facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances at least once daily or at the change of shift and document the results on a Controlled Drug Count Verification... A facility representative should regularly check the inventory records to reconcile inventory. The facility should reconcile current and discontinued inventory of controlled substances to the log used in the facility's controlled drug inventory system. The facility should reconcile the current inventory to the controlled drug declining inventory record and to the resident's medication administration record. The facility should regularly reconcile unused controlled substances held in storage awaiting destruction with the declining inventory record."" Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resient Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520 Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-428 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9629,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,490,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to ensure medication administration policies and procedures were followed for seven of eight residents with pain and/or antianxiety medications (controlled substances) and one of one resident that received a Benzodiazepines without an order. The findings included: Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #16 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records/reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-490 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9630,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,514,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to maintain clinical records in accordance with accepted professional standards and practices for seven of eight residents (#17, #19, #20, #21, #22, #23 and #24) with pain and/or antianxiety medications (controlled substances) and one of one resident (#16) that received a Benzodiazepines without an order. Two residents (#2 and #7) with physician's orders [REDACTED]. The findings included: Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records/reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-514 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9631,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2011-11-08,520,L,1,1,8MQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified related to the facility's failure to identify, develop and implement a plan of action related to the administration of pain and / or antianxiety medications (controlled substances). Seven of eight residents did not receive controlled substances per the physician's orders [REDACTED]. The findings included: On 10/31/11 between 2 PM and 4 PM, the Director of Nurses confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON also could not provide any evidence of investigation, re-education or termination for any nurse involved in potential drug errors. The DON stated that there was not an Action Plan initiated related to medication errors or controlled substances. She also stated that she was unaware of any concerns with controlled substances and had not been notified by the Pharmacy Consultant of any concerns. Review of the Quarterly Quality Assurance Review dated 10/24/2011 revealed the Pharmacist identified the shift to shift narcotic counts were not signed by both nurses for each shift. No other concerns were noted related to controlled substances. During an interview on 11/8/2011 at 2:10 PM, the Consultant Pharmacist #2 stated that during her monthly reviews she did not notice any trends related to controlled substance administration. The Consultant Pharmacist #2 stated that she did a 20% detailed medication review every month and had not noticed any concerns or trends related to controlled substance administration. Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #1 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and / or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires and as needed staff will be inserviced prior to work beginning 11/08/2011 related to the grievance policy. On 11/08/2011 ""...All medication records were audited on 11/8/11 versus the orders and narcotic reconciliation records. The entire resident sample was audited by the Director of Nursing. All deficient practices were identified and corrected immediately on 11/8/11. All staff currently on duty inserviced on... medication administration to include Narcotic Reconciliation Protocol, Medication Rights, Medication Transcripts, Medication Error Protocol and admission orders [REDACTED]"" Observation on 11/08/2011 by the surveyor revealed audits of all resident's medication orders, medication administration records, and narcotic records / reconciliation by the Director of Nurses and the Nurse Practitioner with immediate corrective action taken. On 11/08/2011 prior to exiting the facility the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citation at F-520 was lowered in scope and severity from ""L"" to ""F"".",2015-03-01
9429,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,221,D,1,0,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review, interview and review of the facility's policy on Restraints, the facility failed to assure 2 of 5 sampled residents with restraints were assessed, monitored and had a signed consent. Resident #15 was ordered a criss cross seatbelt restraint. There was no evidence noted that the resident was checked on every thirty minutes and the restraint released every 2 hours. Resident #16 was ordered a lap-n-loc cushion. The resident was unable to remove the device and the device was used with the intent of preventing the resident from leaning and falling. There was no evidence of a consent or assessment for Resident #16 and no documentation that the restraint was released every two hours. The findings included: The facility admitted Resident #15 on 2/17/2011 with [DIAGNOSES REDACTED]. Review of the December 2011 physician's orders [REDACTED].#15 for a ""criss cross belt."" No other orders were written related to the restaint or medical reason necessitating the use of the restraint. Review of the Medication and Treatment Records from September, October, November and December 2011 revealed no indication the resident was monitored every thirty minutes or that the restraint was released every two hours. Review of the Care Plan revealed no restraint care plan had been completed. The facility admitted Resident #16 on 9/6/2005 with [DIAGNOSES REDACTED]. Observation of the resident on 12/12/11 at 10:45 AM revealed the resident sitting up in a wheelchair with a lap cushion secured to the wheelchair. The resident was unable to remove the lap cushion. Observation of the resident's room revealed the resident had a defined parameter mattress. Record review of the December 2011 Cumulative physician's orders [REDACTED]. The resident was also prescribed a raised edge mattress. Review of the Medication Administration Records from October, November and December revealed no indication that the resident was checked on every thirty minutes or that the restraint was released every two hours. Further record review revealed no restraint assessment had been completed. No consent had been signed by the resident's responsible party for the restraint. Review of the Care Plan revealed the resident's ""lap cushion"" was included as an ""enabler."" No interventions were included related to the resident's restraint. During an interview on 12/12 at 11:50 AM, the Assistant Director of Nurses (ADON) confirmed Resident #16 was unable to release the lap cushion and stated that the cushion was in use to keep the resident upright in the wheelchair and to prevent her from falling. The ADON confirmed that no assessment had been completed nor a consent been obtained for restraints. During an interview on 12/12 at 5 PM, the Director of Nurses (DON) and the ADON confirmed there was no documentation that either resident was checked every thirty minutes or evidence the restraint was released every 2 hours. The DON stated that a consultant had informed the facility that defined parameter mattresses and positioning devices were not considered restraints and that was why Resident #16's device was not assessed as a restraint. Both the DON and the ADON confirmed the definition of a restraint and confirmed that Resident #16 was unable to release the lap cushion. Both confirmed that if the lap cushion was not in place the resident would fall. Review of the facility's policy on Restraints revealed: ""Physical Restraints are defined as any manual or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical Restraints include but are not limited to leg restraints, arm restraints, hand mitts, soft ties or vest, lap cushions, and lap trays the resident cannot remove easily..."" ""A physician's orders [REDACTED]. Note: The physician's orders [REDACTED]."" Included in the policy were ""Restraint Assessment"" and ""Restraint Consent"" forms.",2015-04-01
9430,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,278,D,1,0,8N3011,"**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 accurately and completely assess Resident # 16 related to falls. The fall assessment completed for the resident did not include all the fall prevention measures that had been put into place and the resident was identified as a ""low risk for falls."" The findings included: The facility admitted Resident #16 on 9/6/2005 with [DIAGNOSES REDACTED]. Review of the Falls Risk assessment dated [DATE] revealed the resident was at ""low risk"" for falls. However, the resident had orders for and was observed to have fall mats,a raised edge mattress, a lap n lock cushion to the wheelchair and was a Hoyer Lift for transfers. Those interventions were not listed on the assessment. Further review revealed the resident scoring was not completed due to ""complete paralysis or completely immobilized, implement basic safety (low risk) interventions. If the scoring had been completed the resident would have scored a ""15"" representing ""High Fall Risk"" which would have included more falls interventions.",2015-04-01
9431,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,280,D,1,0,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review and interview, the facility failed to assure 2 of 5 sampled residents with the use of a restraint had their care plan's reviewed and revised to reflect the current status of the resident. Resident #15 and #16 did not have a restraint care plan. The findings included: The facility admitted Resident #15 on 2/17/2011 with [DIAGNOSES REDACTED]. Review of the December 2011 physician's orders [REDACTED]."" Review of the Care Plan revealed no restraint care plan had been completed. The facility admitted Resident #16 on 9/6/2005 with [DIAGNOSES REDACTED]. Observation of the resident on 12/12/11 at 10:45 AM revealed the resident sitting up in a wheelchair with a lap cushion secured to the wheelchair. The resident was unable to remove the lap cushion. Observation of the resident's room revealed the resident had a defined parameter mattress. Record review of the December 2011 Cumulative physician's orders [REDACTED]. The resident was also prescribed a raised edge mattress. Review of the Care Plan revealed the resident's ""lap cushion"" was included as an ""enabler."" No interventions were included related to the resident's restraint. During an interview on 12/12 at 11:50 AM, the Assistant Director of Nurses (ADON) confirmed Resident #16 was unable to release the lap cushion and stated that the cushion was in use to keep the resident upright in the wheelchair and to prevent her from falling. The ADON confirmed that no care plan for a restraint had been completed.",2015-04-01
9432,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,156,E,0,1,R83211,"On the days of the survey, based on record review and interview, the facility failed to provide the resident or responsible party with the mandated Notice of Medicare Provider Non-Coverage (CMS Form ) for 3 of 3 residents reviewed who had been determined by the facility to no longer be eligible for Medicare coverage. Three of three Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) reviewed had not been provided to the resident and/or responsible party within the required time frame. The findings included: During an interview on 3/15/11 at 4:40 PM, Business Office Manager (BOM) #1 stated the facility had been sending only the SNFABN and hadn't been using the CMS Form for notification that Medicare services were ending. She stated she was unaware that the CMS had been mandated to be used. According to BOM #1, Resident #1 had been taken off Medicare part A and had 33 days remaining. CMS Form had not been used. Review of Resident #1's SNFABN dated February 16, 2011 revealed the signature of his Responsible Party (RP), but no date indicating when it had been signed. An undated handwritten note on the side of the form stated ""..""she wants him to stay here, understands MA won't pay or be billed..."". According to BOM #1, she had spoken with the RP and had written this note after February 16th. She verified the note had not been dated. Review of an attached letter addressed to Resident #1's RP dated February 15, 2011 revealed that Resident #1's last covered day under Medicare had been February 17. ""He will be private pay on February 18, 2011. I have enclosed a self addressed, stamped envelope for your convenience in returning the form..."". There was no documentation to indicate the RP had 48 hours notice that services would be ending. During an interview with BOM #1 on 3/15/11 at approximately 4:45 PM, Resident D's SNFABN dated November 10, 2010 was reviewed. According to BOM #1, Resident D had been taken off Medicare part A and had 86 days remaining. CMS Form had not been used. Further review revealed the SNFABN had been signed and dated by her RP on 11/20/10. Review of the ""Resident Master File"" statement for Resident D revealed that her last covered day had been 11/11/10 and she had become private pay on 11/12/10. There was no documentation to indicate the RP had 48 hours notice that services would be ending. During an interview with BOM #1 on 3/15/11 at approximately 5:00 PM, Resident C's SNFABN dated November 27, 2010 was reviewed. According to the BOM, Resident C had been taken off Medicare part A and had 24 days remaining. CMS Form had not been used. Further review revealed the SNFABN had been signed and dated by her RP on 11/29/10. Review of the ""Resident Master File"" statement for Resident C revealed that her last covered day had been 11/29/10 and she had become private pay on 11/30/10. There was no documentation that the resident's RP had been notified by phone prior to 11/29/10.",2015-04-01
9433,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,159,E,0,1,R83211,"On the days of the survey, based on record review and interview, the facility failed to obtain written authorization to manage trust fund accounts for Resident #25 and Resident E, 2 of 5 resident trust fund accounts reviewed for authorization. Two of five trust fund account records reviewed for Resident #6 and Resident #24 revealed that disbursements had been made from the accounts to the Responsible Party (RP)/family member without obtaining receipts for items purchased. The findings included: Review of Resident Trust Fund account statements on 3/16/11 at 9:13 AM revealed the facility had been managing funds for Resident #25 and Resident E. Resident #25 had a current balance of $30.00 and Resident E had a current balance of $170.06. Further review revealed there was no written authorization for the facility to manage either of their trust fund accounts. After looking for authorizations in their files, Business Office Manager #1 called the Social Services Director (SSD) to see if he had any authorization in his files, but he could provide none. Review of Resident #24's trust fund account on 3/16/11 at 9:50 AM revealed a ""Resident Funds Trust Account Authorization"" on file for Resident #24 signed by a male representative on 4/7/08. It stated ""...I also authorize reimbursement to my representative when they purchase personal items for me and submit their receipts, etc."". Further review of account statements revealed that $30.00 had been withdrawn from the resident's account on 12/20/10, 11/4/10, and 10/19/10. Upon request, BOM #2, provided copies of the checks for these dates where #30.00 had been made out to the resident's daughter. According to BOM #2, the resident's daughter has been coming since 2009 to pick up the $30.00 the resident gets each month from the resident's trust fund account. He stated that he hadn't asked the daughter to provide any receipts and that he didn't know for sure what she is using the money for. He also provided a copy of a check for $30.00 made out to the resident's daughter dated 9/3/10 and a ""Receipt"" dated 3/2/11 signed by the resident's daughter indicating she had received $30.00 from the resident's trust fund account for ""Supplies for resident"". When asked, BOM #2 stated he had written out the receipt, the resident's daughter had signed it, but no receipts had been provided and nothing was said to indicate what the daughter planned to use the money for. He didn't know if the money had been used for the resident or not. Review of Resident #6's trust fund account on 3/16/11 at 10:20 AM revealed a ""Resident Funds Trust Account Authorization"" on file for Resident #6 signed by her daughter on 5/3/09 which gave authorization for reimbursement to the representative when they purchased personal items for the resident and submitted their receipts. Review of account statements revealed a ""Resident Fund Withdrawal"" of $15.00 on 1/17/11 and a ""Misc(ellaneous) Charge"" of $40.00 on 7/28/10. Upon request, BOM #2 provided copies of the checks for these dates. The checks had been made out to the resident's daughter. According to BOM #2, no receipts had been obtained, but both times the withdrawals were for clothes for the resident. He stated that he did not know if the resident had received the clothes that had been purchased by the daughter.",2015-04-01
9434,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,160,E,0,1,R83211,"**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 convey funds to the proper authority for 4 of 4 resident accounts reviewed for disbursement of funds. The findings included: During an interview on [DATE] at 5:15 PM, Business Office Manager (BOM) #2 provided a ""Resident Master File"" report that revealed Resident F had expired on [DATE]. He also provided documentation that the balance of Resident F's trust fund account, $654.53, had been conveyed to the facility on [DATE]. BOM #2 stated that the resident owed a balance and his Responsible Party (RP) had asked that the facility go ahead and take the money since there was no estate or probate. He could provide no written documentation that the RP had told facility to take the money or that this had been authorized by the resident. BOM #2 provided documentation that Resident G had expired on [DATE] and that the balance of her trust fund account, $90.20, had been conveyed to her daughter on [DATE]. He could provide no written documentation that this had been authorized by the resident. BOM #2 provided documentation that revealed Resident H had expired on [DATE]. According to BOM #2, his trust fund balance of $1.23 had never been conveyed. He stated that the resident owed the facility a lot of money. BOM #2 provided documentation that Resident I had expired on [DATE] and that the balance of her trust fund account, $738.32, had been conveyed to the funeral home on [DATE]. He could provide no written documentation that this had been authorized by the resident.",2015-04-01
9435,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,314,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews and review of the facility's policy entitled Dressings, Dry/Clean, the facility failed to ensure that a resident having a pressure ulcer received necessary treatment and services to promote healing, prevent infection. for A facility staff member wore contaminated gloves during the performance of wound care and cleaned the pressure ulcer wound bed inappropriately for Resident # 18. ( 1 of 3 residents observed for Pressure Ulcer Treatment) The findings included: The facility admitted Resident # 18 on 1/7/2009 and readmitted him on 3/18/2010 with [DIAGNOSES REDACTED]. On 3/15/2011 at 10:25 AM, during an observation of wound care for Resident #18, Licensed Practical Nurse (LPN) #3 failed to enter the room with the adequate supplies needed for the treatment. After the LPN washed her hands and put on gloves she realized that she had no additional gloves in the room. LPN #3 activated the call light from the wall to ask someone to bring gloves and in the process contaminated her gloves. She then proceeded to perform wound care wearing the same gloves. During cleansing of the wound, she sprayed the wound bed with wound cleanser and patted the wound from side to side with a 4X4 while continuing to wear the contaminated gloves. Review of the facility's policy entitled Dressings, Dry/Clean revealed:'...Purpose: The purpose of this procedure is to provide guidelines for the application of a clean dressing...Steps in the procedure:...5. Wash and dry hands thoroughly. Put on clean gloves..."" On 3/15/2011 at 2:20 PM, during an interview with LPN #3, she did not dispute the surveyor's observations. On 3/16/2011 at 3:00 PM, during an interview with the Director of Nursing (DON), she stated that she would expect a nurse to re-wash her hands and put on clean cloves before starting a procedure if the nurse had touched any thing while wearing gloves and that she should have had enough supplies when she entered the room. The DON also verified the wound should have been cleaned from the inside out instead of across the wound bed.",2015-04-01
9436,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,152,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, Resident # 13 current medical record contained a Do Not Resuscitate (DNR) order. ( 1 of 16 residents reviewed for advanced directives ) However, the record failed to document two physicians determined the resident as lacking capacity to make his own health care decisions. The findings included: The facility admitted Resident # 13 on 4/26/10 with [DIAGNOSES REDACTED]. Record review on 3/14/11 revealed a notation in the front of the record, on a red tag, indicating the resident's status was a DNR. There was also a physician's orders [REDACTED]. Further record review failed to reveal documentation which showed two physician's had deemed this resident to be unable to make his own health care decisions thus allowing another person to make his healthcare decisions, The MDS (Minimum Data Set) documented the resident to have a BIMS score of 5 which denoted a severely impaired cognitive skills for decision making. An interview with LPN #8 (Licensed Practical Nurse) on 3/14/11 at 5:40 PM confirmed there was no documentation in the record by two physicians deeming the resident as lacking capacity to make healthcare decisions. Medical Records staff also verified there was not a competency form in the resident's thinned records. At 6:00 PM the Social Service Director confirmed he could not find the required documentation that two physicians had evaluated the resident.",2015-04-01
9437,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,167,C,0,1,R83211,"On the days of the survey based on random observations and interview, the facility failed to post the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The findings included: Random observations on three days of the survey revealed only the annual survey of 12/16/09 and the Life Safety Survey with a comparative Life Safety Survey were posted on the bulletin board of the facility. This was brought to the attention of the Social Service Director. Further conversation with the Administrator and Corporate Consultants confirmed the Complaint Surveys for 5/3/10, 7/19/10, and 11/18/10 were not posted.",2015-04-01
9438,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,272,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and record reviews, the facility failed to update assessment information necessary to develop a care plan, to provide the appropriate care and services for 1 of 1 residents reviewed for smoking. Resident #20 was assessed as not needing supervision and a smoking apron on 1/21/2011. The findings included: The facility admitted Resident #20 on 1/22/2004 and readmitted him on 3/5/2010 with [DIAGNOSES REDACTED]. Review of Resident #20's medical chart was conducted on 3/15/2011 at 4:00 PM. A Smoking Screen Form had a total score of 0 (zero). The form stated ""A score of 6 or above indicates that a resident must be supervised or have a smoking apron on when smoking."" Review of the resident's Care Plan dated 5/12/10 indicated that the resident had ""... potential safety hazard, injury related to smoking. Resident requires supervision when smoking at all times..."" On 3/15/2011 at 4:55 PM, during an interview with Licensed Practical Nurse (LPN) #5, verified that the resident needed supervision for smoking as stated in the resident's Care Plan. When asked by the surveyor why he had a score of 0 (zero) on the smoking assessment, LPN #5 stated that she deemed all of the smokers as safe on the assessment because all smokers had to be supervised and that she was not aware that the care plan had not been updated.",2015-04-01
9439,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,323,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and review of the Material Safety Data Set (MSDS) for Epi-Clenz, and observations of sharp items in resident areas, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The findings included: On 3/13/2011 at 3:45 PM, upon entry to the facility, a 16 ounce (oz.) bottle of Epi-Clenz Hand Sanitizer and a pair of scissors were observed to be sitting on the second shelf of the facility's conference room. A resident nourishment area had two knives on the counter. One was a steak type approximately 4 inches long and the other knife had a forked end and a approximately 10 inch blade. No staff were observed in the area. Residents were observed to be in the Day/Dining Area adjoining the Nurses Station. The nourishment area was located on the left wall of the Day/Dining Area. No residents were observed to enter the area. In an interview with Certified Nursing Assistant #2 at 5:40 PM, she verified the warming label on the Epi-Clenz read ""Keep Out Of Reach Of Children."" On 3/14/2010 at 1:00 PM, the scissors and Epi-Clenz remained in the conference room. Residents were observed trying to enter the room to use the phone. On 3/16/2011 at 11:20 AM, in an interview with the Activity Director, she stated that on occassion, the resident's participated in activities in the Conference Room. She also stated that there had been no activities held in the room that week. She verified that residents enter the room to use the phone. At 11:50 AM, the Director of Nursing (DON) stated that the conference room was also used for employee in-services, usually for new hires and also verified that residents use the room for the telephone. The DON was not aware of the Epi-Clenz and scissors in the room. After being informed, the DON exited the room leaving the scissors and Epi-Clenz on the shelf. When asked if the items should be removed from an area where the residents had access, the DON then removed the items. Review of the facility provided MSDS (Material Safety Data Sheet) for Epi-Clens revealed ""...Section 2-Hazardous Ingredients/Identity Information: Ethyl Alcohol 40-2...1000 ppm (parts per million)...> (greater) 70% (percent)...Appearance and odor: A clear, colorless gel with...or without...a spring fragrance...Section 6- Health Hazard Data...Emergency and First Aid procedures: ...Eye Contact: Immediately Flush with large amounts of water for a minimum of 15 minutes, Get Medical attention...Ingestion: Drink water or milk. Get Medical Attention...Section 7-Spill, Leak, and Waste Disposal Procedures...Precautions to be taken in handling and storing...Keep out of reach of children and other persons who might misuse this product... Random observations on 3/13/11 at 3:45 PM, 3/14/11 at 8:30 AM and 2:00 PM, 3/15/11 at 8:30 AM and 6:00 PM, and 3/16/11 at 10:00 AM revealed a 16 ounce bottle of hand sanitizer sitting on a table between Unit II and the Folk Unit. The label noted ""Keep Out of Reach of Children."" There were confused residents noted to be in the area. During Initial Tour of Unit 2 on 3/13/11 at approximately 4:05 PM and at 9:20 AM on 3/15/11, a 12 ounce bottle of 63% alcohol based hand sanitizer was noted on the over-bed table of the resident in 23L and a 40 ounce bottle of of 63% alcohol based hand sanitizer on the bedside table of the resident in 23R. At approximately 4:40 PM, an 8 ounce bottle of 63% alcohol based hand sanitizer was noted on the bedside table of the resident in 31R. The residents in bed 21R and 31R were marked as being cognitively impaired on the Roster/Sample Matrix furnished by the facility. On 3/14/11 at approximately 10:14 AM, upon completion of wound care treatment of [REDACTED].#6 left a pair of scissors, wound cleanser, medicated ointment (Santyl) and alcohol wipes at the bedside while she removed the trash from the room. LPN #6 had completed the treatment and placed the items on the over-bed table. She then left the room with the trash bag and walked half the length of one corridor and the full length of another corridor to place the trash in the Biohazard Room. She then washed her hands in another room before returning to Resident #2's room to retrieve the supplies. Review of the Minimal Data Set Assessment on 3/15/11 at 8:47 AM revealed the resident had a [DIAGNOSES REDACTED]. During an interview on 3/16/11 at 10:47 AM, the Director of Nursing confirmed that leaving the scissors and wound care supplies constituted a potential hazard and stated that the nurse should have taken them before leaving the room.",2015-04-01
9440,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,371,F,0,1,R83211,"On the days of the survey, based on observations and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions in 2 of 2 kitchens observed. Both kitchens at the facility failed to properly maintain sanitation of the food storage, service, and preparation areas. The kitchen in the main facility contained soiled/broken equipment, and cleaning supplies were stored with food items. The kitchen at the Springfield building contained undated food items, debris in various areas and in cooking equipment. Dietary staff were observed chewing gum while setting up dishes for meals; did not change gloves when appropriate and contaminated plates before using. The resident nourishment kitchen on Unit 4 contained multiple juices with no date when opened. The findings included: During initial tour of the kitchen in the Springfield building on 3/13/2011 at 4:00 PM, the walk in freezer did not contain a thermometer, There were 15 packs of frozen french toast, 4 packages of frozen pancakes and 2 packages of frozen waffles out of the original boxes with no open/expiration dates. There were also 2 trays containing undated, uncovered small bowls of ice cream and sherbert. The floor was littered with paper and food debris and there were areas of a thick beige substances on the floor under the freezer racks. There was also a large bag of bagels and a quart bag of chicken with no date which the Dietary Manager (DM)/ Chef removed and placed in the trash at the time of the tour. The walk in refrigerator contained a large silver pan of peas covered with foil but not dated. The floor of the walk-in refrigerator also contained paper and food debris. The floor under the dish machine was littered with straws, paper and food debris as well as the food cart wash area. A hand washing sink to the left of the entry door had used gloves on the floor beneath it. An oven near the Dietary office was soiled with dried spills on the oven floor and inside the door. A Deep Fryer with 2 frying vats and a holding shelf on the side of each had brownish dark oil in each with french fries and unidentifiable food particles in each. The lifting racks for each had dried food particles and the holding shelves had debris on each. Three steam areas on the steam table had debris in the water. The Brazier had a thick brownish substance on the outer right side. On 3/14/2011 at 8:50 AM, a tour was conducted with the Dietary Manager/ Chef (DM). During the tour he verified the observations of food particles, debris and paper as noted above. The initial tour of the resident kitchen area on Unit 4 at 4:30 PM on 3/13/2011 revealed a brownish film in the drip tray of the ice machine and dried spills and debris in the resident refrigerator. The refrigerator also contained 3- 46 ounce (oz) containers of Prune Juice dated 8/3/10, 3-46 oz. Prune juice dated 10/29/10, 1-46 oz. Prune Juice with no date. 1-46 oz. Orange Juice dated 1/18/2011, 1-46 Orange Juice with no date, 1-46 oz. Orange Juice dated 2/22/11, 1-46 oz. Cranberry Juice dated 2/4/2011, 1-46 oz. Apple Juice dated 3/7/11 and 1-32 oz. Med- Pass 2.0 with no open date. Licensed Practical Nurse (LPN) #5 verified the dates on the juice containers and the spills and debris in the resident refrigerator. She then removed the juice containers. On 3/14/2011 at 2:05 PM, The Dietary Manager/Chef stated that the date on the juice containers was when the stock arrived at the facility from the vendor. When asked if he was sure that was not the dates that they were opened, he stated ""Yes"". When asked if that indicated that the staff did not date the items when they opened them, he again stated ""Yes"". At 11:20 AM on 3/14/2011 during the tray line service, Dietary Aid #2 was observed to be chewing gum. The surveyor asked if she knew that she was not to chew gum in the food preparation area, she stated ""Oh, for real?"" and threw the gum in the trash can. The resident dinner plates were stacked in the pellets on top of each other with the bottom of the pellets resting on the inside of the plates being used for food service. Dietary Aid #3 stated that the plate warmer was broken and that that was the way it had been done since the warmer broke. During tray service Dietary Aid #3 was observed to plate food with serving utensils, pick bread up and put it on the residents plates, open the microwave oven and not wash her hands or change gloves. She then made Bar-B-Q sandwiches wearing the same gloves. In an interview with Dietary Aid #3 at that time she stated that she had not changed her gloves or washed her hands after opening the microwave. At 12:55 PM, on 3/14/2011, the kitchen in the J.F. Hawkins building was observed to have a broken rack in the free standing freezer, a wet-vac stored on a cart beside the bread rack, a wet mop standing beside the free standing freezer and a dust mop stored beside the free standing refrigerator. The plate warmer had a build up of a brownish substance on the inside and where the plates sit. A box of Gluten Free cookies, canned foods, vinegar and Styrofoam cups were stored under a hanging heat unit with the cookie box touching the pipes. The Dietary manager removed these items during the tour and verified the observations of the surveyor. During the survey, the Dietary Manager/Chef was observed to be in the kitchens in both building on 5 occasions with no beard protector in place. These times were 3/13/2011 at 4:00 PM, 3/14/2011 at 8:50 AM, 11:20 AM, 11:50 AM and 12:55 PM. On 3/14/2011 at 6:00 PM during an interview with the Dietary Manager/Chef, he did not dispute the observation of being in both kitchens without a beard protector. Observation in the main facility kitchen on 3/14/11 at 12:10 PM revealed 2 males with facial hair in the food service area without beard restraints. A third male with facial hair and no beard restraint was observed placing a container of chopped meats on the warming table and taking the temperature of the meat at 12:15 PM. During an interview on 3/15/11 at 5:50 PM, the Dietary Manager stated he had been unaware that one of the males had facial hair, but verified the other two observations and stated he would get beard nets.",2015-04-01
9441,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,428,E,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, there was no documented response from the physician related to pharmacy recommendations from February and March 2011 for Residents #8, #9, #14, #21, and #23. ( 5 of 16 records reviewed for Pharmacy recommendations) The findings included: The facility admitted Resident #9 on 1/12/10 with [DIAGNOSES REDACTED]. Record review on 3/14/11 revealed a Pharmacy Consultation Report dated for 2/1 - 2/3/11 for Resident #9 for the physician to address a Gradual Dose Reduction (GDR) for Citalopram 20 mg (milligram) daily. There was no documentation indicating the physician had responded to the recommendation as verified by LPN #8 (Licensed Practical Nurse). She also checked physician progress notes [REDACTED]. None was located in the medical record. On 3/15/11 the nurse faxed the consultant's recommendation to the physician for a response. The facility admitted Resident #14 on 2/5/10 with [DIAGNOSES REDACTED]. Record review on 3/14/11 revealed a Consultant report dated 2/1 - 2/3/11 with comment "" ----- takes a medication with anticholinergic properties, Hydroxyzine HCL, along with a cholinesterase inhibitor, Donepezil. Please re-evaluate Hydroxyzine HCl use."" There was also a recommendation dated 3/4/11 to which the physician had not responded. On 3/16/11 LPN#8, after not finding any response by the physician in the medical record, faxed the recommendation to the physician's office. Documentation by the doctor showed he had made rounds and checked the resident on 2/23/11; however, no response had been made to the Pharmacist's recommendation. The facility admitted Resident #23 on 7/27/05 and readmitted the resident on 12/23/07 with [DIAGNOSES REDACTED]. Record Review on 3/15/11 revealed a Pharmacy Consultation Report dated 2/1 -2/3/11 requesting a GDR (gradual dose reduction) for Risperdal 3 mg bid (Two times per day). The physician documented he checked the resident 2/28/11 but wrote no orders and did not respond to the Pharmacist's recommendation. A 3/1 -3/4/11 pharmacy recommendation addressed consideration of a GRD for Lorazepam 0.5 mg tid ( 3 times per day). The medical record did not reflect a response from the physician for this recommendation. LPN #7 (Licensed Practical Nurse) confirmed on 3/16// at 10:45 AM that the physician had not responded to either of the Pharmacist's recommendations. The facility admitted resident #8 on 5/15/08 with [DIAGNOSES REDACTED]. On 3/15/11 at 3:45 PM, review of the Pharmacist's monthly Medication Regimen Review revealed the Pharmacist had noted irregularities or other recommendations on 2/2/11 and 3/3/11. The Pharmacist's Consultation Report revealed recommendations dated 2/2/11 recommending a gradual dose reduction of Ambien from 5 milligrams at bedtime to 2.5 milligrams at bedtime unless clinically contraindicated. There was no indication the physician had taken any action on the recommendation. There was also a Pharmacist's Consultation Report dated 3/3/11 recommending a gradual dose reduction of Depakote from 500 milligrams BID (twice a day) to 375 milligrams BID unless clinically contraindicated. There was no indication the physician had taken any action on the recommendation. Review of the M. D. (Physician) Progress Notes revealed the Physician had seen the resident on 2/25/11. Review of the February and March Medication Documentation Record Revealed no changes had been made to the dosage of these medications. The facility admitted Resident #21 on 4/1/02 with [DIAGNOSES REDACTED]. On 3/16/11 at 9:00 AM, record review revealed a Pharmacist's Consultation Report dated 2/2/11 with a recommendation for a gradual dose reduction of Temazepam from 7.5 milligrams at bedtime to 7.5. milligrams at bedtime only as needed unless clinically contraindicated. In addition there were 3 recommendations dated 3/3/11 that were repeat recommendations from 12/1/10. One recommendation was to change the dosing of Dilantin to 4 milliliters every 12 hours. Another recommendation was for a gradual dose reduction of Trazodone unless clinically contraindicated. A third recommendation was to consider an alternate therapy to Glucophage due to a BOXED warning. There was no indication in the record that the Physician had taken action on the recommendations though the record indicated the physician had examined the resident on 2/25/11. Review of the February and March Medication Documentation Record Revealed no changes had been made to the dosage of these medications. During an interview on 3/16/11 at approximately 10:57 AM, the Director of Nursing stated she received the Pharmacist's recommendations via mail. She reviewed all recommendations and then gave them to the Unit Managers to place on the chart for the Physician to review. She stated that the Medical Director preferred to assess the resident before acting on the recommendations. She further stated that she would have expected the Physician to have acted on the recommendations in a more timely manner and did not know why the recommendations were not acted upon.",2015-04-01
9442,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,492,D,0,1,R83211,"On the days of the survey, based on personnel record review and interview, the facility failed to do a required license check and a criminal background check prior to the employee's date of hire. ( 1 of 5 personnel folders reviewed.) The findings included: On 3/15/11 five employee personnel files were reviewed for professional license checks and criminal background checks prior to their hire date. RN #1 (Registered Nurse) had a hire date of 11/1/10. Further file review revealed a license check and a criminal background check had been done on 11/2/10 after the employee had been hired. The Administrator confirmed the record documented the checks had not been done prior to hire.",2015-04-01
9443,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,502,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide Physician ordered lab services for 2 of 14 residents reviewed for labs. A [MEDICATION NAME] (PT) / International Normalization Ratio (INR) was not drawn as ordered for Resident #7. A [MEDICATION NAME] was not drawn as ordered for Resident #2. The findings included: The facility admitted Resident #7 on 2/4/09 and readmitted her on 1/20/11 with [DIAGNOSES REDACTED]. Record review on 3/14/11 at 5:35 PM revealed a Physician Telephone Order dated 1/24/11 that stated ""No (change) in present [MEDICATION NAME] dosage. Re(check) PT/INR in 2 wks (weeks)"". Review of Nurses Notes revealed no mention of a PT/INR being drawn after 1/24/11. Review of the Documentation Record for February and March 2011 revealed Resident #7 received [MEDICATION NAME] Sodium 2.5 mg (milligrams) at bedtime from February 1st through March 14th. During an interview 3/14/11 at 6:00 PM, Licensed Practical Nurse (LPN) #9 stated she would see if she could find the missing lab. Record review on 3/15/11 at 8:42 AM revealed a Physician's Telephone Order dated 3/15/11 that stated ""May obtain a PT/INR today, then (check) PT/INR monthly. Review of Daily Skilled Nurses Notes revealed an entry dated 3/15/11 at 7:15 AM that stated ""Call placed to (hospital) lab to check on PT/INR value from Feb' 2011. Per lab no result received only HGB (Hemoglobin)/HCT (Hematocrit)"". During an interview on 3/15/11 at 10:40 AM, LPN #9 stated she did not find a PT/INR result for 2/7/11. She said she had called and notified the Physician of the missed lab and she had drawn a PT/INR on the resident that morning. She stated that nurses check the telephone orders and previous month's cumulative orders against the new month's cumulative orders when these come from the Pharmacy. She stated the nurse then adds any labs for the next month to the lab book so they can be drawn. During an interview on 3/15/11 at 11:00 AM, LPN #9 stated that the PT/INR had not been added to the lab book for February. Review of PT/INR results dated 3/15/11 revealed an INR result of 2.0. Review of Physician Telephone Orders dated 3/15/11 revealed ""Cont(inue) same [MEDICATION NAME] dose 2.5 mg po (by mouth) q (every) hs (bedtime). Check PT/INR monthly"". The facility admitted Resident #2 on 12/13/10 with [DIAGNOSES REDACTED]. On 3/14/11 at approximately 11:25 AM, review of the monthly physician's orders [REDACTED]. On 3/15/11 at approximately 8:47 AM, review of the nurses notes dated 1/17/11 at 2:00 AM revealed that blood had been drawn for labs. During an interview on 3/15/11 at approximately 10:15 AM, Licensed Practical Nurse #6 confirmed that the lab test had not been done. She stated she had called the lab and confirmed that there was no record of the test and stated the lab had told her the [MEDICATION NAME] had not been indicated on the lab request sheet.",2015-04-01
9444,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,309,G,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, record review and interviews, the facility failed to recognize, evaluate and manage pain related to pressure ulcer treatments for Resident #2.Resident B recieved medication mixed with water rather than apple juice as ordered by the physician. ( 2 of 12 sampled residents reviewed for necessary care and services) The findings included: The facility admitted Resident #2 on 12/13/10 with [DIAGNOSES REDACTED]. During observation of a pressure ulcer treatment on 3/15/11 at 10:00 AM, Licensed Practical Nurse )LPN) #6 failed to recognize, assess and treat the resident who exhibited both verbal and non-verbal indicators of pain. At 10:03 AM, as LPN #6 began to remove the foam dressing from the wound bed, Resident #2 yelled out and pulled back his foot. LPN #6 continued with the removal of the soiled dressing. At 10:07 AM, as she began to clean the wound bed, the resident again pulled back his foot, kicked and yelled out to ""leave it alone."" As LPN #6 applied the medicated ointment and re-dressed the wound, Resident #2 continued to kick and yell. At no time did LPN #6 attempt to stop the treatment, ask the resident if he was in pain or offer the resident pain medication. Review of the March Documentation Record revealed the resident had received [MEDICATION NAME] only 1 time during the night shift for the month of March. During an interview with LPN #6 on 3/15/11 at approximately 10:20 AM, she stated she had given the resident [MEDICATION NAME] at approximately 8:00 AM due to a history of resistance during treatments, baths and other care. She confirmed that she had not given him any medication for pain. LPN #6 further verified she had not tried pre-medicating the resident for pain prior to initiating treatments to reduce resistance but further stated that the treatment was usually done on the night shift when resident was just waking and was more compliant. LPN #6 confirmed that a pressure ulcer such as the resident's was most likely painful and stated that, now that it had been brought to her attention, she thought the resident was probably experiencing pain with his treatments. On 3/15/11 at approximately 3:30 PM, the Director or Nursing (DON) stated is sounded as the the resident ""was telling her to stop."" The DON also verbalized that she would have expected the nurse to stop the treatment, attempt to calm the resident and notify the Physician and the Responsible Party She stated she would expect the nurse to medicate the resident for pain. She further verified that the resident ""should have something more than Tylenol for pain"" and that the Physician would be contacted for additional orders for pain medication. During an interview on 3/15/11 at 2:00 PM, Resident #2's Responsible Party stated she thought some of resident's agitation was ""because he hurts,"" especially with dressing changes and catheter care. She stated she thought he should have pain medication prior to his dressing changes. On 3/14/2011 at 9:49 AM, LPN #3, administered Polyethylene [MEDICATION NAME] 17 Gram/1 dose powder ([MEDICATION NAME]) 1/2 capful to Resident B. The LPN mixed the Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) in water. Review of the physician's orders [REDACTED]. On 3/14/2011 at 10:22 AM, in an interview with LPN #3, she did not dispute the above observation.",2015-04-01
9445,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,315,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and review of the facility's ""Catheter Care"" competency check off, the facility failed to provide catheter care in a manner to prevent urinary tract infections for Resident #2, 1 of 3 residents reviewed for catheter care. The findings included: The facility admitted Resident #2 on 12/13/10 and a catheter was placed on 12/26/10 due to difficulty with urination. He was receiving antibiotic therapy for a [MEDICAL CONDITION] (MRSA) urinary tract infection at the time of the survey and was being followed by a Urologist. During observation of catheter care on 3/14/11 at 11:48 AM, Certified Nursing Assistant # 3 contaminated her gloves prior to beginning catheter care. CNA #3 removed gloves from the glove box and placed them on the side of the sink. One glove fell into the wheelchair and CNA #3 picked it up and replaced it on the side of the sink. She then picked up the basin of water and placed it on the over-bed table with the body wash. After washing her hands, the CNA donned the gloves that were on the side of the sink. After donning the contaminated gloves, CNA #3 proceeded to open the trash bag and place it in a chair, used her right hand to lower the head of the bed and her left hand to reposition the call light. She put the side rail down using both hands. The CNA then pulled the blankets down, removed the resident's pants and hip protectors, used her right hand to reposition the bed in the high position and then open the resident's brief. She then proceeded with the catheter care. Upon completion of the catheter care, CNA #3 removed her gloves and washed her hands. She did not change her gloves during the catheter care after contaminating them. During an interview at 12:07 PM, CNA #3 confirmed that she had contaminated her gloves before donning them by placing them on the side of the sink. She also verified that she had contaminated her gloves again before beginning the procedure and that she should have changed her gloves before the procedure. During an interview on 3/15/11 at 3:25 PM, the Director of Nursing (DON) confirmed the CNA should not have used gloves after placing them on the side of the sink. She also stated in-services had been provided for catheter care and provided a copy of a ""Catheter Care"" competency check off for CNA #3 completed 10/7/10. The DON also verified that inappropriate catheter care could have contributed to the resident's current urinary tract infection. Review of the facility's ""Catheter Care"" competency check off revealed the following steps: ... 5. Provides privacy (pulls curtain, shuts door, closes blinds) 6. Raises bed and positions resident in a supine position. 7. Washes hands 8. Put on non-sterile gloves ...15. Gloves removed and hands washed prior to raising bed rail, adjusting linens, pulling curtain, etc.",2015-04-01
9446,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,318,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation. record review and interviews, the facility failed to respond to therapy recommendation for Restorative Nursing Services (RNS) for Range of Motion (ROM) for Resident #2, 1 of 7 Residents reviewed for Range of Motion. The finding included: The facility admitted Resident #2 on 12/13/10 with [DIAGNOSES REDACTED]. Observation revealed Resident #2 was wearing heel protector boots on both heels that extended from his toes to his ankles that limited active ROM. On 3/15/11 at approximately 8:47 AM, record review revealed a Physical Therapy (PT) Discharge Summary dated 2/16/11 with a recommendation for ""Restorative for ROM and amb(ulation.)"" Review of the PT Weekly Progress Report for 2/14-2/16/11 revealed a notation that the therapist had ""Talked with nurse RE(garding): ROM and positioning w/c (wheelchair) mobility (approximately) 30' (feet) (with) max(imum) cues."" Review of the Minimal Data Set assessment dated [DATE] revealed the resident did not have any Restorative Nursing Services for the 7 preceding days. During an interview on 3/15/11, the RNS Certified Nursing Assistant (CNA) #4 stated the Resident was not receiving restorative services.. On 3/16/11 at 10:47 AM, the Director of Nursing stated that the Unit Managers usually followed up on any recommendations from the therapy department and she did not know why there was no follow up done related to the therapy recommendations for Resident #2.",2015-04-01
9447,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,325,D,0,1,R83211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and record review, the facility failed to provide adequate nutrition to meet the needs of Resident #2, 1 of 7 residents reviewed for nutrition needs. The findings included: The facility admitted Resident # 2 on 12/13/10 with [DIAGNOSES REDACTED]. On 3/15/11 at approximately 8:47 AM, review of the laboratory results dated [DATE] revealed a low [MEDICATION NAME] level of 12.1 mg/dl (milligrams per deciliter), a low [MEDICATION NAME] at 2.2 g (grams)/dl and a low total protein at 5.1 g/dl. Further review revealed a Nutrition Note from the Hospital dated 12/9/10 that the resident had experienced a 22% weight loss in one year and was receiving Mighty Shakes with meals at the hospital. Additional review revealed the facility Certified Dietary Manager (CDM) had completed a Nutrition Risk Assessment on 12/20/10 that noted the 12/17/10 [MEDICATION NAME] level but not the [MEDICATION NAME] or total protein level and the goal was to ""maintain wt (weight) 5%."" Review of the Admission and Weekly weight sheet for Unit 2 revealed the resident had lost an additional 6.2 pounds by 1/5/11. Further review of the dietary progress notes revealed the facility faxed notification to the Registered Dietician (RD) on 1/25/11 at 11:30 AM requesting the RD to send recommendations. On 1/25/11 at 3:56 PM the RD faxed a recommendation to the facility for a multivitamin and Health Shakes three times a day between meals and at bedtime and noted the resident's weight at that time to be 118.2 pounds. Resident #2 was receiving Speech Therapy to address Dysphagia. Review of the 3/6/11 MDS (Minimal Data Set) revealed the resident had 2 new stage II pressure ulcers with an onset date of 2/9/11. During observation of the pressure ulcer treatment on 3/15/11 at 10:00 AM, the resident was noted to have an un-stageable pressure ulcer on the right heel. On 3/14/11 at 9:10 AM and 3/15/11 at 8:35 AM, Resident #2 was noted to have his breakfast tray in front of him with very little consumed of the meal. On both days, there was no one in the room to assist the resident to eat. During an interview on 3/16/11 at 10:57, the Director of Nursing stated the CDM and the RD communicate via telephone and fax and the RD faxes recommendations at that time. She further stated that the RD visited the facility twice a month. The Director of Nursing also stated she would have expected the CDM to consult the RD at the time of admission given the resident's history of weight loss.",2015-04-01
9448,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2011-08-24,441,F,0,1,EVID11,"On the days of the survey, based on observations and interview, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Laundry staff were observed sorting linen and soiled linen touching the laundry worker's arm and clothing. The Laundry room was not designed to prevent cross contamination between soiled and clean linen. The findings included: During observation of linen sorting on 8/23/11 at 2:30 PM, Laundry worker #1 was observed sorting soiled linen which touched her right forearm, right sleeve, and right upper chest of her uniform which was not covered by her apron. After sorting the linen, Laundry worker #1 removed her gloves and washed her hands. Laundry worker #1 was not observed to wash her right forearm. During the sorting, the Laundry Manager was in attendance. Review of the laundry area on 8/23/11 revealed there was only one entrance into the laundry area. Upon entering the laundry, soiled linen barrels were stored. To the left of the entry, a clean linen cart was stored. The distance from the soiled linen barrel to the clean linen cart was sixty inches. Beside the clean linen cart was the folding table. Across from the folding table was the double sink. The distance from the folding table to the double sink was two feet. Moving further into the room, a dryer was noted and to the left of the dryer were three washing machines. The distance from the clean folding table to the closest washing machine was seventeen inches. Soiled linen is brought by the clean linen cart and the folding table to be placed in the washing machines. Review of the facility policy titled ""Laundry Handling Practices"" states under procedure 1. Use Standard Precautions in the handling of all soiled laundry. Wear protective gloves and other appropriate personal protective equipment when having contact with contaminated laundry. During an interview with laundry staff on 8/23/11, it was stated that a long sleeve gown was available and used when there was an isolation issue. An inservice was given on 5/20/10 which included Laundry Handling which stated Laundry workers are to use standard precautions (gowns and gloves, frequent handwashing) when handling all laundry. Laundry worker #1 was in attendance. The above findings were shared with the Laundry Supervisor and Administrator on 8/24/11 at 10:50 AM.",2015-04-01
9449,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2012-10-10,371,E,0,1,IG9F11,"On the days of the survey based on observation and interview the facility failed to store and serve foods under sanitary conditions. The findings included: Observations in the kitchen on 10-9-12 at 9:43 AM revealed kitchen staff washing the dishes, trays, silverware and other items through the low temperature dishwasher. As the plates were washed, the kitchen staff would take the plates off the wash racks and stack them together for the next meal. Continued observation of this process revealed 37 plates stacked together wet. An interview with the Certified Dietary Manager (CDM) confirmed this finding. The CDM took the wet plates out of the stacked position and re-ran the plates back through the dishwasher before storing them dry.",2015-04-01
9450,BROOKVIEW HEALTHCARE CENTER,425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2012-10-10,441,E,0,1,IG9F11,"On the days of survey based on observations and interviews, the facility failed to store and handle linen and trash properly in order to prevent the spread of infection. The soiled utility rooms had trash bin lids that could not be secured due to overflowing trash and a linen bin without a liner or secure lid for 2 of 3 soiled utility rooms observed. The findings included: During the initial environmental tour on 10/8/12 at 12:20 PM, the soiled utility room on the 100 hall, had a yellow trash bin which contained trash bags above the rim of the trash bin which did not allow for the bin to be covered with a secure lid. During the survey on 10/9/12 at 12:03 PM, the soiled utility room next to the exit door on the 300 hall had a trash bin with trash bags above the rim of the trash bin which did not allow for the bin to be covered with a secure lid. Observations of the soiled utility rooms on 10/10/10 at 8:55 AM for the 100 hall and 9:00 AM for the 300 hall, revealed a continued overflow of trash in the bins without secured lids. Also, a linen bin on the 300 hall did not have a liner in the bin, which already had linen bags within it, and there was not a lid secured over the linen bin. During an interview with Certified Nursing Assistant (CNA) #1 on 10/10/12 at 10:45 AM on hall 100, revealed that he/she had been instructed that trash and linen lids should be secured and that they should not overflow. The CNA stated that she did see that the trash bin lid was not on the bin but the lid should be down and that the trash should not be overflowing. During an interview with CNA #2 on 10/10/12 at 10:55 AM on hall 300, revealed that the ""first thing"" that he/she did see was that the linen bin did not have a liner in the bin, which already had bags of linen within it and that the trash bin was overflowing and the lid was not secured. He/She stated, ""No, this is not right"". After completion of wound care on 10-9-12 at approximately 11:25 AM, Licensed Practical Nurse (LPN) # 1 was observed taking the bagged soiled linen and bagged trash to the soiled linen room on the Magnolia Hall (300). There were several barrels in the room, some filled with soiled linen and others with trash. The ones closest to the door were noted to be over flowing with bags of soiled linen or trash and did not have the lids secured on top of them. Several barrels towards the back of the room did have at least one or more lids stacked on top of them but they appeared to be empty. LPN # 1 placed the soiled linen from the wound care into one of the over filled barrels of linen and she placed the bagged trash into one of the over filled barrels of trash. She did not secure the lid on top of the barrels. After completion of a tube flush on 10-9-12 at approximately 12:15 PM, LPN # 3 was observed taking a bag of trash from the resident's room to the soiled utility room on Magnolia Hall (300). LPN # 3 placed the bag of trash into a barrel which was overflowing with trash bags and which did not have a secure lid in place. The soiled utility room was noted to have both soiled linen barrels and trash barrels which were overflowing and they did not have the lid secured on the barrels. On 10-10-12 at approximately 10:00 AM, an observation was made of Laundry Worker # 1 using a laundry transport cart in the hall outside of the door to the Soiled utility room on Magnolia Hall (300). Laundry Worker # 1 was observed emptying the soiled linen barrel from inside the soiled utility room into the cart which was located in the hall outside the door. Many of the bags of soiled linen were not tied shut and it was coming out of the bags, falling into the cart, or on the floor. Laundry Worker # 1 had to reach down inside the cart and sometimes down onto the floor to pick up the soiled linen and her clothing was observed coming into contact with the soiled linen. Laundry Worker #1 was wearing gloves but did not have any protective gear over her clothing. On 10-10-12 at approximately 11:10 AM, Laundry Worker # 1 was observed in the clean area of the laundry room wearing the same clothing that she had been wearing when she was observed handling the soiled linen. Laundry Worker # 1 stated at that time that she had been trained to tie the bags shut before handling them if they were not secured in the barrel. She confirmed that she had not been wearing any personal protective clothing over her clothes, but that she had been wearing gloves.",2015-04-01
9451,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2011-04-27,250,D,0,1,NYJR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 11 residents reviewed for behaviors. The findings included: The facility admitted Resident #2 on 04/04/11 with the [DIAGNOSES REDACTED]. The Brief Interview for Mental Status(BIMS) on the Minimum Data Set (MDS) for 4/12/11 was 13 and he was on the facility's current interviewable list. A record review was conducted on 4/25/11 at 3:15 PM and revealed a nurse's note dated 4/9/11 at 11:19 AM which stated, ""CNA stated that resident has been touching her inappropriately. Stated that she asked him not to do that again. This is the second time he has done it."" At 2:25 PM on 4/9/11 a second note stated, ""Resident touched CNA inappropriately again. I talked with resident about his behavior. He started smiling and stated that it was an accident."" Later that day at 6:00 PM the nurse's note stated, ""Reassigned res. to the orderly group r/t female CNA stating she was uncomfortable working with him."" On 4/13/11 at 12:36 PM a Social Service note was made which referred to the resident grabbing at the staff and making inappropriate statements. The Social Worker spoke with the resident regarding the behaviors and he responded that he had not touched any of the staff intentionally. The note read, ""Resident stated if someone looks good or smells good then it is what it is."" The record review revealed another social work note on 4/19/11 which again addressed the resident inappropriately touching the staff. On 4/23/11 at 4:43 PM a nurse's note stated, ""Notified by staff res.(resident) touched another res. on her breast. Spoke with res. about that issue stated that he did not do that and asked why would he want to touch that old lady anyhow."" The nurse informed him to ""be careful"" around other residents and the resident agreed. The record review conducted on 4/25/11 and 4/26/11 revealed there was no social work plan or proposed interventions to address the resident's inappropriate behaviors toward the staff member or the alleged inappropriate behavior toward the resident. Although the social worker had spoken with the resident briefly regarding the incident with the staff member, she had not devised a plan to systemically meet with the resident to investigate the resident's psychosocial needs, adjustment to the facility, adjustment to his disability and medical condition. She had not counseled with the resident to obtain his input for measurable objectives and goals or provided education to him on the rules of the facility as related to abuse. In an interview with the Social Worker on 4/27/11 at 10:55 AM she stated that the resident's inappropriate behavior with staff member was first brought to her attention on 4/13/11 when she entered the first social work note which identified this issue. She stated it(behaviors) should have been addressed from the beginning and was receptive to developing specific social work interventions and a social work plan for the resident.",2015-04-01
9452,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2011-04-27,279,D,0,1,NYJR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews the facility failed to develop a comprehensive care plan which included measurable objectives and timetables to meet the resident's mental and psychosocial needs for 1 of 11 residents reviewed for care plans. The finding included: The facility admitted Resident #2 on 04/04/11 with the [DIAGNOSES REDACTED]. The Brief Interview for Mental Status(BIMS) on the Minimum Data Set (MDS) for 4/12/11 was 13 and he was on the facility's current interviewable list. A record review was conducted on 4/25/11 at 3:15 PM and revealed a nurse's note dated 4/9/11 at 11:19 AM which stated, ""CNA stated that resident has been touching her inappropriately. Stated that she asked him not to do that again. This is the second time he has done it."" At 2:25 PM on 4/9/11 a second note stated, ""Resident touched CNA inappropriately again. I talked with resident about his behavior. He started smiling and stated that it was an accident."" Later that day at 6:00 PM the nurse's note stated, ""Reassigned res.(resident) to the orderly group r/t female CNA stating she was uncomfortable working with him."" On 4/13/11 at 12:36 PM a Social Service note was made which referred to the resident grabbing at the staff and making inappropriate statements. The Social Worker spoke with the resident regarding the behaviors and he responded that he had not touched any of the staff intentionally. The note read, ""Resident stated if someone looks good or smells good then it is what it is."" The record review revealed another social work note on 4/19/11 which again addressed the resident inappropriately touching the staff. On 4/23/11 at 4:43 PM a nurse's note stated, ""Notified by staff res.(resident) touched another res. on her breast. Spoke with res. about that issue stated that he did not do that and asked why would he want to touch that old lady anyhow."" The nurse informed him to ""be careful"" around other residents and the resident agreed. The record review on 4/25/11 and 4/26/11 conducted per computer and hard copy revealed that the comprehensive care plan did not address the resident's alleged inappropriate behaviors which initially occurred on 4/9/11 and later on 4/23/11. On 4/27/11 the facility presented an updated care plan which documented 3 entries which were hand written additions. The first entry was dated 4/25/11 and stated, ""Monitor for and report to nurse any inappropriate behaviors"" and was designated for CNAs and Nursing. The second entry was dated 4/26/11 and was designated for Social Services. The entry stated, ""Visit at least twice weekly for support for one month and prn for s/sx of inappropriate behavior."" The third entry was for Nursing Staff and was dated 4/27/11 and stated, ""Hourly checks per staff."" The plan did not specifically address what behaviors they were monitoring, what interventions were put in place for support, or what they were checking for with the hourly checks. There was no indication the staff had met with the resident and involved him in the care planning or contracted with him regarding his behaviors. In an interview with the Care Plan Coordinator on 4/27/11, she stated that she had read the nurse's note related to the 4/23/11 allegation of resident to resident abuse on the morning of 4/25/11 and had started working on a plan to address the issue that morning. She did not address the previous resident to staff incident on 4/9/11 which resulted in the Certified Nursing Assistant being reassigned due to the alleged repeated inappropriate behaviors by the resident. In an interview with the Administrator on 4/27/11 at 12:20 PM she stated that the staff member (CNA) who reported the inappropriate behaviors by the resident had worked in the facility for a while and had been trained in abuse and neglect and should have known how to handle it and she(Administrator) did not take it as seriously as she should have.",2015-04-01
9453,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2011-06-14,441,E,0,1,UJK811,"On the days of the survey, based on observation and interviews, the facility failed to employ a method to ensure that all laundry items were hygienically cleansed. The findings included: During observation of the laundry process on 6-13-11 at 12:50 PM, a sign was noted on the laundry door (""Laundry System Process Information"") which indicated that wash cycles ""01"" and ""09"" contained no bleach. An interview with the Laundry Aide and Laundry Supervisor at that time revealed that bleach was not used for ""coloreds"". The Aide noted that personal clothes and table linens were washed using the ""01"" and ""09"" cycles in the front-load commercial washers and that there was no chemical method in use to sanitize these laundry items. A top-load home-type washer was set up with a dispensing system that had separate buttons for bleach and detergent, used at the discretion of the Laundry Aide. The contracted laundry chemical representative arrived during the laundry inspection and confirmed this information. When asked about temperature sanitation, the contractor checked the water temperature in commercial washer #2 which ranged from 107 to 116 degrees Fahrenheit. On 6-13-11 at 2:20 PM, the Laundry Supervisor stated that Maintenance had rechecked the water temperature in the laundry at 1:15 PM and it was 116 degrees. On 6-14-11 at 9 AM, the Laundry Supervisor provided a copy of the Material Safety Data Sheet on Interchlor, the sanitizer used in the chemical dispensing systems. This data noted that the sanitizer was a 10% Sodium Hypochlorite solution. At this time, in the laundry room, the Laundry Supervisor re-confirmed that, although this was the chemical sanitizer used in the dispensing systems, the two designated cycles did not automatically dispense this product prior to the survey date.",2015-04-01
9454,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2011-06-14,425,D,0,1,UJK811,"On the days of the survey, based on observation, interviews, review of the facility's pharmacy policy entitled ""General Dose Preparation and Medication Administration (12-1-07)"", and review of Drug Facts and Comparisons, Updated Monthly, the facility failed to follow a procedure to ensure that expired medications were removed from current stock for administration on one of two medication carts on the second floor. Lantus insulin was noted in the cart with an open date of 5-10-11 and had been administered to Resident A for eight days after the expiration date. The findings included: Review of the medication cart for Halls 1 and 2 on the second floor on 6-14-11 at 8:10 AM with Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #1 revealed one 10 milliliter (ml) vial of Lantus Insulin 100 units/1 ml for Resident A with an open date of 5-10-11. No other vials of Lantus Insulin could be located in the cart for this resident. RN #1 verified the open date and confirmed that the medication expired 28 days after opening. She stated, ""We'll have to reorder it."" Review of Resident A's Medication Administration Record [REDACTED]. During an interview on 6-14-11 at 9:45 AM, the Director of Nursing (DON) and Administrator noted that the facility had a policy for the medication carts to be checked on a routine basis. The DON provided a copy of Weekly Assigned Duties at 10:15 AM which instructed the Float Nurse: ""Friday- Second Floor medication carts: Check for...expired med(ication)s. Make sure dates are on insulins..."" She stated that the 11-7 shift nurse who was responsible for checking the cart weekly did not follow the policy for Friday, 6-10-11, and that the nurses who gave the insulin should have checked the expiration date prior to administration. The pharmacy policy entitled ""General Dose Preparation and Medication Administration (12-1-07)"", reviewed on 6-14-11, stated: ""3.2 Facility staff should check the expiration date on the medication."" Review of Drug Facts and Comparisons, Updated Monthly, page 290, related to Lantus Insulin, noted the following: ""Opened vials, whether or not refrigerated, must be used within a 28-day period or they must be discarded.""",2015-04-01
9455,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2011-06-14,314,D,0,1,UJK811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies entitled ""Dressings, Clean Technique (8-3-10)"" and ""Dressing Change Observation List"", the facility failed to provide necessary treatment and services to promote healing and prevent infection for two of three residents observed for wound care. Licensed Practical Nurse (LPN) #1 did not use appropriate wound cleansing technique for Resident #3. For Resident #5, LPN #3 performed the wound treatment in the presence of feces and failed to apply the dressing appropriately. The findings included: The facility admitted Resident #3 on 1-7-06 with multiple chronic diagnoses. During observation of wound care on 6-14-11 at 11:15 AM, LPN #1 soaked non-sterile 4X4 gauze with Saline Wound Flush. She cleansed the six inch long wound and periwound area on the outer aspect of the resident's right lower leg with the 4X4's by repeatedly patting the wound bed and surrounding area proximally to distally. Then, using the same 4X4's, she again cleansed the wound, going over the same areas, this time distally to proximally. During an interview on 6-14-11 at 12:15 PM, the nurse who assisted with Resident #3's treatment (LPN #2) verified the observation. During an interview on 6-14-11 at 12:20 PM, LPN #1 confirmed that she had cleansed the wound bed twice, using the same 4X4. The facility admitted Resident #5 on 6-3-11 with multiple chronic diagnoses. During observation of wound care on 6-14-11 at 11:50 AM, LPN #2 uncovered the resident and detached the brief. LPN #3 washed her hands, gloved, and assisted #2 in positioning the resident on her side. She rolled the soiled brief up close to the resident's left buttock. The entire perianal and sacral area was reddened, at least 8 inches in diameter, extending onto the buttocks. Smeared feces was present around the perianal area and on the dressing closest to the rectum on the left buttock. The nurse removed this dressing and a second dressing from the sacral area. After washing her hands, she cleansed the sacral area which had two stage II ulcers. One measured ""1/2 X 3/4 inches"", and the other (which was undocumented/new) was ""1/2 X 1/8 inches"". LPN #3 then cleansed the stage II wound on the left buttock, approximately 1 1/2 inches from the feces. After cleansing the wound bed, she stated, ""I'll have the CNA (Certified Nursing Assistant) come in when I'm done to do care, clean that little bit of poop off."" She applied Normigel to all open areas and dressed the wound closest to the feces first. As she applied the [MEDICATION NAME] Border Dressing, the one inch tape edging was placed over one of the stage II wounds in the sacral area. After the nurse washed her hands, gloved, and prepared to apply a dressing to the other sacral wound, the surveyor stopped the procedure and brought to the nurse's attention the positioning of the tape directly over the wound. She confirmed that the tape was directly on the wound bed, removed the tape, folded it under, and then applied the dressing to the proximal wound. During an interview at 12:10 PM, LPN #2 and #3 verified these observations. LPN #2 confirmed that pericare should have been done prior to the dressing change and that tape should not have been applied directly over the open wound. At 12:45 PM on 6-14-11, the Director of Nursing (DON) stated that LPN #3 should have cleaned Resident #5 before providing wound care and should not have taped over the open wound. Regarding Resident #3, the DON stated that LPN #1 should not have gone over the wound bed and periwound areas twice with the same 4 X 4's. Review of the policies/procedures entitled ""Dressing Change Observation List"" and ""Dressings, Clean Technique (8-3-10)"" provided by the DON on 6-14-11 at 1:20 PM revealed no specific references to removal of feces from the sacral/buttocks area prior to treatment or to application of tape over existing wounds.",2015-04-01
9456,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2011-07-20,241,D,0,1,UJK812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the follow-up survey, based on observation, record review, and interview, the facility failed to promote care for residents in a manner that enhanced their dignity and respect. Resident #17, one of one residents observed in relation to dignity, was observed naked in a geri-chair at the nuses station being fed by staff. The findings included: The facility admitted Resident #17 on 5/6/11 with [DIAGNOSES REDACTED]. Observation on 7/20/11 at 8:07 AM revealed Certified Nursing Assistant (CNA) #1 feeding Resident #17. Resident #17 was sitting in a geri-chair located in front of the Nurses' Station on the 1st floor. Observation at the time revealed the resident was nude except for a pair of socks. A sheet and gown had been bundled up in a ball into the side of the geri-chair. A soft belt restraint had been tied around the resident's waist. One view by the surveyor revealed exposed genitals. Shortly after the surveyor walked up to the scene, the CNA attempted to cover the resident with the sheet/gown, but the resident uncovered himself. The CNA spoke to the resident and said, ""Let's go to your room and put on clothes"". The resident yelled ""Help! Help!"". The CNA then told another staff member that she didn't know what to do. She then told the resident to ""Hold your feet up"", and when the resident kept his feet down, she stated ""Don't push back (Resident #17), Let's go to your room"". Another staff member came and put the resident's gown and sheet on his abdomen. CNA #1 then lifted the resident's feet, and the three staff members together wheeled the resident to his room. On the way to his room the resident yelled ""Help! Help!"" again. The Health Services Manager identified CNA #1 and the 2 other staff members that assisted as having been Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. Observation on 7/20/11 at 8:37 AM revealed Resident #17 sitting in the geri-chair in his room fully dressed. During an interview on 7/20/11 at 8:45 AM, CNA #1 and the Health Services Manager were present. CNA #1 was asked how the resident was when she came on duty. The CNA stated she came on duty about 5 or 10 minutes to 7:00 AM, and that when she arrived, Resident #17 was sitting at the nurses' station wearing a pull-up with his gown part way off. She stated he eventually took off everything, including his pullup. She stated that she and another CNA dressed him in a gown and covered him with the sheet. She stated that when she started working (because she had things she needed to do), the resident came out of his restraint and she observed the resident walking down the hall naked. She stated she and another CNA attempted to dress the resident, but when resident would not let them put the gown on, they got a sheet over him in the chair, placed the soft belt restraint, and she had attempted to feed him. When asked if she took him to his room to dress him, CNA #1 stated that ""Everything was going so fast I didn't think to take him back to his room"". According to CNA #1, Resident #17 was dressed by the staff at the nurses' station. When asked why the resident had been sitting out at the nurse's desk when she arrived, CNA #1 stated that there were only 2 CNA's on at night and they weren't able to keep him in his room by himself since he was a fall risk. When asked if he had an alarm, she stated he had a clip alarm that he used in the chair. When asked if it had been on the resident when she came on duty or if she had noticed one, she stated that she hadn't paid it any attention. She said that they couldn't keep an alarm on him because he was naked all the time. Observation on 7/20/11 AT 11:38 AM revealed Resident #17 in his room. He was sitting in his geri-chair naked from the waist down with his soft belt restraint intact. CNA #2 was sitting in a chair writing out a note. She stated she was documenting that the resident was combative and had taken off his pants. She stated she couldn't make him wear pants since it was his right. Review of Nurse's Notes on 7/20/11 revealed the following: ""7/20/11 5:15 AM Resident up in gerichair out in commons area-Res.(Resident) has been pulling brief off and taking hospital gown off all night. Resident hit this nurse in the chest with fist. Res yelling and constantly trying to slide under lap belt. CNA's had to take turns sitting with resident while making rounds...7/20/11 6:30 AM Resident continues to pull brief off and gown, yelling out help me. [MEDICATION NAME] ineffective at this time. Res. also continues to slide under lap belt."". During an interview on 7/20/11 at 2:00 PM, the Administrator stated she had spoken to CNA #1 and that CNA #1 had attempted several times prior to the surveyor's observation to cover the resident but the resident had refused and kept removing the sheet. She stated that other staff along with CNA #1 had attempted to get the resident to his room but he had refused."". When asked if she thought it was okay for the CNA to continue feeding a naked resident by the nursing station she said no, but requested the surveyor give her some suggestions about what should have been done.",2015-04-01
9457,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2011-07-20,280,D,0,1,UJK812,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the follow-up survey, based on observation, record review, and interview, the facility staff failed to update the Care Plan in relation to behaviors for Resident #17, one of one residents reviewed for Comprehensive Care Plans. The findings included: The facility admitted Resident #17 on 5/6/11 with [DIAGNOSES REDACTED]. Observation on 7/20/11 at 8:07 AM revealed Resident #17 sitting in a geri-chair at the 1st floor nurses' station naked except for socks and a soft belt restraint being fed by a CNA. When the resident refused to go to his room to get changed, the CNA asked another staff what she should do. Cross Refer to F241. According to staff interviews and record review, Resident # 17's Comprehensive Care Plan had not been updated in relation to his behaviors of physical/verbal aggression, rejection of care, and removal of clothing. Record review on 7/20/11 at 11:45 AM revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] with an Assessment Reference Date (ARD) of 5/12/11 for Resident #17 which documented a BIMS (Brief Interview for Mental Status) score of 10. It also coded the resident as having required extensive assistance with one person physical help for dressing. Continued review revealed Resident #17 had been coded as having ""Signs and Symptoms of [MEDICAL CONDITION]"" that were present and fluctuated which included ""Inattention and Disorganized Thinking"". Review of Section E ""Behavior"" revealed that the resident had been coded as having ""Delusions"". Behavioral Symptoms that had been coded as having occurred 1-3 days included ""Physical behavioral symptoms directed toward others"" and ""Verbal behavioral symptoms directed toward others"". Under ""Impact on Resident"", the following questions were asked: ""Did any of the identified symptom(s): Put the resident at significant risk for physical illness or injury? Significantly interfere with the resident's care? Significantly interfere with the resident's participation in activities or social interactions? All responses had been coded ""Yes"". Under ""Impact on Others"", questions were asked which included the following: ""Did any of the identified symptom(s): Put others at risk for physical injury? Significantly disrupt care of living environment?"". Both answers had been coded ""Yes"". Under ""Rejection of Care- Presence and Frequency"" the question was asked ""Did the resident reject evaluation or care... that is necessary to achieve the resident's goals for health and well-being?"" The answer had been coded that ""Behavior of this type occurred 4-6 days, but less than daily"". Review of the Care Assessment (CAA) Summary revealed that Care Area ""Behavioral Symptoms"" had triggered and would be addressed in the Care Plan. Review of the CAA notes for Behavior Symptoms revealed ""Resident has some impaired memory. He has dx (diagnosis) of chronic [MEDICAL CONDITION]. He continues to get out of bed and chair without calling for assistance. He is at high risk for falls"". Review of the Comprehensive Care Plan dated 6/22/11 for Resident #17 revealed ""Resident is at risk for undesirable side effects related to [MEDICAL CONDITION] drug(s) resident is prescribed a(n) antianxiety and a [MEDICAL CONDITION]"". An approach had been listed to ""Chart frequency and describe behaviors for which drug is being used"". However, there was no mention in the Care Plan of any problems with or interventions listed for Physical and/or Verbal behavioral symptoms or for rejection of care. During an interview on 7/20/11 at 12:05 PM, Registered Nurse (RN) #1 and RN #2 were present. According to RN #1, Resident #17 had been having behaviors since he came back from the hospital in June. She stated he didn't want help with dressing or anything. She stated that the resident has been combative and had hit staff and that he didn't want to stay dressed. She stated the resident had a sitter from 10:00 AM until 2:00 PM and from 5:00 PM until 10:00 PM. She stated that he does better when someone stays with him, and that the facility had been trying since yesterday to get a sitter for him 24 hours a day. She stated that staff used distraction and walking to help with his behaviors. Review of Nurse's Notes revealed the following documentation: ""7/20/11 5:15 AM Resident up in gerichair out in commons area-Res.(Resident) has been pulling brief off and taking hospital gown off all night. Resident hit this nurse in the chest with fist. Res yelling and constantly trying to slide under lap belt. CNA's had to take turns sitting with resident while making rounds...7/20/11 6:30 AM Resident continues to pull brief off and gown, yelling out help me. [MEDICATION NAME] ineffective at this time. Res. also continues to slide under lap belt."". ""7/19/11 11 AM Res. sent to ER (emergency room ) this morning at (:30 AM due to res. very combative. Yelling, cursing, & hitting staff. Several attempts made to redirect resident..."" ""7/17/11 [MEDICATION NAME] ...given at 1:30 PM. No results as of yet hitting @ staff @ intervals"". ""7/17/11 7 AM Resident is alert but unoriented. Frequent agitation, combativeness and uncooperative..."". ""7/16/11 6 AM Remains with intermittent agitation and combativeness"". ""7/14/11 7:15 PM Res. removing clothes and yelling out in commons area. Gave [MEDICATION NAME] 1 mg PO (By Mouth) resident crushed foam cup and threw water on floor"". ""7/10/11 10 PM Resident agitated, yelling and cursing at staff while removing clothes this shift..."". ""7/10/11 9 PM Resident remains agitated, yelling an pulling at clothing..."". ""7/8/11 2:45 PM ...Resident yelling out, try to remove lap belt, and when he was abe to stand he would sit in floor"". ""7/4/11 7:40 AM Resident up in chair in nurses station. He is combative and agitated. Resident constantly standing and walking. He hit nurse and attempt to hit CNA..."". ""7/2/11 7 AM Resident getting up (without) assist hitting @ staff and cursing..."". ""7/1/11 3:30 PM ...Resident very agitated & hitting staff. Provided 1:1 care, tried to redirect resident still combative, cursing, yelling, & hitting staff..."". ""6/22/11 6-7 PM Attempted to take resident to toilet as he had previously stated he wanted to go, res dragging heels on carpet, grabbing doorframe as we entered room. Res. refused toilet & was assisted by myslef + CNA to lay down..."". ""6/19/11 Resident continues to take off his clothes"". ""6/17/11 7:15 PM ...Res arrived (with) mittens in place to both hands, swinging fists in the air..."". ""6/17/11 6:10 PM ...Resident sent back to ER- agitated, swing(ing) at staff coninuously trying to climb out of bed"". During an interview on 7/20/11 at 12:35 PM, RN #2 stated the 6/22/11 Comprehensive Care Plan was currently being used for Resident #17. When asked if the copy provided to the surveor was the complete Care Plan, she checked her computer and stated it was. She verified that Resident #17's Care Plan had not been updated related to his behaviors of verbal/physical aggression as well as his removal of clothing. She stated that the MDS nurses update the Care Plans as well as the floor nurses. She stated when asked that Resident #17's behaviors as well as interventions should have been included on the Comprehensive Care Plan as soon as they were happening. RN #2 stated that Social Services usually filled out the MDS related to behaviors and that Social Services was still learning and had not updated care plans as of yet.",2015-04-01
9458,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2011-12-14,225,F,1,0,Y2XQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on interviews, review of facility investigative documents for incidents of alleged abuse, neglect and misappropriation and review of the facility Abuse, Neglect or Exploitation of Residents policy, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to the State survey and certification agency. Facility staff members witnessed an interaction between Registered Nurse (RN) #1 and Resident #1 allegedly on 08/07/2011 but failed to report it despite thinking it was extreme and / or abusive. The facility failed to report allegations of abuse and / or neglect received in an anonymous letter. The daughter of Resident #10 alleged on 11/29/2011 that her father and two other resident were not fed and on 11/12/2011 Resident #11 alleged that $700.00 dollars was stolen from him, neither concern was reported to the State survey and certification agency. The findings included: Cross Refers to F-226 On 9/13/2011, Resident 1's responsible party (RP) made allegations of mistreatment and neglect during a meeting with the Ombudsman and Administrator. The allegations included 1. A nurse threw juice at Resident #1 and 2. A nurse attempted to coerce Resident #1 to hit him. In an interview with the surveyor on 11/18/2011 at 10:40 AM Licensed Practical Nurse (LPN) #1 revealed that on the day of the alleged abuse, Resident #1 said to her ""watch this"" before he began touching the female residents. LPN #1 said RN #1 was speaking loudly to Resident #1 but he did not seem overly angry with the resident. However, LPN #1 thought RN #1's response was extreme. An interview with RN #2 on 11/17/2011 at 4 PM revealed there were other witnesses to this incident. He provided the name of a dietary employee. The dietary employee was interviewed on 11/18/2011 and confirmed that she passed by the nurses' station while RN #1 was yelling at Resident #1, saying ""hit me, hit me if you want to."" At that point Resident #1 and RN #1 were facing each other across the top of the desk. Resident #1 was quiet and his face was red. The dietary employee stated she felt the incident was verbal abuse. It occurred on a Sunday and she reported it to her supervisor on Monday. The dietary manager was interviewed on 11/18/2011 at 2:30 PM and confirmed that her employee reported the incident to her several days later. However, the dietary employee insisted that the manager not say anything to Administration because ""LPN #1 should report it."" A written statement received from the dietary manager on 11/18/2011 said: ""... I instructed .... to report it. I encouraged her to think about what happen and how she would feel if it was her family this happen to and she stated she would report it. I did report in Team Conference or other mtg. (meeting) I'm not sure which one that ... witness the incident, however noone (sic) ever gave her a paper (including myself) to write it up. (Sheets was given to other staff, however noone (sic) gave Dietary or talk with Dietary regarding this incident. I also told ... Social Services that ... had witness this incident."" An interview with the MDS (Minimum Data Set) Coordinator on 11/18/2011 at 2:50 PM revealed that at Resident #1's last care plan meeting on 08/22/2011, the RP brought up the allegations of mistreatment but stated she would not give the nurse's name who allegedly threw the juice and she did not want to go forward with the incident concerning RN #1 urging the resident to hit him. The MDS Coordinator said she was going to talk with RN #1 about it, but at the time the staff were all busy with the annual recertification survey follow-up and there was no further discussion. Facility staff members witnessed an interaction between the RN #1 and Resident #1 allegedly on 08/07/2011 but failed to report it despite thinking of it as extreme and / or abusive. Other staff members were aware of the incident and they also failed to report their knowledge to Administration for investigation. An anonymous letter, copied to the State Agency, was received by the facility allegedly postmarked 11/02/2011. The Bureau of Certification failed to receive a report from the facility related to any of the allegations detailed in the letter. The letter contained allegations of verbal abuse, neglect and misappropriation of medications and abandonment of residents during the night shift. During an interview on 12/13/2011 at approximately 12:30 PM, the Administrator stated she had not reported the letter to the Bureau of Certification. She did not recall the date she had received the letter but the envelope was postmarked 11/02/2011. On 12/14/2011, the Administrator stated that she had not reported it to the State agency because the letter stated that a copy had been sent to DHEC, the Department of Health and Environmental Control. She verified that the letter did not indicate it had been sent to the Bureau of Certification. The facility failed to report these allegations. On 12/14/2011 at approximately 11:00 AM, review of the grievance log revealed Resident #10's daughter alleged that her father and 2 other residents had not been fed on 11/26/2011 and on 11/12/2011 Resident # 11 alleged $700.00 had been stolen from him. The review of the [MEDICATION NAME] (reports of allegations of abuse, neglect mistreatment or misappropriation reported by the facility to the Bureau of Certification) revealed the allegations had not been reported to the appropriate State agency. The Administrator confirmed that the allegations had not been reported to the State survey and certification agency. Review of the facility's policy on Abuse, Neglect, or Exploitation of Residents stated, "" ... 2. Training: All new employees receive orientation that includes Resident rights and the professional duty to report abuse ...""",2015-04-01
9459,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2011-12-14,226,F,1,0,Y2XQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on interviews, review of facility investigative documents for incidents of alleged abuse, neglect and misappropriation and review of the facility Abuse, Neglect or Exploitation of Residents policy, the facility failed to ensure it's policy and procedures to prevent misappropriation of property, mistreatment, neglect and abuse of residents were followed. Facility staff members witnessed an interaction between Registered Nurse (RN) #1 and Resident #1 allegedly on 08/07/2011 but failed to report it despite thinking it was extreme and / or abusive. The facility failed to report and / or thoroughly investigate allegations of abuse and / or neglect received in an anonymous letter. The daughter of Resident #10 alleged on 11/29/2011 that her father and two other resident were not fed, the facility failed to timely and / or thoroughly investigate. The facility failed to report and / or investigate timely an allegation made by Resident #11 that $700.00 dollars was stolen from him. The findings included: On 09/13/11, Resident #1's responsible party (RP) made allegations of mistreatment and neglect during a meeting with the Ombudsman and Administrator. The allegations did not include details such as date(s) or the name of the staff member(s). Resident #1's RP was asked to provide the details that she said she had. The facility began its investigation and on 09/19/2011, the Director of Nurses (DON) filed her five-day report with the State survey and certification agency. The allegations included 1. A nurse threw juice at Resident #1 and 2. A nurse attempted to coerce Resident #1 to hit him. In an interview with the surveyor on 11/18/2011 at 10:40 AM Licensed Practical Nurse (LPN) #1 revealed that on the day of the alleged abuse, Resident #1 said to her ""watch this"" before he began touching the female residents. LPN #1 said RN #1 was speaking loudly to Resident #1 but he did not seem overly angry with the resident. However, LPN #1 thought RN #1's response was extreme. An interview with RN #2 on 11/17/2011 at 4 PM revealed there were other witnesses to this incident. He provided the name of a dietary employee. The dietary employee was interviewed on 11/18/2011 and confirmed that she passed by the nurses' station while RN #1 was yelling at Resident #1, saying ""hit me, hit me if you want to."" At that point Resident #1 and RN #1 were facing each other across the top of the desk. Resident #1 was quiet and his face was red. The dietary employee stated she felt the incident was verbal abuse. It occurred on a Sunday and she reported it to her supervisor on Monday. The dietary manager was interviewed on 11/18/2011 at 2:30 PM and confirmed that her employee reported the incident to her several days later. An interview with the MDS (Minimum Data Set) Coordinator on 11/18/2011 at 2:50 PM revealed that at Resident #1's last care plan meeting on 08/22/2011, the RP brought up the allegations of mistreatment but stated she would not give the nurse's name who allegedly threw the juice and she did not want to go forward with the incident concerning RN #1 urging the resident to hit him. The MDS Coordinator said she was going to talk with RN #1 about it, but at the time the staff were all busy with the annual recertification survey follow-up and there was no further discussion. Facility staff members witnessed an interaction between the RN #1 and Resident #1 allegedly on 08/07/2011 but failed to report it despite thinking of it as extreme and/or abusive. An anonymous letter, copied to the State Agency, was received by the facility allegedly postmarked 11/02/2011. The Bureau of Certification failed to receive a report from the facility related to any of the allegations detailed in the letter. The letter contained allegations of verbal abuse, neglect and misappropriation of medications and abandonment of residents during the night shift. During an interview on 12/13/2011 at approximately 12:30 PM, the Nursing Home Administrator stated she had not reported the letter to the Bureau of Certification. She did not recall the date she had received the letter but the envelope was postmarked 11/02/2011. On 12/14/2011, the Administrator stated that she had not reported it to the State agency because the letter stated that a copy had been sent to DHEC, the Department of Health and Environmental Control. She verified that the letter did not indicate it had been sent to the Bureau of Certification. On 12/14/2011 at approximately 11:00 AM, review of the grievance log revealed Resident #10's daughter alleged that her father and 2 other residents had not been fed on 11/26/2011 and Resident # 11 alleged $700.00 had been stolen from him. The Review of the [MEDICATION NAME] (reports of allegations of abuse, neglect mistreatment or misappropriation reported by the facility to the Bureau of Certification) revealed the allegations had not been reported to the appropriate State agency. The Administrator confirmed that the allegations had not been reported to the State survey and certification agency. The facility failed to implement their written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Review of the facility's policy on Abuse, Neglect, or Exploitation of Residents stated, "" ... 2. Training: All new employees receive orientation that includes Resident rights and the professional duty to report abuse ... 5. Investigation: A. An investigation will be conducted on all reports of missing property, severe injuries, unexplained injuries, and / or inappropriate aggressive behaviors ... G. Sufficient evidence or proof is collected to substantiate whether or not neglect, abuse, or misappropriation has occurred ... 7. Reporting and Facility Response: A. The Unit Manager where the incident occurred will report the incident to the Director of Nursing, Director of Social Services, or Administrator who will file the appropriate reports to state or federal agencies ... """,2015-04-01
9460,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2011-12-14,499,D,1,0,Y2XQ11,"On the days of the Complaint and Extended survey, based on record review and interviews, the facility failed to ensure that all professional staff were licensed. One Licensed Practical Nurse (LPN) and one Registered Nurse (RN) held North Carolina Nursing licenses, identified on the license as a Single State License that restricted practice to the state of North Carolina. The findings included: On 12/14/2011 at approximately 4:00 PM, during review of personnel files for the extended survey, LPN #6 and RN #1 both had North Carolina Nursing License Verifications dated 01/06/2011 that identified the licenses as Single State licenses. The original date of Licensure for both was 09/01/2010. An explanation of a single state license was provided under a sub-heading ""Important Notes: Single State Licensure: Authority to practice as a licensed nurse only in the state of North Carolina and the privilege otherwise restricted."" RN #1 also had a License Verification dated 11/28/2011 that indicated his North Carolina License was a MultiState License. LPN #6 had no additional License Verification. During an interview with the Administrator, she confirmed that the initial verifications indicated the licenses were Single State. A verification was obtained at that time for LPN #6 which indicated the license was now a MultiState License. RN #1 had no license verification in his file that extended authority to work in South Carolina from his date of hire, 01/10/2011, until 11/28/2011. LPN #6 had no license verification in her file that extended authority to work in South Carolina from her date of hire, 01/10/2011, until the date of the extended survey, 12/14/2011.",2015-04-01
9461,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,225,D,0,1,7XVN11,"**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 report an Injury of Unknown Origin in a timely manner for 1 of 2 reportable incidents reviewed. Resident C sustained a fracture of unknown origin and the incident was not immediately reported to the appropriate state agency. The findings included: Resident C complained of leg pain on 5/8/10. She was admitted to the hospital with [REDACTED]. The facility conducted an investigation as to cause of the fracture. State agencies were not notified until 5/17/2010, eight days after the injury occurred of the injury of unknown origin. The Director of Nurses (DON) was interviewed on 4/12/11 at 10:45 AM regarding the incident. The DON stated she did not think of the incident as an injury of unknown origin at the time that she made the report. She stated she was reporting the serious injury of the fracture. The DON stated that Resident C had been combative earlier during the day on 5/8/2010. The injury was felt to have occurred during the time of the combative behavior, but it ""could not be determined for sure"". However, Resident C did not complain of pain in her leg until later in the day. The facility failed to report the injury of unknown origin within the required 24 hour time period.",2015-04-01
9462,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,309,F,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, staff interviews and observations, the facility failed to provide services including, monitoring and tracking of pacemakers for 7 of 9 residents with pacemakers. ( Resident # 31, #20, #14, #7, #29, #27 and #22) The facility failed to follow-up for a resident receiving thickened liquids without a physician's order for 1 of 1 residents receiving thickened liquids.( Resident #12) The facility failed to provide documentation of CNA visits and Durable Medical Equipment provided by Hospice for 1 of 2 residents receiving Hospice services. The findings included: The facility admitted Resident #14 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the resident's medical record on 4/12/11 revealed the hospital History and Physical dated 1/8/11 included under ""Impression: Dual chamber pacemaker"". The resident had a Pacemaker check done on 12/16/2010 before admission to the facility. The care plan for Pacemaker, dated 2/4/11 stated the pacemaker had been inserted on 6/3/2008. The approaches included: ""Evaluate for proper functioning of pacemaker by monitoring vital signs as indicated per policy. Complete pacemaker checks as indicated and document per Dr. (doctor)--- office."" Review of the Physician's orders since admission, (January 2011, February 2011, March 2011 and April of 2011) did not contain any orders pertaining to the resident's pacemaker checks/monitoring. The Physician's progress notes since admission did not speak to the resident having had a pacemaker. On 4/12/11 at 4:00 PM, the Unit Manager for the North Wing was interviewed. She stated, ""We don't have a schedule for the pacemaker checks. Dr. --- doesn't send out schedules. "" The Unit Manager called the doctors office and an appointment was made for 4/14/11. On 4/13/2011 at 9:00 AM, the Administrator stated, ""We don't have a policy on pacemakers"". We do have a procedure. On 4/13/2011, at 10:45 AM a schedule was provided. The schedule stated that the resident's last pacemaker check was done in January and his next scheduled appointment was scheduled for June 2, 2010. The information regarding his last check was the same information on the medical record that was dated for 12/16/10. There was no documentation in the medical record of a schedule or appointment for the pacemaker to be checked for proper functioning. The facility had no policy for monitoring or checking pacemaker function. The facility admitted resident #20 on 6/25/10, with [DIAGNOSES REDACTED]. During review of the medical record on 4/13/11, a Cardiology Consultation dated 2/23/11 had documentation for a pacemaker check to be done on 4/8/2011 at 10:15 AM at Dr's office. There was no documentation in the medical record of the results of the appointment on 4/8/2011. The Physician's orders did not contain orders for pacemaker checks or monitoring. The Physician's progress notes dated from 8/9/10 through 4/12/11 did not contain any mention of the resident having a pacemaker. The nurses notes were reviewed, there was no documentation of the pacemaker, nor the resident going or not going for the cardiology appointments on 4/8/11 or 2/23/11. The Unit Manager of the South wing was interviewed on 4/13/2011. She did not know if the resident went to the Dr's. appointment on 2/23/11. She stated that an appointment was on the Schedule Calender for 4/8/2011. The Unit Manager reviewed the medical record and did not find any documentation regarding the appointment. She then called the Cardiologist and stated the the appointment had been cancelled by the wife. At 9:50 AM the DON (Director of Nursing) was interviewed with the Unit Manager. The DON stated that the resident's wife"" handled the appointments."" The wife made the appointments and cancelled appointments without informing the facility. ""We are responsible, but we don't always know"". The DON reviewed the medical record and stated that the information regarding the Cardiology visit should have been in the nurses notes, whether the resident went or not. The DON was not able to locate any information in the nurses notes for 4/8/11 regarding the pacemaker visit. The DON stated that she would call the Cardiologist herself. The DON was interviewed on 4/13/11. She stated, ""I called the office myself. They said the appointment was cancelled by the office because the resident owes them money..... They (Cardiologist office) have not let us know anything about the money. They deal with the wife. If they had let us know we could have looked into other options... to check the pacemaker."" The resident had been scheduled to have his pacemaker checked on 4/8/11. The facility was not aware whether the resident had the pacemaker checked or not. There was no documentation, the Unit Manager and the DON were unaware that the resident did not receive his follow-up care. The facility admitted Resident #31 on 6/25/10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a care plan dated 11/17/10 and 2/11/11 for Pacemaker. The approaches listed for the pacemaker included: ""Evaluation for proper functioning of pacemaker by monitoring vital signs as indicated. Notify Physician if any signs of pacemaker failure: *Heart Palpitations, *Heart beat 5-10 beats more or less than setting, *Swollen ankles, feet, *[MEDICAL CONDITION] dizziness, *Shortness of breath, anxiety, forgetfulness, confusion. Complete pacemaker checks as indicated and document...."" Review of the Physician orders for April 2011, March 2011, February 2011, January 2011 and admission orders of June 2010, did not have any orders regarding treatment, follow-up or monitoring of the pacemaker. Physician's progress notes dated 12/14/10 through 4/12/11 did not contain any documentation regarding pacemaker, checks, monitoring or that the resident had a pacemaker and was care planned for the pacemaker. There was no documentation in the medical record other than the [DIAGNOSES REDACTED]. No further information was provided. The resident had a pacemaker implanted in March of 2010. He was admitted in June of 2010. There was no evidence provided that the resident had his pacemaker checked for proper functioning. The Unit Manager was not aware that the resident had not had his pacemaker checked. On 4/13/11 the Administrator provided a copy of the ""Pacemaker Procedure"". The copy consisted of copied pages from an unidentified book. ""TREATMENTS Permanent Pacemaker Care"". ""Permanent pacemakers are designed to last 3-[AGE] years . ...function in the demand mode, allowing the patient's heart to beat on its own but preventing it from falling below a preset rate....Candidates for permanent pacemakers include patients with [MEDICAL CONDITION] infarction [MEDICAL CONDITIONS] (low heart rate)and patients with complete heart block or slow ventricular rates...."" The procedure instructs nurses in the equipment needed to insert a Pacemaker, the Preoperative and Postoperative Care of the Pacemaker site. It then provides teaching instructions for the patient who has a permanent pacemaker. The instructions include: Checkups: Be sure to schedule and keep regular checkup appointments ... ""keep your transmission schedule and instructions in a handy place"". The facility admitted Resident #7 on 11/13/09 with [DIAGNOSES REDACTED]. Record review on 4/12/11 revealed Resident #7 had a pacemaker. Review of the resident's care plan revealed a pacemaker care plan had been developed and reviewed on 9/30/10, 12/28/10, and 3/24/11 with an approach to complete pacemaker checks as indicated and document. Further record review revealed no pacemaker check could be located on the record. Review of physician's orders revealed no order to perform pacemaker checks. An interview with the Unit Manager on 4/13/11 revealed that she could not find the pacemaker checks and that the Director of Nursing (DON) was handling locating the pacemaker checks. On 4/14/11 a pacemaker check was presented with the date of 11/10/10. No other pacemaker checks were provided during the survey process. The facility admitted Resident #29 on 7/19/10 with [DIAGNOSES REDACTED]. Record review on 4/13/11 revealed Resident #29 had a Cardioverter-Defibrillator. Review of the resident's care plan revealed a Defibrillator/Pacemaker care plan had been developed and reviewed on 7/26/10, 10/7/10, 12/10/10, and 3/8/11 with an approach to complete Defibrillator/Pacemaker checks as indicated and document at office visit. Further record review revealed no pacemaker check could be located on the record. Review of current physician's orders revealed no order to perform pacemaker checks. On 4/14/11, material was presented which had a facsimile date of 4/13/11 at 10:33 AM and 4/13/11 at 4:10 PM which revealed the resident had Defibrillator checks on 5/14/09, 8/20/09, 8/5/10, and 11/2/10. A letter was presented from xxx Medical Consultants which explained the resident's next appointment for a check was scheduled for 4/28/11. At the bottom of the letter, a hand written statement explaining the resident's appointments are made every 3 months when he comes into the office. The facility admitted Resident #27 on 11/12/10 with [DIAGNOSES REDACTED]. Review of the medical record on 4/13/11 revealed Resident #27 had a pacemaker in place. Review of the Report of Consultation dated 12/07/10 indicated Resident #27 had an appointment with the Cardiologist with a pacemaker check at that time. Further record review revealed a letter from the Cardiologist's office dated 12/06/10 indicated a Remote Pacemaker Check was due 3/09/11. The letter stated, ""Below is a schedule of your clinic visits and remote pacemaker check dates. Please use your Medtronic xxx Network monitor to complete the pacemaker checks."" Review of a pacemaker summary report from the Cardiologist's office indicated a remote follow-up was due 3/23/11. The report indicated remote pacemaker checks were to be done every 12 weeks. Review of the cumulative Physician's Orders revealed no order for pacemaker checks. Review of the care plan revealed approaches to pacemaker included, ""Complete pacemaker checks as indicated and document."" The care plan did not include documentation indicating when the last pacemaker check was done, how often the pacemaker was to be checked, and when the next pacemaker check was due. Review of the Treatment Record did not indicate when the last check was done and when the next pacemaker check was due. Review of the Nurse's Notes revealed no documentation related to pacemaker checks. During an interview on 4/13/11, Registered Nurse (RN) #5 was asked to review the medical record for information related to Resident #27's pacemaker checks. RN #5 confirmed that according to the medical record, a remote pacemaker check was due to be done 3/23/11 or 3/09/11. At that time, RN #5 was unable to locate documentation indicating a pacemaker check had been done since 12/07/10. In addition, RN #5 was unable to locate information indicating when the next pacemaker check was due. RN #5 stated that pacemaker check dates should be documented on the Appointment Calendar at the Nurse's Station. Review of the Appointment Calendar with RN #5 revealed no pacemaker check documented for 3/09/11 or 3/23/11. The facility admitted Resident # 22 on 5/11/07 with [DIAGNOSES REDACTED]. On 4/13/11 at 1:35 PM, review of the Physician's Monthly Orders dated 4/1/11 through 4/30/11 revealed there was no order for pacemaker checks. Review of the Physician's Telephone Orders revealed an order dated 2/3/11 for pacemaker check by xxx. A review of the record revealed a Transtelephonic Pacemaker Follow-up Report dated 2/3/11 that stated ""Normal battery function. Normal ventricular capture. Normal ventricular sensing."" The report also stated the next TTM (TransTelephonic Monitoring) was scheduled for 5/5/2011. At 1:52 PM on 4/13/11 review of the unit appointment book revealed no notation for the TTM on 5/5/11. During an interview on 4/13/11 at 2:25 PM, the Acting Unit Manager stated that the MDS (Minimal Data Set) Coordinator kept up with pacemaker checks. At 2:35 PM on 4/13/11, the MDS Coordinator stated that she obtains pacemaker information such as model, serial number and name of the physician for the care plan but does not keep up with when pacemaker checks are due. She further stated that the unit managers and nurses do that. The facility was unable to provide any documentation of any pacemaker checks prior to 2/3/11. The facility failed to track and/or monitor 7 of 9 residents with pacemakers to ensure that the pacemakers were functioning appropriately. The nurses were not aware when or if the resident's had their pacemakers checked. There were no pacemaker schedules for the nurses to follow and no documentation by the nurses or the physicians of residents having appointments. The facility did not have a policy on maintaining or checking pacemakers. During an interview with the Medical Director on 4/14/2011, he stated that he was not aware that the facility did not have a policy concerning pacemakers. Substandard Quality of Care related to CFR 483.25 F-309 was identified on 4/13/11 at 3:37 PM related to the facility's failure to identify and provide necessary medical services as needed for 7 of 9 sampled residents with a pacemaker. The facility Administrator was advised on 4/13/11 at approximately 4:00 PM by the Team Leader that Substandard Quality of Care had been identified by the team after conferring with the Sate Agency. Additionally, the facility admitted resident #12 on 4/2/2009 with [DIAGNOSES REDACTED]. On 4/11/2011 at 6:10 PM the resident was observed with a water pitcher on his bedside table. At 6:50 PM, the resident was observed with his supper tray. The tray contained a Cola, a carton of skim milk and a container of nectar thick liquid. Review of the medical record on 4/11/11, revealed a physician's order for a puree diet, large portions. There was no physician's order for thickened liquids. There were no notes in the Physician's Progress notes dated from 4/28/2010 through 4/16/11 regarding swallowing and/or need for thickened liquids. A care plan for noncompliance dated for 2/25/11 and a care plan for difficulty swallowing (dysphagia) stated that the resident was non compliant with his thickened liquids. A Speech Therapy Evaluation dated 4/27/10 was on the medical record. Under the section entitled precautions, ""aspiration risk"" was documented. Under the section entitled Long Term Goals, it was documented: ""to develop safe functional swallow in order to determine highest/safest diet without any clinical s/s (signs/symptoms) aspiration penetration"". Under the section entitled Short Term Goals it was documented: ""Pt. (patient) to receive MBSS (Modified [MEDICATION NAME] Swallow Study) to determine safest means of nutrition/hydration."" There was no report of a MBSS performed. On 4/12/11 at 10:45 AM an interview was conducted with the DON. She stated that the resident did not get the swallowing study because he refused to go. ""He refuses the thickened liquids. He does what he wants, when he wants"". A Physician's telephone order obtained from medical records dated 3/10/10 contained a clarification order ....""nectar thick liquids"". The thickened liquid order was not carried over on the cumulative orders of April 2011. A nurses note obtained from medical records dated 5/4/2010 stated resident had ""refused swallow study."" The policy for thickened liquids was reviewed. The policy stated a symbol would be placed on the name plate... ""Flower =Nectar"". The resident did not have a symbol on his name plate of any kind during observations of 4/11/11 at 5:00 PM, 6:50 PM, 4/12/2011 at 9:30 AM, 12:30 PM, and 3:00 PM. The policy stated that the resident's water pitcher would be removed from the room. Review of the Resident Care Specialist Assignment Sheet had the resident listed as ""Nectar"" under the Thickened Liquids section. On 4/12/11 at 12:30 PM, the resident was observed with his lunch tray, feeding himself. The lunch tray contained tea, a cola, not thickened and a container of thickened juice and thickened water. The resident was observed drinking the unthickened soda and did not drink any of the nectar thick fluids. There was no follow-up from the physician as to the resident's ability to take regular fluids or need for thickened liquids. There was no documentation that the Speech Therapist followed up or an attempt to reschedule the swallowing study. Although the resident refused to drink the thickened liquids, the facility continued to provide both thickened and regular liquids to the resident. The resident was documented to be at risk for aspiration.",2015-04-01
9463,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,371,F,0,1,7XVN11,"On the days of the survey based on observation and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. Out of date meat was stored in the walk in refrigerator. The findings included: The initial tour of the dietary department on 4/11/11 revealed two large turkey breast and one large cut of ham on the bottom shelf of the walk in refrigerator. The turkey breast was dated 4/7/11 and the ham was dated 4/6/11 and was in a zip lock bag that was not closed. The Dietary Manager (DM) stated during the tour: ""We were going to use the turkey tomorrow, but the ham should have been removed."" On 4/13/11 at 2pm, the DM stated during a interview "" I thought I had 72 hours after it thawed to cook the meat."" The DM then stated: ""We are not suppose to leave anything in the refrigerator past 72 hours, that is our policy.""",2015-04-01
9464,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,441,F,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of facility policy for Ice Chests and Ice Machines, Hand Hygiene, and Infection Control Inservices, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Resident #11 was noted with Isolation Precautions not implemented and contact precautions not followed for 1 of 1 residents reviewed on isolation. Resident #7 and #21was observed with improper handwashing before, after and during treatments for 2 of 8 treatments observed. Inappropriate cleaning of equipment was noted in the shower room in the East building on the South Unit. There were three random observations of inappropriate storage of an ice scoop. There was no physical separation between clean and dirty linen handling in the West laundry. Observation of linen handling in the West laundry was inappropriate to prevent cross contamination. There was observation of excessive dust and lint build-up in laundry on the West building. The findings included: The facility admitted Resident #7 on 11/13/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 4/12/11 at 10:35 AM revealed that during the procedure, Licensed Practical Nurse(LPN)#3 was observed to obtain soap from the dispenser, place her hands under running water and immediately remove her hands and dry them, repeating the above process six times during the procedure. On 4/13/11 at 10:45 AM, after asking LPN #3 if she could identify any concerns the surveyor may have had during the procedure, she confirmed that she had not washed her hands properly. She stated that she should have washed her hands long enough to sing ""Happy Birthday"". Review of the facility policy titled ""Hand Hygiene"", revealed the following: A. Turn on water to a comfortable warm temperature. B. Moisten hands with soap and water and make a heavy lather. C. Wash well under running water for a minimum of 15 seconds, using a rotary motion and friction. D. Rinse hands well under running water. E. Dry hands with a clean paper towel. Use the paper towel to turn off the faucet, then discard. Review of the Infection Control Course log, documented that LPN #3 received training on Infection Control procedures on 2/3/10. On 4/11/11 at 6:20 PM and on 4/12/11 in the East building, South Wing, the ice scoop was noted in the ice chest. Review of the facility policy titled ""Ice Chests and Ice Machines"" revealed under Section II. the following: Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on top of the chest or in a mounted holder when not in use. CNA (Certified Nursing Assistant)#3, during an interview on 4/13/11 at 9:30 AM related to Infection Control procedures, explained the cleaning process of shower chairs/trolleys. She stated that after a resident had used a shower chair or trolley, she used the body wash/shampoo on the chair or trolley and then obtained hand sanitizer in a cup and repeated the process. CNA #3 took the surveyor during the interview process to the clean utility room and pulled the kiwi/mango body wash/shampoo from the shelf and identified the item as what she used to clean the shower chair/trolley. She then took the surveyor to the resident day room and pointed out the hand sanitizer that she used to repeat the cleaning process of the shower chair/trolley. It was noted at that time that the hand sanitizer was empty. Further Infection Control interviews with a CNA and the Housekeeping Supervisor revealed that in a locked cabinet in the shower room was an appropriate germicidal spray which was to be used to clean the shower chairs/trolleys. During a tour of the west laundry with the Housekeeping/Laundry Supervisor and the Maintenance Supervisor on 4-13-11 at 10:30 AM, both verified a thick lint/dust build-up noted on the water pipes, the chemical dispensing units and tubing, wiring near the roof deck, inside of the vent duct and on the blades of a non-functioning exhaust fan. During observation of the unattended west laundry at 10:30 AM on 4-13-11 and again when observing the laundry process at 11:50 AM, it was noted that there was no physical separation between clean and soiled linen handling. Both times, clean linens were noted uncovered on a folding table and in an open bin next to it. After sorting the soiled linen outside the laundry in a covered area, the Laundry Aide brought the soiled barrel into the laundry to load the washer. As she did so, the soiled barrel bumped against the empty clean bin and the sheets used to cover the clean linen during transport. The soiled bin also bumped against the uncovered bin containing the clean linen near the folding table. As the Laundry Aide removed clothing protectors from the soiled linen barrel, she scraped food into the waste basket and shook the clothing protectors out, causing food particles to fly into the air. This was done within 3 feet of the uncovered clean linen. When the Laundry Aide finished loading the machine, as she was pushing the barrel outside, it again came into contact with the bin containing the clean unfolded linen and the clean transport bin. During an interview at that time, the Housekeeping/Laundry Supervisor verified the above observations and agreed that the clean and soiled linens were not handled appropriately. The facility admitted resident # 21 on 1/24/07 with the following Diagnosis: [REDACTED]. During the observation of the Pressure Ulcer treatment on 4/13/11 Registered Nurse # 4 (RN #4) failed to wash her hands prior to starting the treatment, and during the treatment. She left the room with the trash from the treatment before washing her hands. After disposing of the trash, she went back to the room and washed her hands. When ask about hand washing she stated "" I know, I forgot to wash my hands, I was nervous."" The facility admitted Resident # 11 on 2/9/11 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During Initial tour on 4/11/11 at approximately 1:25 PM, the Staff Development Coordinator (SDC) stated Resident #11 was on contact isolation precautions related to an E. Coli UTI. No Isolation cart or PPE (Personal Protective Equipment) were noted outside the resident's room. There were no instructions posted to alert staff or visitors to see the nurse or delineating what PPE was needed before entering. On 4/12/11 CNA (Certified Nursing Assistant) #2 was observed entering Resident #11's room without donning any PPE, set up the resident's lunch tray, placed a clothing protector around the resident's neck and pushed the resident's wheelchair up to the over bed table to eat. He then left the room without washing his hands, returned to the tray cart and pulled out another tray. (That tray was left on the cart as the resident had refused.) CNA #2 then left the unit. He did not wash his hands after leaving Resident #11's room or before leaving the unit. Review of the Nurse's Notes on 4/12/11 at 9:55 AM revealed an entry dated 4/6/11 at 10:30 AM that stated ""ESBL in urine - placed on isolation."" The Nursing Daily Skilled Summary dated 4/5/11 did not indicate the resident was on contact precautions on 4/5/11. On 4/12/11 at 11:25, record review revealed a discharge summary from the hospital dated 4/5/11 stating the resident had a urine culture that ""grew greater than 100,000 colonies of Escherichia coli that was an extended spectrum beta-lactamase producer (ESBL)..."" Further review revealed Physician's Telephone Orders dated 4/6/11 at 10:00 AM to place the resident on contact precautions. At 11:00 AM, review of the care plan for Resident #11 revealed that it had not been updated to include the MDRO infection or the contact precaution. At 11:28 AM, review of the Social Progress Notes revealed Resident #11 had been ""transferred to Rm (room) 110 for medical needs. Contact isolation."" On 4/12/11 review of the facility's ""Infection Prevention Manual for Long Term Care"" revealed ESBL's were included in the list of MDRO infections and recommended standard and contact precautions. No duration for precautions was listed. At 3:55 PM on 4/12/11, review of the facility's policy on Contact Precautions from the ""Infection Prevention Manual for Long Term Care"" revealed: ""II. GLOVES AND HAND HYGIENE A: Hand hygiene should be completed prior to donning gloves. B. Gloves should be worn when entering the room and while providing care for the resident. ... D. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. III. GOWNS A. A gown should be donned prior to entering the room or resident's cubicle B. The gown should be removed before leaving the resident's room. C. After removal of the gown, clothing should not come in contact with potentially contaminated environmental surfaces."" Review of the facility's policy titled ""Multidrug- Resistant Organisms (MDROs) from the ""Infection Prevention Manual for Long Term Care"" revealed: ""I. General Measures: E. Employees shall be educated about the need for precautions including how and when to use them."" II. Isolation precautions ... D. Contact Precautions shall be considered for residents infected or colonized with an MDRO. NOTE: New resistant and significant pathogens continue to emerge. ... Other organisms, not as well known are capable of causing severe infection and death in infected individuals, especially the immunocompromised host. These include ...extended spectrum beta-lactimase producers,..."" On 4/11/11 at 6:15 PM, before walking to the resident's room to verify the lack of supplies, LPN (Licensed Practical Nurse) #2 picked up an unopened stethoscope, thermometer and box of masks to take to the resident's room. During an interview at that time, LPN #2 confirmed there was no PPE outside the resident's room and was unable to locate any supplies in the resident's room. She stated she didn't know where they could have gone unless a staff member had discarded them. She further stated that the PPE should have been outside the resident's room and easily accessible. On 4/12/11 at 10:40 AM, CNA #2 confirmed that he did not don any PPE before entering the resident's room or wash his hands before leaving the room on 4/11/11. He also verified that he should have had on gloves and a gown if coming into contact with the resident or equipment. 3:55 PM, the SDC confirmed that there were no instructions posted to educate staff or visitors to see the nurse or delineating what PPE was needed before entering the resident's room. She stated that the staff try to stop visitors before they enter and instruct them at that time. She also confirmed that the PPE should have been outside the room and easily accessible to staff and visitors. She stated she would have expected CNA #2 to have donned PPE before entering the resident's room and to have washed his hands prior to leaving. She confirmed that she did not notice that isolation supplies were not available during Initial Tour.",2015-04-01
9465,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,323,E,0,1,7XVN11,"On the days of the survey, based on observation and interview the facility failed to provide a safe environment free from hazards and accidents. Four areas in Physical Therapy Hall were noted with trip hazards and therapy stairs were observed with trip hazards Findings included: Observations during the initial tour on 4-11-11 at approximately 11:30 am revealed four areas in the floor of the physical therapy hall in the West Building with four, approximately one inch circular holes in the floor with metal projections raised above floor level on the outer rim of the holes. Blue tape was placed over each hole in the form of an x with the hole punctured through. Four of the therapy stairs were noted to have the non-slip sheeting that was peeling up around the edges. Interview with the Maintenance Director on 4-13-11 at 9:55 am revealed the holes in the floor were caused by the removal of a railing that was removed due to a resident ""getting stuck"" underneath. The supporting poles of the railing had been cut off and blue tape was temporarily placed over the holes until the tiles in the floor was replaced. He stated that this had been completed approximately 3 months ago. He verified that the Physical Therapy stairs with rubber non-slip sheeting peeling was a safety issue and needed to be repaired.",2015-04-01
9466,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,159,F,0,1,7XVN11,"On the days of the survey, based on observation and interview, the facility failed to ensure that residents have daily access to personal funds. The facility failed to provide residents with access to personal funds on weekends and after normal business hours. The findings included: Observation of the facility on 4/12/11 revealed a sign located near the Business Office indicated ""Resident Banking Hours"" as Monday through Friday 9:30 - 11:30 AM and 2:30 - 4:30 PM. During review of Resident Funds on 4/13/11, the surveyor questioned the Business Staff that observation of the signage indicated that residents only had access to petty cash funds Monday through Friday. The facility's Accounting Staff was asked if residents have access to petty cash funds on the weekends and after business hours. The Business Staff stated that she was the only staff member who dispersed petty cash to residents, and confirmed that petty cash was not available on the weekends and after business hours.",2015-04-01
9467,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,280,D,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, the facility failed to review and revise the care plan for Resident #11 (1 of 1 record reviewed care plans related to isolation precautions) to reflect that the resident had a Multi-Drug Resistant Organism (MDRO) urinary tract infection or that the resident was on contact isolation. The findings included: The facility admitted Resident #11 on 2/9/11 and readmitted her on 4/5/11 with [DIAGNOSES REDACTED].) Coli Urinary Tract Infection [MEDICAL CONDITION]. During the initial tour of the facility on 4/11/11 at approximately 1:25 PM, the Staff Development Coordinator (SDC) stated Resident #11 was on contact isolation related to an E. Coli UTI. On 4/12/11 at approximately 11:00 AM record review revealed the care plan for Resident #11 had been reviewed following her return from the hospital on [DATE]. However, review of the care plan revealed it had not been updated to include the MDRO UTI. The care plan also did not indicate the resident was on Contact Isolation precautions. Cross Refer CFR 483.65(b) F441 related to Infection Control",2015-04-01
9468,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,315,D,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interviews and review of the facility's policy titled ""Perineal care of the female resident"", the facility failed to provide incontinent care in a manner to prevent urinary tract infections for Resident #11, 1 of 1 residents reviewed for incontinent care. The findings included: The facility admitted Resident # 11 on 2/9/11 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During observation of incontinent care on 4/34/11 at 11:32 AM, Certified Nursing Assistant (CNA) #2 donned gloves and gown prior to knocking and entering the resident's room, explained the procedure and closed the door. Warm water was drawn into 2 basins, 1 with soap and 1 without, and placed on the over-bed table. Towels and wash clothes were also placed on the over-bed table and a plastic bag was opened and placed in a chair. The resident was assisted to bed and the curtains closed to provide privacy for the treatment. The residents pants were drawn down to just above the knees and her brief was opened. CNA #2 wet a washcloth with the soap and water solution and cleaned the mons pubis area using several [MEDICAL CONDITION] without turning or folding to a clean area of the wash cloth. He then repeated the procedure with a second cloth using plain rinse water and without turning or folding the cloth. CNA #2 wet a third washcloth with the soap and water solution and cleaned the groin and thigh area on both legs using several [MEDICAL CONDITION] without turning to a clean area of the wash cloth and then repeated the procedure with a fourth wash cloth using the plain rinse water without turning or folding the cloth. The resident was turned on her left side and the brief removed and discarded into the trash. CNA #2 the wet a another washcloth with the soap and water solution and cleaned the perirectal area using several up and down [MEDICAL CONDITION] without turning to a clean area of the wash cloth and repeated the procedure using the plain rinse water. He then wet a washcloth and cleaned both buttocks using multiple [MEDICAL CONDITION] without turning to a clean area of the wash cloth, repeated the process with the rinse water using multiple [MEDICAL CONDITION] on both buttocks and then dried both buttocks with one wash cloth. A clean brief was applied and the resident clothes adjusted. CNA #2 did not separate the labia or clean the between the labia. During an interview at 11:49 AM on 4/14/11, CNA #2 verified that he did not separate or clean between the labia and that he had not turned or folded the washcloth for each stroke. Review of the facility's policy titled ""Perineal care of the female resident"" in the section titled ""Implementation"" states ""Separate her labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum to prevent intestinal organisms from contaminating the urethra or vagina. Avoid the area around the anus, and use a clean section of washcloth for each stroke by folding each used section inward."" This method prevents the spread of contaminated secretions or discharge. Review of a skills checklist for CNA #2 revealed he had been checked off on incontinent care on 8/26/10.",2015-04-01
9469,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,156,D,0,1,7XVN11,"On the days of the recertification and extended survey, based on closed record review and interview, the facility failed to offer one of twenty-five sampled residents (Resident #24) the right to formulate his own advance directive. The findings included: The facility admitted Resident #24 on 3-14-11 for rehabilitation following a Total Hip Replacement. Record review on 4-12-11 at 2:20 PM revealed that the Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt form was signed by a friend on admission. Review of the 3-24-11 Admission Minimum Data Set Assessment Section B revealed that the resident had no deficits in ability to understand or to make himself understood. Under Section C, the Brief Interview for Mental Status scored the resident at ""14"" with no cognitive deficits. During an interview on 4-12-11 at 4:40 PM, Social Services stated that advance directives were routinely discussed with new residents and/or their responsible parties at the time of admission. If the residents were incapable of signing their own admission paperwork or wanted someone else to sign for them, she stated that this would be documented under Social Services in the medical record. Review of Social Progress Notes revealed no reference to this, though the resident was noted as ""Alert + oriented X 3.""",2015-04-01
9470,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,456,E,0,1,7XVN11,"On the days of the recertification and extended survey, based on observation and interview, the facility failed to maintain mechanical equipment in the west laundry in safe operating condition. A thick excess of lint/dust was observed in the laundry area. The findings included: During a tour of the laundry on 4-13-11 at 10:30 AM, a thick lint/dust build-up was noted on the inside of the vent duct and the blades of a non-functioning exhaust fan. The Housekeeping/Laundry Supervisor and the Maintenance Supervisor verified that the exhaust fan had not been working ""for awhile"". When asked about a preventive maintenance program, the Maintenance Supervisor stated that it should be checked ""every month, but it hasn't been done for 2-3 months"".",2015-04-01
9471,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,501,F,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on observations, record reviews, and interviews, the facility failed to involve the Medical Director in the development, review, and implementation of policies and procedures, consistent with current standards of practice. The facility had no established policy or procedure related to ongoing monitoring of residents with cardiac pacemakers. Substandard quality of care was identified related to facility failure to ensure that residents with pacemakers had their cardiac/pacemaker status evaluated/monitored by the physician on a routine basis. Concerns were identified for seven of nine residents with pacemakers who had no Physician's Orders for routine monitoring, no documentation of pacemaker status by the physician, no scheduling and/or tracking mechanism in place for pacemaker checks, and/or no documentation of completion of the pacemaker checks as ordered. The findings included: During an interview on 4-14-11 at 8:50 AM, the Medical Director stated that he had not been involved in the development of facility policies and that he was unaware that the facility had no policies/procedures related to the routine on-going monitoring of residents with pacemakers. He stated that policies were developed for the facility at the corporate level. He was involved ""somewhat"" in the review of policies related to clinical issues if they were discussed in the Quality Assurance meeting, but he could not recall ever having discussed deficient practice related to pacemakers. When asked about the standard of care, the Medical Director stated that pacemakers should be checked every 3-6 months. The Cardiologist should be primarily responsible for determining the frequency of the monitoring which should be done during office visits or telephonically. He stated that there should be Physician's Orders and that the attending physician should also be aware and follow up if the Cardiologist did not. The nursing staff should have notified the attending physician if there was a problem. He further stated that he was unaware that 7 of 9 residents with pacemakers were not being routinely monitored prior to the survey, and that if he had been aware of the current concern, he would have suggested interventions and/or acted as liaison with other physicians to address the problem. When asked if the lack of facility policies and procedures could affect the residents' care, he stated, ""It could. The battery or wiring could go bad."" Examples of resultant outcomes cited when pacemakers were not checked regularly included syncopy, falls, lethargy, and weakness. ""I hope none of them would die, but they could."" He felt that the staff would recognize signs of [MEDICAL CONDITION] and notify the physician because vital signs were done at least weekly on these residents. Cross Refer CFR 483.25 Related to facility failure to provide necessary care and services, including routine monitoring/tracking of pacemakers for 7 of 9 sampled residents with pacemakers (Residents #31, #20, #14, #7, #29, #27 and #22). Cross Refer CFR 483.75(o) Related to facility failure to identify care- and service-related issues and develop a plan of action related to seven of nine residents with pacemakers who were not monitored appropriately to determine pacemaker function on a routine basis. The facility failed to have a continuous evaluation process in place to maintain the function of systems within the facility so as to determine if current practice standards related to routine monitoring of pacemakers were met and to identify concerns related to this.",2015-04-01
9472,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,503,C,0,1,7XVN11,"On the days of the recertification and extended survey, based on contract reviews and interview, the facility failed to provide a current contract for laboratory services. The findings included: As a part of the extended survey, contracts for services provided by outside resources were reviewed on 4-14-11 at 9:30 AM. Review of the contract for provision of laboratory services, signed in April, 1998, revealed that it had not been signed by either the current Administrator or anyone representing the Governing Body of the current corporate ownership. During an interview on 4-14-11 at 10:30 AM, the Administrator verified that the Long-Term Care Laboratory Services Agreement had not been updated to reflect the change in ownership or management. No updated contract was provided for review prior to the Exit Interview.",2015-04-01
9473,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,520,F,0,1,7XVN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended survey, based on observations, record reviews, and interviews, the facility failed to identify care- and service-related issues and develop a plan of action related to seven of nine residents with pacemakers who were not monitored appropriately to determine pacemaker function on a routine basis. The facility failed to have a continuous evaluation process in place to maintain the function of systems within the facility so as to determine if current practice standards related to routine monitoring of pacemakers were met and to identify concerns related to this. Substandard quality of care was identified related to facility failure to ensure that residents with pacemakers had their cardiac/pacemaker status evaluated/monitored by the physician on a routine basis. Concerns were identified for seven of nine residents with pacemakers who had no Physician's Orders for routine monitoring, no documentation of pacemaker status by the physician, no scheduling and/or tracking mechanism in place for pacemaker checks, and/or no documentation of completion of the pacemaker checks as ordered. The findings included: The facility admitted Resident #14 on 1/27/11 with [DIAGNOSES REDACTED]. Review of the resident's medical record on 4/12/11 revealed that the resident had a dual chamber pacemaker and had had a pacemaker check done on 12/16/2010 before admission to the facility. The 2/4/11 care plan approaches for the pacemaker included: ""Complete pacemaker checks as indicated and document per Dr. (doctor)--- office."" There were no Physician's Orders or Physician's Progress Notes since admission referencing pacemaker checks/monitoring. The Unit Manager for the North Wing stated that the staff had no schedule for pacemaker checks on Resident #14. On 4/13/2011, at 10:45 AM a faxed schedule was provided. The schedule stated that the resident's last pacemaker check was done in January and his next scheduled appointment was for June 2, 2010. The information regarding his January check was the same information on the medical record that was dated for 12/16/10. The facility staff was unaware of a schedule or appointment for the pacemaker to be checked for proper functioning until the dates of the survey. The facility admitted Resident #20 on 6/25/10, with [DIAGNOSES REDACTED]. During review of the medical record on 4/13/11, a Cardiology Consultation dated 2/23/11 noted instructions for a pacemaker check to be done on 4/8/2011 at 10:15 AM at the doctor's office. There was no documentation in the medical record of the results of the appointment on 4/8/2011. The Unit Manager of the South Wing stated that the appointment was on the Schedule Calendar for 4/8/2011. She reviewed the medical record, but was unable to determine if the resident had kept the appointment for 4-8-11. She verified that Nurses Notes contained no documentation of the pacemaker, nor of the resident's cardiology appointments. There were no Physician's Orders for pacemaker checks or monitoring. The Physician's Progress Notes (8/9/10 through 4/12/11) contained no mention of the pacemaker. The Unit Manager called the Cardiologist and stated the the appointment had been canceled by the wife. At 9:50 AM the Director of Nursing (DON) was interviewed with the Unit Manager. The DON stated that the resident's wife handled the appointments. The wife made and canceled appointments without informing the facility. ""We are responsible, but we don't always know."" The DON reviewed the medical record but was not able to locate any information in the Nurses Notes for 4/8/11 regarding the pacemaker visit. She stated that the information regarding the Cardiology visit should have been in the Nurses Notes. The DON called the and stated that the 4-8-11 appointment had been canceled by the office because the resident owed them money. ""They (Cardiologist office) have not let us know anything about the money. They deal with the wife. If they had let us know we could have looked into other options... to check the pacemaker."" The resident had been scheduled to have his pacemaker checked on 4/8/11. The facility was not aware whether the resident had the pacemaker checked or not. There was no documentation and the Unit Manager and DON were unaware that the resident did not receive his follow-up care. The facility admitted Resident #31 on 6/25/10 with [DIAGNOSES REDACTED]. Review of the medical record revealed a care plan dated 11/17/10 and 2/11/11 with approaches listed for the pacemaker including: ""Evaluation for proper functioning of pacemaker by monitoring vital signs as indicated. Notify Physician if any signs of pacemaker failure: *Heart Palpitations, *Heart beat 5-10 beats more or less than setting, *Swollen ankles, feet, *[MEDICAL CONDITION] dizziness, *Shortness of breath, anxiety, forgetfulness, confusion. Complete pacemaker checks as indicated and document...."" Review of the Physician Orders (January through April 2011), June 2010 admission orders [REDACTED]. There was no documentation in the medical record other than the [DIAGNOSES REDACTED]. On 4/13/2011, the Unit Manager of the South Wing could provide no information regarding the pacemaker. The resident had a pacemaker implanted in March of 2010. He was admitted in June of 2010. There was no evidence available that the resident had ever had his pacemaker checked for proper functioning. The Unit Manager was not aware that the resident had not had his pacemaker checked. The facility admitted Resident #7 on 11/13/09 with [DIAGNOSES REDACTED]. Record review on 4/12/11 revealed Resident #7 had a pacemaker. Review of the resident's care plan revealed a pacemaker care plan had been developed and reviewed on 9/30/10, 12/28/10, and 3/24/11 with an approach to complete pacemaker checks as indicated and document. Further record review revealed no pacemaker check could be located on the record. Review of Physician's Orders revealed no order to perform pacemaker checks. An interview with the Unit Manager on 4/13/11 revealed that she could not find the pacemaker checks and that the Director of Nursing (DON) was handling locating the pacemaker checks. On 4/14/11 a pacemaker check was presented with the date of 11/10/10. No other documented pacemaker checks were provided during the survey process. The facility admitted Resident #29 on 7/19/10 with [DIAGNOSES REDACTED]. Record review on 4/13/11 revealed that a Defibrillator/Pacemaker care plan had been developed and reviewed on 7/26/10, 10/7/10, 12/10/10, and 3/8/11 with an approach to complete Defibrillator/Pacemaker checks as indicated and document at office visit. Further record review revealed no pacemaker check could be located on the record. Review of current Physician's Orders revealed no order to perform pacemaker checks. On 4/14/11, material was presented which had a facsimile date of 4/13/11 at 10:33 AM and 4/13/11 at 4:10 PM which revealed the resident had Defibrillator checks on 5/14/09, 8/20/09, 8/5/10, and 11/2/10. A letter was presented from xxx Medical Consultants which explained the resident's next appointment for a check was scheduled for 4/28/11. At the bottom of the letter, a hand-written statement explained that the resident's appointments were made every 3 months when he came into the office. The facility admitted Resident #27 on 11/12/10 with a pacemaker and [DIAGNOSES REDACTED]. Review of the medical record on 4/13/11 revealed a 12/07/10 Report of Consultation during which a pacemaker check had been done. A letter from the Cardiologist's office dated 12/06/10 indicated that a Remote Pacemaker Check was due 3/09/11. The letter stated, ""Below is a schedule of your clinic visits and remote pacemaker check dates. Please use your Medtronic CareLink Network monitor to complete the pacemaker checks."" A pacemaker summary report from the Cardiologist's office indicated a remote follow-up was due on 3/23/11 and were to be done every 12 weeks. Review of the cumulative Physician's Orders revealed no order for pacemaker checks. Review of the care plan revealed approaches for the pacemaker included, ""Complete pacemaker checks as indicated and document."" No record could be located regarding the 3-11 pacemaker check. During an interview on 4/13/11, Registered Nurse (RN) #5 reviewed the medical record and confirmed that a remote pacemaker check had been due on 3/23/11 or 3/09/11. She was unable to locate any documentation to indicate that the pacemaker had been checked since 12/07/10. In addition, RN #5 was unable to locate any tracking information to indicate when the next pacemaker check was due. RN #5 stated that pacemaker check dates should be documented on the Appointment Calendar at the Nurse's Station. Review of the Appointment Calendar with RN #5 revealed no pacemaker check scheduled for 3/09/11 or 3/23/11. The facility admitted Resident #22 on 5/11/07 with [DIAGNOSES REDACTED]. On 4/13/11 at 1:35 PM, review of the Physician's Monthly Orders dated 4/1/11 through 4/30/11 revealed there were no orders for pacemaker checks. Record review revealed a 2/3/11 Physician's Telephone Order for a pacemaker check by xxx which was done as ordered. The 2/3/11 Transtelephonic Pacemaker Follow-up Report stated that the next TTM (TransTelephonic Monitoring) was scheduled for 5/5/2011. At 1:52 PM on 4/13/11 review of the unit appointment book revealed no notation for the TTM to be done on 5/5/11. During an interview on 4/13/11 at 2:25 PM, the Acting Unit Manager stated that the Minimal Data Set (MDS) Coordinator kept up with pacemaker checks. At 2:35 PM on 4/13/11, the MDS Coordinator stated that she obtained pacemaker information such as model, serial number and name of the physician for the care plan but did not keep up with when pacemaker checks were due. She further stated, ""The Unit Managers and nurses do that."" The facility was unable to provide any documentation of any pacemaker checks prior to 2/3/11. During an interview on 4/13/2011 at 9:00 AM, the Administrator stated, ""We don't have a policy on pacemakers. We do have a procedure."" On 4/13/11 the Administrator provided a copy of the ""Pacemaker Procedure"". The copy consisted of copied pages from an unidentified book: ""TREATMENTS Permanent Pacemaker Care"". ""Permanent pacemakers are designed to last 3-[AGE] years....function in the demand mode, allowing the patient's heart to beat on its own but preventing it from falling below a preset rate....Candidates for permanent pacemakers include patients with [MEDICAL CONDITION] infarction [MEDICAL CONDITIONS] (low heart rate)and patients with complete heart block or slow ventricular rates...."" The procedure instructed nurses in the equipment needed to insert a Pacemaker, the Preoperative and Postoperative Care of the Pacemaker site. It then provided teaching instructions for the patient with a permanent pacemaker which included: ""Checkups: Be sure to schedule and keep regular checkup appointments...keep your transmission schedule and instructions in a handy place."" The facility did not track and/or monitor 7 of 9 residents with pacemakers to ensure that the pacemakers were functioning appropriately. The nurses were not aware when or if the residents had their pacemakers checked. There were no pacemaker schedules for the nurses to follow and no documentation by the nurses or the physicians of residents having appointments. The facility did not have a policy on maintaining or checking pacemakers. During an interview with the Medical Director on 4/14/2011, he stated that he was not aware that the facility did not have a policy concerning pacemakers. During an interview on 4-14-11 at approximately 10:15 AM, the Administrator and Director of Nurses stated that the Quality Assessment and Assurance Committee met on a monthly basis, but had not identified the deficient practice related to failure to monitor pacemaker function. The committee had a set agenda for discussion which did not include this item for regular review. Each department head presented areas of concern related to compliance audits done in the previous month. The Director of Nurses stated that she and the two Unit Managers completed compliance audits on approximately 10% of the resident records on a monthly basis. She further stated that 70-80 records had been reviewed during the previous two months, but that no problems had been noted regarding monitoring of pacemakers. The Ongoing Chart Audit form (audit tool) was reviewed with the DON who verified that pacemakers were not identified as an area to be audited. During an interview on 4-14-11 at 8:50 AM, the Medical Director stated, ""Pacemaker monitoring has been 'hit or miss' over the last 5 years."" He did not recall ever discussing this deficient practice in the Quality Assessment and Assurance meetings. Cross Refer CFR 483.25 Related to facility failure to provide necessary care and services, including routine monitoring/tracking of pacemakers for 7 of 9 sampled residents with pacemakers (Residents #31, #20, #14, #7, #29, #27 and #22).",2015-04-01
9474,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,425,E,0,1,7XVN11,"On the days of the survey based on observations and interview, the facility failed to follow a procedure to ensure that expired medications were removed from two of eight medication carts. The findings included: On 4/12/11, observation of two of eight facility medication carts revealed expired Novolog Insulin. In the West building, on the 100 Hall, the medication cart contained Novolog Insulin which was opened on 3-10-11 currently in use which was past the 28 day recommendation by the manufacturer and contrary to facility policy. In the East building, on the 100/200 Hall, Novolog Insulin was dated as opened on 3/8/11and also currently in use which was past the 28 day recommendation by the manufacturer and contrary to facility policy. The findings were verified by Registered Nurse # 1 and Licensed Practical Nurse # 1.",2015-04-01
9475,COMMANDER NURSING CENTER,425119,4438 PAMPLICO HIGHWAY,FLORENCE,SC,29505,2011-03-15,280,D,0,1,5THG11,"**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 a plan of care to ensure care needs were met for 2 of 21 resident care plans reviewed. The facility failed to review and update Resident #18's care plan related to exit seeking behaviors and failed to review and revise Resident #20's care plan related to possession of a hazardous object. The findings included: The facility admitted Resident #18 on 4/04/08 with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/11 revealed the Nurse's Notes indicated Resident #18 ambulated ""ad lib"" throughout the facility and had short and long term memory deficits with severely impaired decision-making skills. In addition, the Nurse's Notes indicated Resident #18 stated on numerous occasions that he/she wanted to go home, attempted to leave through the exit doors, followed staff and visitors to the exit doors ""attempting to exit,"" and ""walked out of West door"" on 12/02/10. Review of the medical record revealed three care plans with care plan Team Conference Dates of 8/11/10, 11/03/10, and 1/26/11. Review of the Nurse's Notes dated 8/30/10 at 6:55 PM indicated, ""Resident followed a visitor out of front door in East Wing lobby. Resident sat down on chair on porch. Staff redirected resident inside facility."" Review of the care plan dated 11/03/10 revealed Resident #18 ""continues to become restless and experiences wandering behavior"" identified as a problem area. This problem area did not indicate that Resident #18 exited the front door of the East Wing on 8/30/10. In addition, approaches on the care plan did not include interventions to prevent recurrence of this behavior. Review of the Nurse's Notes dated 12/02/10 at 6:45 PM indicated, ""...Reported to this writer resident walked out of West door. No injures (sic). Resident was called back in to Building (without) difficulty."" The Accident or Incident Report dated 12/02/10 revealed, ""...Reported to this nurse that resident walked out of side door and was walking away from building."" Review of the care plan dated 1/26/11 revealed Resident #18 ""experiences wandering behavior...staff reported is becoming harder to redirect at times which is probably due to the progression of (his/her) Alzheimer's"" identified as a problem area. Further review of the care plan indicated the care plan did not note that Resident #18 exited the West Wing door on 12/02/10 and did not include interventions to prevent recurrences of this behavior. During an interview on 3/15/11, the MDS Coordinator was asked to review the care plan dated 11/03/10 and 1/26/11 and the Nurse's Notes that referred to the resident exiting the facility. When asked about the process used to update resident care plans, the MDS Coordinator stated that 24 Hour Reports are reviewed, and information is conveyed from nursing and various disciplines during staff meetings and care plan meetings. The MDS Coordinator confirmed that Resident #18's care plan should have been revised to include information that Resident #18 had exited the facility on more than one occasion and should include interventions to prevent recurrences. The facility admitted Resident # 20 on 09/17/10 with the following [DIAGNOSES REDACTED]. The Record Review on 3/5/11 at 1:45 PM revealed the admission Minimum Data Set ((MDS) dated [DATE] which coded the resident as having short and long term memory loss and moderate difficulty with decision making. The Brief Interview for Mental Status (BIMS) score was (10), moderately impaired, on the quarterly MDS dated [DATE]. The Plan of Care dated 9/30/10 cited ""Potential for Agitation and Resistance"" and documented ""(he) was aggressive toward a resident who wandered into his room earlier this month (no injuries reported)"" under the ""Problem"" category. The ""Problem"" category also documented the resident had ""Impaired Decision Making Skills"". Under the ""Goal"" category for this care plan it stated, ""Resident will not harm self or others during any periods of agitation."" A review of the nurse's notes for 9/23/10 revealed that the resident was out of his bed and entering another patient's room at 6:15 AM stating, ""Shut the hell up, quit making all that noise!"" Staff intercepted the resident and assisted him back to his room according to the notes. On 9/24/10 the nurses notes revealed the nurse was summoned to the resident's room by the resident and ""resident stated do something with him, told him I couldn't do nothing about his roommate his roommate was sick. Resident stated, 'I will make him shut up'. 'Informed that he was not going to make him shut up'. Res stated take me to another room. Told him I don't have another room to put him in. Resident(stated) your(sic) a liar. Informed him I was not lying. He told this nurse ""GET OUT""..was very aggitated(sic). Left room. Is monitoring Res #--W (roommate) often."" A nurses note on 12/06/10 revealed that the ""resident pushed Resident # --down as he attempted to enter the wrong room."" ""When asked what happened he stated he didn't want him in his room so he pushed him."" Further review of the nurses notes revealed on 11/26/10 ""(Resident) back to facility 7:40 PM with family. Brought back a pocket knife which was put in Narc box to give to social services on Monday."" On 02/07/11 at 3:00 AM the nurses note stated, ""CNA informed this nurse that resident had pocket knife in room. Upon inspection resident told this nurse it was in his drawer next to bed. Pocket knife found. Informed res. he was not allowed to have weapons here and that I will see to it that the pocket knife will be given to SS (social services) to hold until family gets it. Also found hand sanitizer and to gel air freshners(sic) in room. Removed and is in med (medication) room. Will inform day nurse of above."" Review of the record revealed no documentation on the current care plan dated 12/23/10 related to the resident bringing a hazardous object into the facility on 2 occasions. The social service notes from 11/10 through 3/11 were reviewed and there was no documentation related to the resident bringing in the knife or the social worker talking with the resident or family about the pocket knife. During an interview with Licensed Practical Nurse #1 on 3/15/11 at 2:00 PM, she stated that she had talked to the daughter following the 02/07/11 incident involving the pocket knife, but she had not documented this. She was not aware that this had happened earlier, on 11/26/10. When questioned about the pocket knife issue not being documented on the care plan, she stated it was ""overlooked"". The Social Work Assistant who followed this case was interviewed on 3/15/11 at 2:20 PM and she recalled talking with the daughter about the knife and informed her that the resident could not have this item in the facility, but she did not recall the approximate date. She stated that she had not documented this in the social services notes. On 3/15/11 on 3:45 PM the MDS Coordinator provided an updated care plan to include the patient bringing the pocket knife into the facility, this was after it was brought the staff's attention by this surveyor . The Director of Nursing stated on 3/15/11 at 4:45 PM that they had been working with only one MDS Coordinator and this is why she thought it was not included on the care plan. .",2015-04-01
9476,COMMANDER NURSING CENTER,425119,4438 PAMPLICO HIGHWAY,FLORENCE,SC,29505,2011-03-15,278,D,0,1,5THG11,"**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 ensure assessments accurately reflected the status of 1 of 3 residents identified with exit seeking behaviors. The Wandering/Elopement Assessments for Resident #18 did not reflect that the resident attempted to exit the facility on numerous occasions. In addition, the most current assessment did not reflect that Resident #18 exited the facility on 12/02/10. The findings included: The facility admitted Resident #18 on 4/04/08 with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/11 revealed the Nurse's Notes indicated Resident #18 ambulated ""ad lib"" throughout the facility and had short and long term memory deficits with severely impaired decision making skills. In addition, the Nurse's Notes indicated Resident #18 stated on numerous occasions that he/she wanted to go home, attempted to leave through the exit doors, followed staff and visitors to the exit doors ""attempting to exit,"" and ""walked out of West door"" on 12/02/10. Review of the medical record revealed Risk for Wandering/Elopement Re-evaluation Assessments dated 8/09/10, 11/01/10, and 1/24/11. Instructions at the top of the form indicated, ""List any alleviating or aggravating factors"" and ""List any attempts of elopement."" Review of the Nurse's Notes dated 7/06/10 at 3:00 PM indicated, ""State (sic) wants to go home...Attempting to leave through doors...States 'I'm going home and you're not going to stop me.' Requires 1:1 (with) minimal success (sic) monitoring in progress."" Review of the Nurse's Notes dated 8/06/10 at 6:00 PM indicated, ""stating that (he/she) 'wants to go home.' Redirection...of no use, resident remains focused. Followed two staff members to the door attempting to exit, redirected successfully."" Review of the Risk for Wandering/Elopement Re-evaluation assessment dated [DATE] revealed, ""Ambulates throughout the facility. Picture on Wandering Sheet on each hall. Staff monitoring - no attempt for elopement."" Review of the Nurse's Notes dated 8/30/10 at 6:55 PM indicated, ""Resident followed a visitor out of front door in East Wing lobby. Resident sat down on chair on porch. Staff redirected resident inside facility."" Review of the Risk for Wandering/Elopement Re-evaluation assessment dated [DATE] noted, ""No attempts for wandering or elopement."" Review of the Nurse's Notes dated 12/02/10 at 6:45 PM indicated, ""...Reported to this writer resident walked out of West door. No injures (sic). Resident was called back in to Building (without) difficulty."" The Accident or Incident Report dated 12/02/10 revealed, ""...Reported to this nurse that resident walked out of side door and was walking away from building."" The Wandering/Elopement Re-evaluation assessment dated [DATE] noted, ""No attempt for elopement."" During an interview on 3/15/11 at approximately 3:30 PM, the Director of Nursing (DON) reviewed the Nurse's Notes and Wandering Assessments. At that time, the DON confirmed that the Wandering Assessments did not accurately reflect Resident #18's status related to exit seeking.",2015-04-01
9477,COMMANDER NURSING CENTER,425119,4438 PAMPLICO HIGHWAY,FLORENCE,SC,29505,2011-03-15,323,D,0,1,5THG11,"On the days of the survey, based on observations, the facility failed to ensure the resident environment remained free of accident hazards on 1 of 4 resident units. Observation during the Initial Tour of the facility revealed hazardous supplies unsecured in the Supply Closet at the Nurses' Station on the East Wing. The findings included: During the Initial Tour of the facility on 3/13/11 at approximately 3:58 PM, observation of the Supply Closet at the Nurses' Station on the East Wing revealed the closet did not have a door. An open-shelved metal rack was observed with supplies stored on the left side of the closet. The right side of the closet contained several storage units with doors. Further observation revealed these doors were not locked. In addition, the half-door on one side of the Nurses' Station was observed to be standing open at that time. The door had a door knob with locking mechanism. The other side of the Nurses' Station was observed to have an opening without a door, and the opening was unsecured giving easy access to the area. Observation at that time revealed no staff seated in the Nurses' Station. Twelve residents were observed sitting in wheelchairs in the area near the Nurses' Station, and one resident was observed sitting in a chair. At approximately 4:08 PM, one ambulatory resident was observed to walk through the lobby area in front of the Nurses' Station. Observation of the storage units with doors revealed the following hazardous items/supplies: (1) 1 IV Tray with 23 G needle, (2) 1 24 G Jelco Catheter with needle, (3) 1 BD Canula with needle, (4) 1 Blood Collection Set with 23 G needle, (5) 1 100 count box of Kendall Insulin Safety Syringes with 1 ml needles approximately 1/2 full, (6) 1 100 count box of Kendall Tuberculin Safety syringes with needles approximately 1/2 full, (7) 1 plastic bag of BD Safety Lok 3 ml syringes with 23 G needles, (8) 1 Suture Removal Kit, (9) 10 BD Instep Autoguard IV Catheters with needles, (10) 14 Jelco IV Catheters with 24G needles, (11) 11 BD Interlink Lock Cannulas with needles, (12) 2 BD Filte Needles with needles, (13) 3 No. 10 Bard-Parker Scalpels, (14) 2 Minor Laceration Trays with scissors and forceps, (15) 19 BD Safety Lok 1 ml syringes with needles, (16) 14 LF Safety syringes with 3 ml needles, (17) 1 unopened box of 150 count Lancets, (18) 60 Kendall Insulin Syringes with needles, (19) 3 Suture Removal Trays, (20) 2 5 oz. tubes of Baza Antifungal Moisture Barrier Cream labeled ""Keep Out of Reach of Children"" and ""Seek Medical Help if Swallowed,"" (21) 2 100 count plastic bags of Gillette disposable razors approximately 3/4 full, and (22) 2 oz. tubes of Triple Antibiotic Cream. Observation of the open-shelved storage units revealed the following hazardous items: (1) 1 100 count box of Kendall Insulin Syringes and (2) 2-3 dozen of Butterfly Blood Collection Sets with 23G needles. During observation of the supply closet and Nurses' Station from approximately 3:58 PM until approximately 5:00 PM, numerous staff members were observed walking into and out of the Nurses' Station through the half-door and through the other opening into the Nurses' Station. Staff was also observed walking into and out of the Nutrition Kitchen located adjacent to the Nurses' Station, into and out of the Supply Closet obtaining supplies, and into and out of the Supply Closet obtaining ice from the container in the Supply Closet. During this time, no staff closed the half-door to the Nurses' Station and no staff attempted to block the other unsecured opening to the Nurses' Station. These concerns were shared with the Director of Nursing (DON) on 3/13/11 at approximately 5:20 PM. The DON stated that he/she would contact Maintenance to request the supply storage units be secured. Observation on 3/13/11 at approximately 7:15 PM revealed the storage units were secured with locks. The Nurses' Station half-door was observed to be closed and locked, and a metal rack containing records was observed to block the open end of the Nurses' Station.",2015-04-01
9478,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-06-01,371,F,0,1,UEJ611,"On the days of the survey, based on observation, and interview, the facility failed to store, prepare, and serve food under sanitary conditions. Perishable food items were stored beyond usage; food service items were in need of replacement; and concerns were identified during observation of the trayline. The findings included: On 6/1/11 at 10:15 AM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). It was observed that a box of oranges in the walk in cooler had 3 oranges covered in a mold like substance. A gallon of milk was noted with an expiration date of 5/30. Ice build up was observed by the fan in the walk in cooler. The slicer blade was observed with chips in the blade. Twenty-five trays were cracked and broken on the corners and being used to serve food to residents. The CDM (Certified Dietary Manager) confirmed all findings. On 6/1/11 at 11:15 AM, observation of the trayline was conducted. It was observed that the cook placed a piece of chicken onto a plate with zucchini and then scraped chicken back into steam table pan. It was also observed that the cook placed a pan of meat above the steam table and used the item to serve residents requesting the alternate meat.",2015-04-01
9479,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-06-01,441,F,0,1,UEJ611,"On the days of the survey, based on observation, interview, and review of the facility policies entitled ""Housekeeping and Laundry Services"", ""Laundry In-Service Introduction to Infection Control 1/1/2000"", the facility failed to provide a sanitary environment in 2 of 2 laundry rooms observed. The findings included: On 6/1/11 at 9:15 AM, observation of laundry was conducted with Housekeeper #1. Housekeeper #1 had a cart of bagged, dirty laundry placed next to the clean folding laundry table and up against the clean hanging rack of clothes. The housekeeper donned a plastic apron that covered the front of her shirt but her arms and sleeves were exposed. She placed disposable gloves on her hands. Housekeeper # 1 then took clean clothes from the washer and placed them in the dryer. She picked up two plastic bags of dirty clothes using gloved hands to place laundry into the washer. The sleeves of her shirt touched the rim of the washer. The housekeeper removed the soiled gloves and threw them into the trash can with the plastic bag that had contained the dirty laundry. She then placed another pair of disposable gloves onto her hands and took clean clothes out of the washing machine to place into a plastic bag. The Housekeeping Supervisor entered the laundry area and told Housekeeper #1 to place goggles on while she was loading the washer. Using the same gloved hands the housekeeper placed the goggles on her face. She did not know how to tighten straps and asked Housekeeping Supervisor to get her a pair of goggles that's fit her. The Housekeeping Supervisor tightened the goggles for the housekeeper and gave them back to her. Housekeeper #1 placed goggles back on her face while continuing to wear soiled gloved hands. She then took another bag of soiled laundry and using her soiled gloved hand pulled dirty laundry out of the bag by putting her whole arm into the bag to retrieve the dirty clothes. The housekeeper then removed her disposable gloves and placed another pair of disposable gloves on her hands without washing her hands. . On 6/1/11 at 9:30 AM, an interview with Housekeeper #1 was conducted. She stated that they have always used the plastic apron and disposable gloves. She stated that she has never worn anything that covered her arms. She stated that she has not been in-serviced on how to use goggles. Per review of the facility policy entitled ""Housekeeping and Laundry Safety"" dated 1/1/2000, it states that ""safety glasses and gloves are required"". Per review of the facility policy entitled ""Laundry In-Service Introduction to Infection Control"" dated 1/1/2000, it states ""Control of spreading bacteria through direct contact: a. Use of Personal Protective Equipment such as gloves, masks, etc. b. Use of engineering controls such as good hand washing techniques"". Per review of the facility policy entitled ""Housekeeping In-Service Hand Washing Technique"" dated 1/1/2000, which states ""Employees must wash their hands immediately (or as soon as feasible) after they remove gloves or other Personal Protective Equipment.""",2015-04-01
9480,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-06-01,248,D,0,1,UEJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interview the facility failed to provide an ongoing structured program of activities for 1 of 1 residents reviewed placed on a one to one program of activities. Resident #4 was not observed in a structured program of activities during the days of the survey and there was no documentation of the resident's response to previously provided activities. The finding included: The facility admitted Resident #4 on 3/10/04 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a care plan that indicated the resident was to be in one to one activities and encourage out of room activities. A MDS (Minimum Data Set) dated 2/22/11 and 5/17/11 indicated the resident had some cognitive impairments. On 5/31/11 from 10 AM to 6:30 PM the resident was noted in her room in bed. The resident received lunch and dinner in her room in bed. On 6/01/11 from 8:30 AM to 11 AM the resident was noted in her room in bed. There was a small television close to the bed. Review of the one to one program of activities for the month of March, April and May 2011 revealed the resident's one to one activities program consisted television and conversation. The one to one for April and May 2011 indicated the resident was observed watching TV for the entire month. The March, April and May one to one program documented the resident has her nails polished three to four times each month as a part of her program of activities. An interview on 6/01/11 at 10:40 AM with the Activity Director confirmed the surveyors findings. The Activity Director stated there should have been some documentation to indicate the resident's response to the one to one activities provided.",2015-04-01
9481,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-06-01,281,D,0,1,UEJ611,"**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 adhere to accepted standards of practice for one of one sampled [MEDICAL TREATMENT] residents reviewed. Nursing staff were not knowledgeable of the amount of fluids they were to offer Resident #15 who was on a physician ordered fluid restriction. The findings included: The facility admitted Resident #15 on 3/2/11 and readmitted him on 4/23/11 with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders on 6/1/11 at 8:40 AM revealed an order dated 5/16/11 which stated ""1500 cc (cubic centimeters) fluid restriction"". Further review revealed a Nutritional Progress Note dated 5/17/11 that stated ""Resident has a new diet order of 1500 cc fluid restriction as of 5/16/11. He is an 80 yo (year old) male with [DIAGNOSES REDACTED]. Review of the ""Beverage Plan Worksheet"" dated 5/17/11 located in front of the current June 2011 Medication Administration Record (MAR) revealed that Nursing was to provide 300 cc of fluids and Dietary was to provide 1200 cc of fluids over a 24 hour period. There was a breakdown included on the sheet for the Nursing Shift(s) 7-3, 3-11, and 11-7, however, no information was filled in as to how much the resident should receive each shift by nursing. Review of the May 2011 Nurse's Notes, Medication Administration Record, and Documentation Record revealed no mention of how much fluid nursing had provided the resident. After reviewing computer records, Registered Nurse (RN) #1 was unable to find any documentation of liquid intake for Resident #15. During an interview on 6/1/11 at 9:10 AM, Licensed Practical Nurse (LPN) #1 was asked how much liquid the resident was allowed to have during her shift. She went to the Beverage Plan Worksheet in front of the June MAR and after reviewing it, stated that Nursing provided 300 cc of liquid every shift. She then verified this with RN #1 who was standing beside the medication cart. The surveyor asked the nurse again and the nurse verified that Resident #15 was to receive 300 cc for each shift on 7-3, 3-11, and on 11-7. The Director of Nursing (DON) approached and entered into the discussion. When asked about the amount of liquid that nursing was to provide for the resident, the DON reviewed the Beverage Plan Worksheet and was not able to state how much nursing was supposed to give. She called the Certified Dietary Manager (CDM) over, who stated that nursing was to provide 300 ml of liquids over a 24 hour period and that she would clarify how much liquid nursing was to give to Resident #15 each shift. During an interview on 6/1/11 at 9:53 AM, LPN #1 verified there was no documentation of the amount of fluids offered by nursing in the May 2011 MAR and Nurse's Notes. She also stated that there was no Intake and Output documentation for Resident #15.",2015-04-01
9482,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2011-06-01,328,D,0,1,UEJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to provide Oxygen at the ordered rate for Resident #5, one of four resident reviewed for Oxygen therapy. The findings included: The facility admitted Resident #5 on 4/10/08 and readmitted her on 8/4/08 with [DIAGNOSES REDACTED]. Observations on 5/31/11 at 12:13 PM and 5:20 PM revealed Resident #5 lying in bed with Oxygen infusing via Nasal Cannula from a concentrator at 3 1/2 L/Min (Liters Per Minute). Review of physician's orders [REDACTED]. Review of the Documentation Record for May 2011 revealed an entry for ""O2 @ 2L/Min via N/C as needed, FYI"". However, there were no initials on the record to indicate when or why the Oxygen had been started for Resident #5. Review of Nurse's Notes for May 2011 revealed an entry dated 5/25/11 which stated ""VS (Vital Signs) 125/60- 84- 20- 96 (degrees), Resident alert, oriented. O2 on per N/C. Continues on ABT (Antibiotic) for URI (Upper Respiratory Infection). [MEDICATION NAME] given for cough"". The Nurse's Notes did not indicate if the Oxygen had been started at this time or if it had just been continued, and did not indicate a rate of flow or reason for placing the resident on Oxygen. Nurse's Notes dated 5/26/11 and 5/27/11 also documented that O2 was on per N/C, however the rate the oxygen was infusing was not included in the documentation. Nurse's Notes dated 5/28/11 and 5/30/11 indicated the resident's Oxygen saturation but did not indicate whether this reading was taken on room air or if Oxygen was infusing at the time. Record review on 5/31/11 revealed an annual Minimum Data Set (MDS) Assessment for Resident #5 with an Assessment Reference Date (ARD) of 4/8/11 which revealed a BIMS (Brief Interview for Mental Status) score of 15. During an interview on 5/31/11 at 5:20 PM, Resident #5 stated that she never adjusted the Oxygen herself. During an individual interview on 5/31/11 at 5:45 PM, the resident was asked if the Oxygen she was now using had been started at her request. She stated she had not requested it, and that nursing staff had started the Oxygen when she started coughing. She could not recall the exact date it had been started. During an interview on 5/31/11 at 5:25 PM, Registered Nurse (RN) #1 was asked to check the resident's oxygen. She stated she was having trouble reading the rate on the concentrator and adjusted the rate from 3 1/2 L/Min to 3L/Min. When asked what the ordered rate was supposed to be, she stated she would have to check the order. After reviewing the order, she returned to the resident's room and decreased the rate to 2 L/Min. During an interview on 5/31/11 at 5:42 PM, the Director of Nursing (DON) verified there had been no documentation in the Nurse's Notes or on the Documentation Record as to why the Oxygen was placed on the resident or exactly when it had been started. She verified the first mention of the Oxygen was noted on the 5/25/11 note which stated ""...O2 on per N/C..."" and this did not include the rate. She stated that once the Oxygen had been started the nurses should have initialed the Documentation Record that the Oxygen was in use.",2015-04-01
9483,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-12-13,502,D,1,0,IYFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review and interview the facility failed to assure one of five residents received timely laboratory services per the physician's orders [REDACTED].#1 did not have a stool culture collected for 9 days. The findings included: The facility admitted Resident #1 on 6/29/2007 with [DIAGNOSES REDACTED]. Record review revealed a Nurses Note dated 9/26 that documented: ""[MEDICATION NAME] precautions discont (discontinued) finished c (with) antibiotic therapy. Room disinfected. (Responsible Party) notified of this and need to have family member in per their request to observe to observe her nicknacks disinfected. She stated she would call her sister and have her come in tomorrow."" At 7 PM, ""Informed by infection control nurse policy states no repeat stool culture necessary and RP notified of this."" On 10/3/2011 at 6 PM, ""...order obtained to repeat stool specimen for [DIAGNOSES REDACTED] per family request."" On 10/12 at 2 AM, ""Stool for [DIAGNOSES REDACTED] collected and ready for lab pick up."" Review of the physician's orders [REDACTED]. Diff per family request."" The order was signed by the physician. Review of the Laboratory Data revealed on 10/12 a stool sample was received by the lab and on 10/12 the lab reported to the facility [DIAGNOSES REDACTED]icile Toxins A and B were detected in the stool. [MEDICATION NAME] 200 mg three times daily for 10 days was ordered. During an interview on 12/13/2011 at 2 PM, the Director of Nurses confirmed the stool specimen was not collected and sent timely. She stated that the facility policy was to not re test a resident for [DIAGNOSES REDACTED]. She stated that the resident was asymptomatic but the family requested the test regardless. The DON stated that she had discussed the re test with the physician and the infection control preventionist. The DON confirmed the order was written and signed by the physician. She also confirmed that the stool should have been collected with the next bowel movement and not 9 days later.",2015-04-01
9484,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-12-06,250,E,1,0,LY1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Inspection based on observations, record review and interview the facility failed to ensure 3 of 8 sampled residents received medically related social services. Residents #1, #4 and #5 did not receive the necessary social services related to suicidal ideation, behaviors and/or thoughts of harming themselves. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 12/6/2011 revealed a Nurses Notes from 10/30/2011 through 11/14/2011 that documented the resident's increased confusion and behaviors. On 11/14/2011 at 3:25 PM: ""Resident stated today that he was depressed and having suicidal ideation stating, ""I want to kill myself."" Having confusion, sitting in room naked, would not allow (Attending Physician) to enter room. (Attending Physician) requested that resident have in-house mental evaluation. Center for Behavior called-information sent by fax to Jennifer. (Responsible Party) notified. Awaiting return call to discuss resident's condition. Will continue to closely monitor resident."" At 3:55 PM, ""Spoke to (RP) she stated she doesn't want to make a decision today about her father going to Center for Behavioral Health. Told daughter awaiting call from Behavioral Health after they evaluate his information."" At 11 PM, ""(RP) called this evening to check on father's status. Update given. Discussed last few weeks behavior. Reiterated the need to be evaluated and meds (medication) being adjusted to meet his needs. Body Audit: Skin warm, dry, pale and intact. Area of discoloration to L (left) FA (forearm). Small scab to R (right) outer knee. Turgor good and oral mucous membranes are pink and moist. Q 2 H (every two hours) checks done c (with) resident cooperative this evening. Appetite fair, feeds self, ate in room, c/o (complains of) not feeling right, and ""I want to sleep and can't."" On 11/16/2011 at 1:50 PM, ""...Responsible Parties notified of orders in face to face meeting with (Social Worker and MDS). Meeting r/t informing daughters of resident's condition and how best to meet his needs. Voiced understanding and agreement to consult Carolina Behavioral Center for evaluation and tx...Resident stated he would be better off lost."" On 11/18 the resident was sent out to the Behavioral Health Center. Review of the Behavior Monitoring Sheets for October 2011 revealed the behaviors were Paranoia, Insomnia, Cursing, Anxiety and Yelling. The resident had 5 episodes of Insomnia during October 2011. No other behaviors were listed. No behavior monitoring sheets were located for November 2011. Review of the Social Services Notes revealed on 11/14/2011, ""SSD spoke with (Resident #1). (Resident #1) states that he thinks he would be better off dead. He has been more confused over the past few days. SSD talked with daughter. We will plan a care plan meeting to discuss his confusion. SSD will continue to be available for any questions, concerns or social needs."" On 11/16, ""A care plan meeting was held today for (Resident #1). Both daughters attended. The care plan team discussed his care needs. The care plan team discussed sending (Resident #1) to Carolina Behavioral Health for an eval (evaluation) at the request of our doctor."" On 11/18, ""(Resident #1) has been deemed not competent by our doctors. Paperwork was signed on his advance directive choices and placed in his chart."" No social service interventions were put in place related to the resident's suicidal ideation, depression or increased behaviors. Review of the physician's orders [REDACTED]. On 11/11/2011, Namenda and Aricept were ordered. On 11/15/2011 an order for [REDACTED]. On 11/16/2011, a Wanderguard was placed. On 11/18/2011, the resident was discharged to the Behavioral Health Center. The Responsible Party was notified of all changes and new orders. Review of the Progress Notes revealed on 11/11/2011, the Attending Physician documented, ""(Resident #1) has been slowly advancing in his disease of mild dementia; he now scores a 15 on a Folstein mini mental status examination. He is becoming increasingly confused. Clearly not able to make his own healthcare decisions at this time; therefore we will deem him unable to consent...With his severe depression, I made some therapeutic interventions as did (Psychiatrist)... I am going to start him on Namenda and Aricept to see if this will help improve some of his aggressive and agitated behaviors, it may help with his mood disorder, specifically depression..."" On 11/14/2011, ""I made two attempts to see (Resident #1) today, but he refused to be seen. Apparently, nursing reports that he is becoming increasingly depressed and having some suicidal ideation. My concern is that his depression has gotten to the point that he will need inpatient stay ...we will made arrangements for transfer to an inpatient site for further evaluation because of worsening depression and suicidal ideation."" The resident was sent out until 11/18/2011. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident received a 12 on her BIMS score. Further review revealed the resident reported having thoughts of hurting herself and would be better off dead 2-6 days during the assessment period. Review of the Nurses Notes revealed no documentation related to the residents reports of thoughts of self harm and thought of being better off dead. Review of the Social Services notes revealed no notes related to Depression, Suicidal Ideation or Self Injurious thoughts. Review of the Physician's Progress Notes revealed on 9/16/2011 the resident was seen by the Attending Physician and documented the following: ""The patient was evaluated today in response to a resident mood interview where she did indicate that at times she does feel like she would be better off dead than alive. She does not want any therapeutic interventions for this at this time."" No interventions were put in place related to the residents Depression, Suicidal Ideation or Self Injurious thoughts. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Nurses Notes from November 2011 revealed the resident had an increase in aggressive behaviors and an increase in resisting care. Review of the physician's orders [REDACTED]. On 11/8 the resident was ordered Zyprexa Zydis 5 mg now. Review of the Physician's Progress Notes revealed on 11/11/2011 the Attending Physician documented, ""(Resident #5) is having increasing behavior issues and becoming more aggressive and resistant to care; she does have a [DIAGNOSES REDACTED]. We have had several phone calls over the last week or two because of uncontrollable behaviors..."" Review of the Social Services Notes revealed the last entry was made on 10/10 and did not reference any behaviors. No social services interventions were put in place related to the resident's increase in behaviors. During an interview on 12/6/2011 at 10:15 AM, the Social Worker confirmed that Resident #1 was having an increase in behaviors. She stated that the resident's daughter was very involved and kept updated of the resident's condition. She also stated that the resident had a ""definite change"" and was more and more depressed. She stated that resident would state that he was depressed and that he would be better off dead and if he could find a way to he would. The Social Worker confirmed the suicidal ideation on 11/14/2011 and confirmed that no interventions were put in place. She also stated that the resident's daughter was hesitant to consent to send her father to an inpatient setting. She stated that a care plan meeting was held and the daughters consented to sending him out. During a follow up interview on 12/6/2011 at 12:30 PM, the Social Worker confirmed there was no Social Service interventions or documentation for Resident #4 or #5. The Social Worker confirmed that social service interventions and medical interventions were separate and that the residents needed both. The Social Worker stated that the nursing staff did not always inform her of resident behaviors. She stated that when she was informed she would go and speak with the resident but would not always write it down. She also confirmed that if there was no documentation and the care plans were not updated then the other disciplines would not know what was put in place.",2015-04-01
9485,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-12-06,280,D,1,0,LY1P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint Inspection based on record review and interview the facility failed to ensure 2 of 8 resident's care plans were reviewed and revised. Resident #1 and #4 had suicidal ideation and/or increasing behaviors. The care plans had not been updated to reflect those behaviors. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 12/6/2011 revealed a Nurses Notes from 10/30/11 through 11/14/2011 that documented the resident's increased confusion and behaviors. On 11/14/2011 at 3:25 PM: ""Resident stated today that he was depressed and having suicidal ideation stating, ""I want to kill myself."" Having confusion, sitting in room naked, would not allow (Attending Physician) to enter room. (Attending Physician) requested that resident have in-house mental evaluation. Center for Behavior called-information sent by fax to Jennifer. (Responsible Party) notified. Awaiting return call to discuss resident's condition. Will continue to closely monitor resident."" Review of the Behavior Monitoring Sheets for October 2011 revealed the behaviors were Paranoia, [MEDICAL CONDITION], Cursing, Anxiety and Yelling. The resident had 5 episodes of [MEDICAL CONDITION] during October 2011. No other behaviors were listed. No behavior monitoring sheets were located for November 2011. Review of the Care Plan revealed the care plan had not been updated to address the resident's increased confusion, behaviors or suicidal ideation. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident received a 12 on her BIMS score. Further review revealed the resident reported having thoughts of hurting herself and would be better off dead 2-6 days during the assessment period. Review of the Physician's Progress Notes revealed on 9/16/2011 the resident was seen by the Attending Physician and documented the following: ""The patient was evaluated today in response to a resident mood interview where she did indicate that at times she does feel like she would be better off dead than alive. She does not want any therapeutic interventions for this at this time."" Review of the Care Plan revealed it had not been updated to reflect the resident's self injurious thoughts or her thoughts of being better off dead. No interventions were put in place related to the residents Depression, Suicidal Ideation or Self Injurious thoughts. During an interview on 12/6/2011 at 10:15 AM, the Social Worker confirmed that Resident #1 was having an increase in behaviors. She also stated that the resident had a ""definite change"" and was more and more depressed. She stated that resident would state that he was depressed and that he would be better off dead and if he could find a way to he would. The Social Worker confirmed the suicidal ideation on 11/14/2011 and confirmed that no interventions were put in place. During a follow up interview on 12/6/2011 at 12:30 PM, the Social Worker confirmed there was no Social Service interventions or documentation for Resident #4. She also confirmed that if there was no documentation and the care plans were not updated then the other disciplines would not know what was put in place.",2015-04-01
9486,KINGSTON NURSING CENTER,425173,2379 CYPRESS CIRCLE,CONWAY,SC,29526,2011-04-13,323,D,0,1,GH6B11,"**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 identify the potential hazards of prescription medications stored in a resident's room. Resident # 8 had two prescription medication creams in her room. The findings included: The facility admitted Resident # 8 on 1-6-11 with [DIAGNOSES REDACTED]. During initial tour on 4-11-11 at approximately 12:00 Noon, a partial tube of Mycostatin Cream was noted on the back of the commode in Resident # 8's room. At that time, the resident identified the item as belonging to her, and said that she had a rash on her bottom, that had since healed and she no longer used the cream. On 4-12-11 at approximately 2:15 PM, during an interview with LPN (Licensed Practical Nurse) # 1, she stated that she was unaware that medication was present in Resident # 8's room. At that time, LPN #1 and this surveyor went into the room and asked Resident # 8 if she had medication in the room. Resident # 8 stated that she had two medications in her room, that she had brought from the hospital with her. The medications were identified as Betamethasone-Clotrimazole topical Cream 0.05 % - 1% and Mycostatin Cream 100,000 USP units. Both items had been prescribed by the Hospital's Doctor and were partially used.",2015-04-01
9487,KINGSTON NURSING CENTER,425173,2379 CYPRESS CIRCLE,CONWAY,SC,29526,2011-04-13,322,D,0,1,GH6B11,"**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 provide care and services to prevent aspiration for 1 of 3 Residents sampled with a Gastrostomy tube. (Resident # 1) The resident's head of the bed was lowered while receiving a tube feeding during the provision of incontinence care. The findings included: The facility admitted Resident # 1 on 2-7-11 with [DIAGNOSES REDACTED]. During observation of incontinent care on 4-12-11 at approximately 1:20 PM, Certified Nursing Assistant (CNA) # 1, was observed to lower the head of the bed and and perform incontinence care. The tube feeding was flowing at a rate of 50 cc's (cubic centimeters) per hour. At approximately 1:40 PM, CNA # 1 raised the head of the bed when she finished providing care. At that time this surveyor asked CNA # 1 if she usually performed incontinent care while the tube feeding was in progress? She stated that normally she would turn it off before starting the incontinent care. These findings were shared with the Assistant Director of Nursing at 1:55 PM on 4-12-11, who confirmed that the tube feeding should have been off during the incontinent care.",2015-04-01
9488,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,225,D,1,1,9LOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of facility's reportable files, the facility failed to ensure that 2 of 8 allegations of neglect and 1 of 1 injury of unknown origin were reported to the State survey and Certification agency within the allowed time frame. The findings included: Review of the reported incidents showed the facility failed to report two allegations of possible neglect and one injury of unknown origin to the State Survey and Certification agency. Documentation in the files included the following information: On 4/1/11, a Certified Nursing Assistant transferred Resident A without assisancet in which Resident A received a fracture to the Right Distal Femur and an abrasion above the left eye. On 4/3/11, the incident was reported to Licensure but not reported to Certification. On 4/15/10, a Certified Nursing Assistant(CNA) did not place alarms on Resident B and Resident B fell sustaining a compression fracture of L2. Resident B had also vomited and was not cleaned up by the CNA. On 4/23/10, Resident B's fall was reported to Licensure. On 6/18/10, Resident B was diagnosed with [REDACTED]. There was no indication that the [MEDICAL CONDITION] proximal phalanx was reported. .",2015-04-01
9489,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,226,D,1,1,9LOU11,"On the days of the survey, based on review of the facility's written abuse policies, the facility failed to follow abuse policies related to reporting injuries of unknown origin and possible neglect to the State Survey and Certification agency. The findings included: Review of the facility's written abuse policies and procedures revealed the following: ""Definitions Section F - Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."" Section III. Reporting - A. - ""Alleged violations involving abuse of any kind, neglect, injuries of unknown origin, misappropriation of resident property, involuntary seclusion or corporal punishment are reported accordingly."" Section III. Reporting - E. -"" The initial report must be phoned or faxed by the Director of Nursing or Administrator or designees within 24 hours to appropriate agencies to include Ombudsman, DHEC Certification and Licensure and/or appropriate law enforcement agencies."" Review of reportable incidences during the survey process revealed the facility did not follow the reporting guidelines related to injuries of unknown origin and possible neglect. The incidences were not reported to the State survey and certification agency as required.",2015-04-01
9490,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,280,D,1,1,9LOU11,"**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 a plan of care to ensure care needs were met for 1 of 6 residents reviewed for behaviors. The care plan for Resident #13 was not revised and updated to address [MEDICAL CONDITION]. The findings included: The facility admitted Resident #13 on 5/05/10 with [DIAGNOSES REDACTED]. Review of the medical record on 4/18/11 revealed the Admission Minimum Data Set ((MDS) dated [DATE] assessed Resident #13 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. Review of the care plan with review date of 5/24/10, 8/19/10, and 11/18/10 indicated the resident was a new admission to the facility and identified depression as a problem area. A handwritten notation under this problem area dated 6/27/10 indicated Resident #13 ""took belt out of bedside drawer - wrapped under arms/around neck."" The intervention dated 6/27/10 under ""Approaches"" stated, ""send belt home (with) family."" The care plan did not include additional interventions to address the 6/27/10 behavior. Review of the care plan with review date of 11/18/10 and 2/03/11 revealed [DIAGNOSES REDACTED]. Interventions included ""observe for any s/s (signs/symptoms) of mood/behavior changes."" Review of the Social Service Progress Notes dated 2/23/11 indicated the resident made a statement that he/she was ""going to take (his/her) belt and hang (himself/herself."" The notation further stated that the Social Worker, RN Supervisor, and resident's physician spoke with the resident at that time regarding the statement. Review of the care plan with review date of 4/11/11 indicated depression, ""episodes of feeling bad about himself,"" and dementia were identified as problem areas. Interventions to address this problem area included ""observe for any s/s of mood/behavior changes,"" ""SS (social services) to visit one on one as needed for supportive interaction,"" and ""acknowledge any outward exhibition of resident feeling bad about (himself/herself) or s/s of depression with verbal reassurance & notification of MD as needed."" The care plan did not identify the [MEDICAL CONDITION] as a problem area and did not include interventions to address this behavior. During an interview on 4/20/11 at approximately 9:40 AM, the surveyor informed the Social Services Director that the care plan did not identify the [MEDICAL CONDITION] expressed in the 2/23/11 Social Service Progress Notes as a problem area and did not include interventions to address this behavior. During an interview on 4/20/11, the MDS Coordinator stated that information reported by staff is used to update resident care plans.",2015-04-01
9491,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,151,E,1,1,9LOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey the facility failed to make residents aware of how to exercise their right to vote, to review the survey results, and to be knowledgeable of the ombudsman and how to access the services of the ombudsman. Ten of 10 group members and 3 of 3 interviewable residents revealed they were not aware of their right to vote, their right to review the survey results from the previous year, or who the ombudsman was and their right to contact the ombudsman. The findings included: On 04/19/11 at 3:25 PM until 4:25 PM a Resident Council Group was conducted by the surveyor and 10 interviewable residents attended the group meeting. During the Group meeting the surveyor asked about resident rights and 10 of the 10 group members stated they were not informed of their right to vote, they did not know they had a right to look at last year's survey results and were not aware of its location, and were not aware of the ombudsman and his/her role. The facility admitted Resident #8 on 10/25/06 with the following [DIAGNOSES REDACTED]. Her most recent Brief Interview for Mental Status (BIMS)score on the Minimum Data Sets((MDS) dated [DATE] was 13 and she was listed on the facility's current Interviewable List. During an individual interview with Resident #8 on 4/21/11 at 12:15 PM she stated that she did not know about the ombudsman or anything about the survey results. The facility admitted Resident #10 on 5/26/09 with the following [DIAGNOSES REDACTED]. Her most recent BIMS score on the MDS dated [DATE] was 15 and she was listed on the facility's current Interviewable List. During an individual interview with Resident #10 on 4/21/11 at 11:50 AM the resident was unaware of her right to vote in the facility, the ombudsman, or anything about the survey results. The facility admitted Resident #16 on 4/9/10 with the following [DIAGNOSES REDACTED]. Her most recent BIMS score on the MDS dated [DATE] was 15 and she was listed on the facility's current Interviewable List. During the individual interview with Resident #16 on 4/21/11 at 12:25 PM the resident stated she did not recall her resident rights being discussed with her at the time she was admitted or at the Council meetings. She stated that she had seen the information on the board in the hall about the Ombudsman, but had never had anyone tell her anything about the Ombudsman, the survey results, or voting information.",2015-04-01
9492,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,323,G,1,1,9LOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, interviews, and review of the facility's investigative materials related to a fall with serious injury, the facility failed to ensure residents received adequate supervision and devices for 1 of 7 residents reviewed for falls (Resident # 13). The facility failed to develop a plan to ensure that Resident # 13, with a known history of repeated falls was provided with adequate supervision to prevent falls. The resident sustained [REDACTED]. Additionally, Resident #8, designated to self-administer 4 medications, was found with unsecured medications in her room. The findings included: The facility admitted Resident #13 on 5/05/10 with [DIAGNOSES REDACTED]. Review of the medical record on 4/18/11 revealed the Admission Minimum (MDS) data set [DATE] assessed Resident #13 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The resident ambulated using a wheelchair. Observations of Resident #13 on the days of the survey revealed a self release, Velcro seatbelt in place. Review of the medical record revealed the resident fell on [DATE] at 6:00 PM. He was found lying face down on the bathroom floor. Documentation stated, ""...Resident stated he tried to get up and hit his face on the face basen (sic) in room..."" The resident was assessed and found to have blood coming from his mouth and a swollen left eye with coming from the side of the eye. The physician was notified and the resident was transferred to the emergency room . Review of the hospital CT scan dated 11/23/2010 stated, ""...Impression: Very proptrotic left eye with associated soft tissue swelling... The superior nasal spine is fractured..."" The care plan dated 11/18/2010 showed a problem of ""Potential for falls/injuries r/t (related to) hx (history) of falls, will attempt to transfer without assist @ x's (times)..."" The facility's planned approaches to assist the resident with this problem were: Investigate all falls/injuries/circumstances, place gold star on door and chart to identify as a fall risk, follow facility fall/head injury protocol if actual fall/head injury occurs, keep call light within easy reach, keep frequently used items within easy reach, may use w/c (wheelchair), keep room well lit and free of clutter, fall/contracture assessment quarterly and prn (as needed), bed alarm, chair alarm, observe seizure precautions assure adequate airway and safety or res (resident) if seizure noted, observe of s/s (signs/symptoms) of seizure activity, reg (regular) ophthalmic visits, lift/transfer res (resident) per assessment, meds (medications) per MD order, labs per MD order, monitor labs as ordered per MD, Floor mats beside bed @ all x's, top s/r (siderail) up x 2 to aid in t & r (transfer/repositioning), OOB (out of bed) with lap belt in place - check & release per MD order, may use r/w (rolling walker) with restorative &/or skilled therapies, floor mat to (L) (left) side of bed @ all x's (times), position res's (R) (right) side of bed against wall, restorative nrsg (nursing) to tx(treat) per restorative plan when not working with skilled therapies, floor alarm WIB (when in bed), Toilet res (resident) per plan and prn as res will allow, supervise resident at all times while in bathroom, staff may wait outside bathroom with door slightly cracked open."" A review of Resident #13's Plan of Care Sheet (purpose: Ensure proper communication among staff members about what this particular resident needs. Listed below is specific plan of care that staff needs to be paying close attention to. Note the date the plan was put in place and write d/c (discharge) beside it if it was discontinued or changed) indicated: ""Fall Risk Bed and Chair Alarm 11/28/10 - Left SR (side rail) x's 1 Resident wants to raise bed up high 1 Person assist Check mats on floor every shift R/T(related to) res.(resident) urinating on them Wander Band... 11/23/10 - Self Release Velcro Alarm Belt 11/30/10 - Resident will be supervised at all times while in the bathroom. Resident prefers to have bathroom door slightly cracked open; assigned staff may wait outside of the bathroom door..."" The facility's investigation dated 12/01/2010 stated, ""On 11/24/2010, I spoke with --- who is his regular CNA (Certified Nursing Assistant) on 3/11 shift in an effort to determine Mr.--- (Resident #13) ability to alert staff or his needs as well as his ability to comprehend and or follow instructions given..."" The facility's investigation and interviews with the Certified Nursing Assistant (CNA) who routinely provide Resident #13's care, revealed no consistent plan regarding how Resident #13 was to be supervised during toileting despite his known history of multiple falls. On 11/30/2010, after the fall on 11/23/2010, the statement, ""Resident will be supervised at all times while in the bathroom. Resident prefers to have bathroom door slightly cracked open; assigned staff may wait outside of the bathroom door..."" was added to the Plan of Care Sheet. Additional information and Plan of Care Sheets requested during the survey from the Director of Nursing, were not provided prior to exiting the facility on 04/21/2011. The facility admitted Resident #8 on 10/25/06 with the following [DIAGNOSES REDACTED]. Her most recent Brief Interview for Mental Status (BIMS)score on the Minimum Data Sets((MDS) dated [DATE] was 13 and she was listed on the facility's current Interviewable List. The resident was care planned to self administer Biotene Toothpaste, Thera Tears, Sinus Rinse Kit, and Aquaphor Ointment. The Self Administration assessment dated [DATE] documented that the Aquaphor Ointment was to be kept on the medication cart, the toothpaste and sinus rinse were to be kept in the bathroom, and there was no documentation of where the Thera Tears were to be kept. During an observation of the resident's room on 4/21/11 at 10:00 AM it was observed that the Aquaphor Ointment was on the bedside table. There was a warning label on the ointment which read, ""Keep out of reach of children, if swallowed get medical help or contact Poison Control Center right away."" The resident stated she always kept it there and when questioned stated she was out of her Thera Tears, but they were usually kept in her room in the bedside table drawer. She stated that the Biotine Toothpaste was kept in her bathroom and she showed the surveyor that the Sinus Rinse was kept in her dresser drawer. In an interview with Licensed Practical Nurse(LPN) #1 (who administered medications on the resident's hall ) on 4/21/11 at 10:15 AM, she was unaware of the hazard presented by the medications being kept in the resident's room unsecured. She did not recall the assessment specifically stating that Aquaphor was to be kept on the Medication Cart.",2015-04-01
9493,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2011-04-21,319,D,1,1,9LOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to ensure 1 of 6 residents who displayed suicidal thoughts/actions received appropriate treatment and services. Resident # 13, with known depression, was observed displaying a behavior indicating suicidal thoughts. There was no documentation or plan developed to address the residents behavior. The findings included: The facility admitted Resident #13 on 5/05/10 with [DIAGNOSES REDACTED]. Review of the medical record on 4/18/11 revealed the Admission Minimum (MDS) data set [DATE] assessed Resident #13 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. Review of the care plan with review date of 5/24/10 indicated the resident was a new admission to the facility and identified depression as a problem area. A handwritten notation dated 6/27/10 indicated Resident #13 ""took belt out of bedside drawer - wrapped under arms/around neck."" Interventions included ""send belt home (with) family."" Review of the Nurse's Notes and Physician's Progress Notes revealed no documentation and no interventions related to the 6/27/10 care plan notation. There was no documentation in the medical record to indicate Resident #13 was referred for further evaluation or provided with counseling sessions to address the behavior. Review of the Social Service Progress Notes revealed no documentation related to the care plan notation dated 6/27/10 and no documentation the Social Worker was involved in developing a plan to address the resident's behavior. Further review of the Social Service Progress Notes indicated a notation dated 2/23/11 which stated the resident made a statement that he/she was ""going to take (his/her) belt and hang (himself/herself)."" The notation further stated that the Social Worker, RN Supervisor, and resident's physician spoke with the resident at that time regarding the statement. However, the visit was not documented and there was no indication that an interdisciplinary plan was put in place to further assess, monitor or treat the resident. During an interview on 4/20/11 at approximately 9:40 AM, the Social Services Director stated he/she did not know which staff member noted the 6/27/10 behavior on the care plan. The Social Services Director was informed the Social Service Progress Notes did not contain documentation related to the 6/27/10 notation and did not include related to the behavior. The Social Services Director was asked to review the 2/23/11 notation in the Social Service Progress Notes. The Social Services Director stated that he/she did not recall which staff member reported the resident's statement, but indicated that he/she was informed of the statement on 2/23/11. The Social Services Director confirmed that staff, including the resident's physician, spoke with the resident about the statement and determined that the resident was unhappy about being in the facility. He/she stated that a senior mental health facility was located in the area; however, the resident was not referred for counseling. Review of the Physician's Progress Notes indicated the physician did not address the statement noted in the 2/23/11 Social Service Progress Note and did not address that the physician spoke with the resident on that date. During the survey, the Administrator, Director of Nursing, and Assistant Director of Nursing reviewed the care plan notation dated 6/27/10 and offered no information to clarify the notation.",2015-04-01
9494,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,167,C,0,1,Y1HD11,"On the days of the survey, based on observation and interview, the facility failed ensure the most recent survey was readily accessible to the residents. The findings included: Initial tour of the facility on 8/28/11 at approximately 2:45 PM revealed a small enclosed decorative wall cabinet high on the wall above a large wooden rocking chair in the day area with small print that indicated the most recent survey was located inside the box.. An observation and interview on 8/29/11 at approximately 2:50 PM with the Administrator and Unit Manager revealed the survey was located high on the wall above a large wooden rocking chair. The Administrator confirmed a resident in a wheel chair could not reach the survey. The Unit Manager confirmed the findings that a rocking chair was positioned in front the most recent survey. On 8/29/11 at approximately 10 AM, the ""Quality of Life Assessment Group Interview"" revealed, six of six residents in the group were not aware of the location of the facility's latest survey inspection results. During the ""Quality of Life Assessment Group Interview"" the Resident Council President stated he knew about the posting of the results but could not find its location. When the surveyor pointed out where the results were located the members of the group responded ""We thought that was a deposit box"".",2015-04-01
9495,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,280,E,0,1,Y1HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide evidence of participation in planning of care and treatment for two of three sampled residents and five of five members of the ""Quality of Life Assessment Group Interview"" reviewed for care planning (Residents #5 and #7). The findings included:: The facility admitted Resident #5 on 12/17/08 with [DIAGNOSES REDACTED]. Record Review of the 8/4/11 of the Quarterly Minimum Data Set Assessment on 8/29/11 in section B revealed that the resident ""Makes Self Understood"" . The Resident was listed on the facility's interviewable list. On 8/29/11 at approximately 9 AM, Resident #5 stated that he had never been invited to a care plan meeting. Record Review of the Interdisciplinary care plan revealed there was no documentation of participation in planning of care. On 8/29/11 at approximately 10 AM, during the ""Quality of Life Assessment Group Interview"" five of five residents stated that they were not notified of care plan meetings. An interview on 8/30/11 at approximately 9:30 PM with the Director of Nursing, verified there was no documentation of residents being notified of their care plan meeting. The facility admitted Resident #7 on 6/07/11 with [DIAGNOSES REDACTED]. An interview on 8/29/11 at approximately 3 PM with the Resident #7 identified by the facility as being an alert, oriented and interview-able resident revealed she was not informed of care plan meetings. The resident further stated her family was invited but she could not recall being invited to her care plan meeting. Record review revealed there was no documentation to indicate that the resident was invited to care plan meetings. An interview on 8/30/11 at approximately 9:15 AM with the DON (Director of Nursing) confirmed there was no documentation to indicate the resident was invited to her care plan meeting.",2015-04-01
9496,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,328,E,0,1,Y1HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to provide proper care and services related to oxygen administration. Random observations revealed 3 of 4 oxygen concentrators on Hall C with dusty filters. The findings included: An observation on initial tour on 8/28/11 at approximately 2:45 PM revealed oxygen concentrators in use in rooms [ROOM NUMBERS] with gray lint buildup on the filters on each side of the concentrator. Observation on 8/29/11 at 9:15 AM revealed oxygen concentrators in use in rooms [ROOM NUMBERS] with gray lint buildup on the oxygen filters. This was verified at the time by Licensed Practical Nurse (LPN) #2 who stated that Housekeeping was supposed to clean the filters weekly. Observation on 8/29/11 at 10:30 AM revealed an oxygen concentrator in use in room [ROOM NUMBER] which had gray lint buildup on the filters. During an interview on 8/29/11 at 2:00 PM, Housekeeper #1 stated that she was not aware that Housekeeping cleaned the oxygen concentrator filters. Further interview with the Housekeeping Supervisor revealed that Housekeeping was to change the oxygen filters weekly.",2015-04-01
9497,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,367,D,0,1,Y1HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interviews, the facility failed to provide the diet as ordered for 1 of 4 sampled residents reviewed for mechanically-altered diets. Resident #3 did not receive ice cream supplement for lunch and dinner. The findings included: The facility admitted Resident #3 on 6/08/11 with [DIAGNOSES REDACTED]. Record review on 8/28/11 revealed a monthly cumulative order signed by the physician ordering resident to have ice cream as a supplement for lunch and dinner. An observation of the evening meal on 8/28/11 at approximately 5:52 PM revealed resident did not receive ice cream on tray as ordered. CNA (Certified Nursing Aide) #1 confirmed the findings. An observation of lunch on 8/29/11 at approximately 12:22 PM revealed resident did not receive ice cream supplement as ordered. Review of the resident's diet card revealed ice cream supplement was not added for lunch and dinner. An interview on 8/29/11 at approximately 12:30 PM with Unit Manager confirmed the findings. The Unit Manager further stated the ice cream supplement was put in place for wound healing. An interview on 8/29/11 at approximately 12:35 PM the CDM (Certified Dietary Manager) stated the resident did not want ice cream so dietary stopped sending it. The CDM further stated the ice cream supplement order should have been discontinued.",2015-04-01
9498,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,371,F,0,1,Y1HD11,"On the days of the survey, based on observations and interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Cleanliness concerns were identified, food items were not labelled/dated/ stored appropriately, and employee food was inappropriately stored. Staff members were observed handling bread being served to the residents with their bare hands. The findings included: On 8/28/11 at 2:45 PM, an initial tour of the kitchen was conducted. The can opener was observed to be soiled and not in use at the time. A container of employee food was noted above the stove. The cook stated that it was an employees meal. A partially used bottle of water was in the reach in cooler and it was identified as belonging to an employee. The Walk in Cooler contained a box with three tomatoes with a mold-like substance and a bowl of sausage that was uncovered and undated. On 8/28/11 at 4:45 PM, tray line observation was conducted with the Certified Dietary Manager (CDM). The cook was observed placing a bowl of pureed ham above the steam table at 5:00 PM and did not place the pureed ham into the steam table until 5:31 PM. Throughout the tray line the cook was observed to repeatedly use the same soiled napkin to wipe food off of her gloves. She was observed touching the napkin after plating food at least 15 times during tray line. The cook used the same spoon for serving chopped ham to scoop mixed vegetables on two occasions. On 8/29/11 at 9:00 AM, a refrigerator for resident food, located on the nursing unit, contained a milk carton that was opened and not dated. On 8/29/11 at 9:30 AM, an interview with the CDM was conducted and she confirmed all findings. She stated that staff told her that they had put sausage in the cooler uncovered. A random observation of the dining room on 8/29/11 between 12:02 PM and 12:12 PM revealed 3 different Certified Nursing Assistants removing bread from their wrappers and placing the bread on residents' plates (5 observations) or handing the bread to the resident (1 observation) with their bare hands. During interviews on 8/29/11 at approximately 12:15 PM, CNAs #2 and #3 verified the observations and stated they were either not aware they shouldn't handle bread with their bare hands or that they would correct the way they served the bread. During an interview at 8/29/11 at 2:22 PM, CNA #4 verified she touched the bread with her bare hands because the bread had stuck to the wrapper.",2015-04-01
9499,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,514,D,0,1,Y1HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices. One of ten sampled residents reviewed for advance directives did not have an accurate Physician's order related to code status from 5/23/11 through 7/31/11. The findings included: The facility admitted Resident #6 on 5/23/11 with [DIAGNOSES REDACTED]. Record review on 8/28/11 at approximately 4:45 PM revealed an ""Authorization Of Do Not Resuscitate Order Without Decision-Making Capacity"" signed by 2 Physician's and the resident's Responsible Party (RP) and dated for 5/23/11. Review of Physician's admission orders [REDACTED]"". Review of the August 2011 Cumulative orders revealed an order for [REDACTED]. During an interview on 8/28/11 at 5:45 PM, Licensed Practical Nurse (LPN) #2 verified the ""Authorization of Do Not Resuscitate Order Without Decision-Making Capacity"" had been signed by the RP and 2 Physicians and dated 5/23/11. He also verified the Physician's Orders stated the resident had been a ""Full Code"" from 5/23/11 through 7/31/11. He stated that on admission, the RP and one Physician would sign that the resident should be a DNR and did not have decision-making capacity. The form would then be carried over or mailed to the Physician's office where the 2nd Physician would sign that the resident did not have decision-making capacity. He stated that until the form came back signed by 2 Physicians, the resident would be a full code. Upon receipt of the completed form, the resident would be changed to a ""DNR"". He did not know when the completed form for resident #6 had been placed on the chart and verified the order had not been changed to DNR until 8/1/11. He stated that if a resident does code, nursing staff do not look at the Physician's orders but instead check for the ""Authorization of Do Not Resuscitate Order"" to check if the resident is to be coded or not. Record review on 8/29/11 at 9:55 AM revealed a Care Plan dated 7/5/11 which included an entry for ""Advance Directive: DNR"". The ""Problem Onset"" date was listed as 6/3/11 and stated ""...Resident/Patients wishes will be honored and carried out as indicated x 90 days"". Approaches listed included ""Obtain MD (Physician) order and signatures for DNR, Tag medical record to alert staff of advance directive..."". During an interview on 8/29/11 at 10:00 AM, LPN #2 verified the Care Plan entry date of 6/3/11 for the ""Advance Directive: DNR"" and stated he had been unaware the Physician's Order did not match the Care Plan/Advance Directive at that time and that ""someone should have told him"". During an interview on 8/29/11 at 10:10 AM, Registered Nurses (RNs) #1 and #2 were present. RN #2 stated the Problem Onset date listed on the Care Plan was the date the Care Plan information had been entered into the computer. Interview with RN #1 revealed she used to do Care Plans. She stated she did not look at the Physician's Orders but relied on the advance directive information. She stated that the Care Plan was based on the form having been signed by 2 Physicians for residents without decision making capacity. She stated that in hindsight, she should have also reviewed the resident's orders. During an interview on 8/29/11 at 9:20 AM, the newly hired Social Worker stated that once the 2nd Physician signed that the resident was without decision making capacity, it was Social Services responsibility to communicate this information to the Physician, Director of Health Services and the Unit Manager in order to get a DNR order signed.",2015-04-01
9500,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,156,C,0,1,Y1HD11,"On the days of the survey, based on record review, observation, and interview, the facility failed to ensure that the required 48 hours ""Notice of Medicare Provider Non-Coverage"" was submitted timely for three of three Medicare notices reviewed. The CMS (Centers for Medicare and Medicaid Services) form did not indicate when coverage would end. Additionally, the facility failed to provide a posting related to refunds of benefits. The findings included: Record review on 8/29/11 at approximately 2 PM, revealed three of three ""Notice of Medicare Provider Non-Coverage"" notices given that did not include the effective date the Medicare coverage would end. There was no documentation to ensure the residents/and or responsible parties were informed timely to request further services. The ""Notice of Medicare Provider Non-Coverage"" CMS form indicated the noticed had been sent out and dated with no effective date to indicate when the coverage would end. On 8/29/11 at approximately 2:20PM, the Director of Nursing verified that she did not complete the form properly by including the effective date when coverage would end. On 8/28/11 at approximately 2:50 PM, initial tour of the facility revealed there was no posting in the facility related how to obtain a refund from Medicare and Medicaid. On 8/30/11 at approximately 9 AM observation of the facility revealed, there was no posting of written information to provide the residents instructions as to how to receive refunds for previous payments covered by benefits. During an interview on 8/30/11 at approximately 9:20 AM, the Financial Counselor verified that there was no posting related to refunds.",2015-04-01
9501,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,150,E,1,1,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews, staff interviews, and resident interviews, the facility failed to ensure that Residents #7 and #9 were afforded the right to make their own decisions related to leave of absence and notification of family. (Two of four alert and oriented resident's reviewed for resident rights) The findings included: The facility admitted Resident #7 on 7/9/10 with the following Diagnoses: [REDACTED]. During the initial tour with the wound care nurse on 4/25/11, the wound care nurse stated the resident was ""interviewable"". Record review of the resident's Minimum (MDS) data set [DATE] and 4/12/11 in section C indicated the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. An individual interview with the resident on 4/25/11 at 12:30 PM revealed that the resident was alert and oriented to time, place, person and situation. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated the residents first cousin could take the resident on LOA (leave of absence) to Lake City (uptown) per the (RP) Responsible Party, without calling her. Further record review revealed the physician had not determined the resident as lacking capacity to make decisions. The resident had signed the necessary paperwork to determine his own advanced directive status. The residents bill of rights was signed on admission by the resident's sister. On 4/26/11 at 9:00 AM, when asked about going out of the facility, the resident stated "" I go home sometimes with my brother or sister. I made a list of three people that can take me out. Well, I didn't, my sister did that before I got here. My sister can sign papers for me only if I am sick or it's an emergency."" When asked about the facility calling his sister when he goes out for any reason he also stated ""They do not need to call my sister when I go out. My cousin can even take me to my house, that is not up to her. My sister does not have anything to do with when I go out. I don't know why they have to call her.... I would like to go out more, but I didn't know I could. My brother (in New Jersey) and my sister (Anderson, SC) lives a long way and so I am limited as to who can take me out. I didn't know I could go with anyone else."" During an interview with the SSD (Social Service Director) on 4/27/11 at 9:20 AM, when asked about the note placed on Resident #7's medical record regarding his LOA's, she stated: "" It is our policy to notify the family member to let them know that the resident is leaving the building, even if they are alert and oriented."" She also stated "" He never asked to go out, but I can see how he thought he couldn't. I see how wrong that is, I'm so sorry"". A SSD note placed on the chart on 4/27/11(dated 4/19/11) stated: "" SW talked with resident today about his rights in the facility. Resident did not know why the facility had to call his emergency contact when he left the facility or wanted to go on LOA. SW talked to resident and reassured resident that he is totally in charge of what he wants or who he wants to go on LOA with. Sister will not be contacted to get permission for resident to leave facility or contacted to make decisions if resident does not want facility to. SW called MD (Medical Director) about a standing order for resident to have LOA's. Awaiting call back. SW also told resident about note in front of chart that it was wrong for SW to put note in chart for that reason. (LOA with cousin) Note taken out of chart. Resident was satisfied with conversation to assist resident with any contacts he would like to make for LOA's."" The facility admitted Resident # 9 on 2/19/03 with the following Diagnoses: [REDACTED]. An individual interview with the resident on 4/25/11 at 4:30 PM revealed that the resident was alert and oriented to time, place, person and situation. Further record review revealed the MDS (Minimum Data Set) dated 3/16/11 (section C) BIMS (Brief Interview for Mental Status) score of 15, indicative of no cognitive impairment. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated ""Attention Nurses No one (underlined 3 times) is allowed to take the resident on LOA's unless it is the Responsible Party. (The name of the resident's sister was listed). During a second interview with the resident on 4/26/11 at 10:00 AM, Resident #9 stated "" I don't make my own decisions, my sister does. I don't like it, but she says she is the only one that can take me out. I would like to go out with my brother some and see some old friends but she won't let me. They won't let me... they call her."" When ask about the note placed on the cover of the chart he stated: "" They say if you don't go with her you can't go out. She thinks I just want to go out and drink, but I tell her I just want to go and be with friends and my brother. She said if I say you can't go out, then you can't go"". "" I sure would like for this to be straightened out. I want to be able to make my own decisions."" During an interview with Licensed Practical Nurse # 3 (LPN) on 4/25/11 at 5:25 PM the LPN stated when asked about the note in front of the resident's chart, "" if someone comes for him we have to call the RP and get it okayed with her."" On 4/26/11 at 5:15 PM the Director of Nursing (DON) stated - "" his sister just wants him not to go with a certain person that drinks. She is aware that it is up to him."" On 4/27/11 at 10:30 AM LPN # 2 stated "" If I saw that note on the front of the chart, I would let him go because he is alert and oriented. But, I would call the sister and let her know."" On 4/26/11, the SSD made a note on the residents chart which stated "" SW talked with resident about resident rights. SW explained to resident that his sister (RP) could not say who resident could go on LOA's with. The note that SW put in front of chart was taken off. Explained to resident that since he was alert and oriented times three he could make his own decisions. SW will not be calling his sister anymore without his permission. Resident verbally understands and was very happy about this information. SW will continue to educate on resident rights.""",2015-04-01
9502,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,322,D,0,1,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy, the facility failed to ensure that 1 of 2 residents fed by a gastrostomy tube received the appropriate treatment and services related to checking for placement and checking residual. Neither residual nor placement were checked prior to the administration of medications via [DEVICE] for Resident #6. The findings included: The facility admitted Resident # 6 on 3-18-06 with [DIAGNOSES REDACTED]. During observation of medication administration via [DEVICE], on 4-26-11 at 1:20 PM, Licensed Practical Nurse (LPN) # 1 was observed to prepare medication ([MEDICATION NAME] 10 ml (Milliliters) Suspension). She then knocked on resident's door, identified herself, provided privacy, washed hands and gloved. LPN #1 obtained water from the sink, placed it on the bedside table and put the tube feeding on hold. She placed the syringe barrel in the tubing and measured 30 cc (cubic centimeters) of water into the syringe, and allowed it to flow by gravity, then poured the medication into the syringe and followed it with another 30 cc's of water. All were allowed to flow by gravity. LPN # 1 then reconected the continuous feeding and turned it on. At that time this surveyor asked if she usually checked for placement or for residual. LPN # 1 stated that she was so nervous that she just forgot. Review of the facility provided policy revealed the following : ""Steps in the Procedure 5. Clamp tube and attach sixty (60) cc catheter tip with ten (10) to thirty (30) cc air to the tube. 6. Verify placement of tube by forcefully injecting air into tube while listening with stethoscope to the abdomen for a loud bubbling sound. 7. Check for residual and note amount, if any.""",2015-04-01
9503,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,333,G,0,1,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to ensure that 1 of 13 residents reviewed for medications remained free from significant medication errors. Resident # 5 failed to receive [MEDICATION NAME] 100 mcg (microgram)as prescribed which resulted in the resident having abnormal lab values. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. On 2-3-11 Resident # 5 was sent to the hospital and returned to the facility on [DATE]. She was out of the facility at the hospital again from 2-28-11 till 3-2-11. Review of the medical record revealed a lab tests for a [MEDICAL CONDITION]-Stimulating Hormone (TSH) level were done on 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The acceptable parameter range was noted as .350-4.5) The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of ""Repeat (lab) 1-9-11 and 100 mcg every day."" Review of the Medication Administration Record [REDACTED]. The medication was signed as administered on March 24-29. During a conversation with the Director of Nursing (DON), on 4-26-11, at approximately 1:15 PM, this surveyor asked if additional MAR's could be located for Resident # 5. On 4-27-11 at approximately 9:30 AM, two additional MAR's for February and March were noted to be in the chart. [MEDICATION NAME] 100 mcg was documented as being given on February 2nd, 3rd and from February 11th -28th. A second March MAR indicated [REDACTED]. The April 2011 MAR indicated [REDACTED]. There were a total of 69 days that the medication was signed as administered. During an interview with the Pharmacy Consultant on 4-27-11 at approximately 10:00 AM, she stated that the pharmacy last supplied this medication on 1-27-11 and had sent only 30 pills to the facility at that time which would have depleted the medication on 2-15-11. On 4-27-11 at approximately 10:05 AM, Licensed Practical Nurse # 1 confirmed that there was no [MEDICATION NAME] 100 mcg in either of the medication carts on Hall 100. On 4-27-11 at approximately 10:45 AM, during an interview with the DON, she stated she did not know of any source of medication except the pharmacy, and did not know why the medication was documented as given, when there was not any available. A TSH level obtained on 4/26/11 returned with an abnormal result of 23.231 (high) resulting in the physician increasing the resident's medication and ordering the lab to be repeated in one month.",2015-04-01
9504,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2011-04-27,502,G,0,1,I04T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview the facility failed to provide laboratory (lab) services to meet the needs of 1 of 13 residents reviewed for labs. Resident # 5 with an order for [REDACTED]. The findings included: The facility admitted Resident # 5 on 6-23-08 with the following Diagnoses: [REDACTED]. Review of the medical record revealed labs drawn for [MEDICAL CONDITION]-Stimulating Hormone (TSH) on 5-25-10 with a level of 1.09 and again on 6-4-10 with a level of .78. The most recent TSH lab in the chart was dated 12-8-10 with a level of 13.025 H (high) which had the instructions listed of ""Repeat (lab) 1-9-11 and 100 mcg every day."" There was no evidence provided indicating the lab result was obtained as ordered to determine if the levels remained elevated and a medication dosage change might be indicated. After the inquiry from the surveyor, the TSH was drawn on 4-26-11, and the lab value was 23.231 H(igh) with the recommended lab value parameter being .350-4.500 as noted on the lab report.",2015-04-01
9505,PRUITTHEALTH ESTILL,425315,252 LIBERTY STREET SOUTH,ESTILL,SC,29918,2011-06-14,281,E,0,1,3QIP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, review of the Nursing 2005 Drug Handbook, facility policies titled ""Medication Administration: Oral Medications"", [MEDICAL TREATMENT] Patients/Residents, and reconciliation for medication pass, the facility failed to ensure that services that met professional standards were provided to 1 of 3 residents reviewed for [MEDICATION NAME] administration, 1 of 2 residents reviewed for [MEDICAL TREATMENT], and 1 of 8 residents observed during medication pass. Resident #3 received [MEDICATION NAME] with a pulse below 60; Resident #15 on [MEDICAL TREATMENT] with bruit and thrill not checked consistently; and Resident A with transcription of Klonopin on Medication Administration Record [REDACTED] The findings included: The facility admitted Resident #3 on 9/3/10 with [DIAGNOSES REDACTED]. Record review on 6/13/11 revealed a physician's order for [MEDICATION NAME] .125 milligrams(mg) by mouth every day. Further review of the resident's care plan revealed a care plan for risk for irregular pulse and chest pains secondary to history of [MEDICAL CONDITION]. Approaches were: 1) Medications as ordered. Monitor Blood Pressure and Pulse as ordered. 2) Lab work if ordered with abnormals reported promptly to MD. 3) Encourage activity and mild exercise daily. 4) Monitor for chest pains or abnormal pulses and report to MD. 5) Monitor for 6-8 hours of sleep. 6) Encourage activity attendance. Review of the Medication Administration Records(MAR's) for the months of April, May, and June 2011 in which [MEDICATION NAME] was administered revealed the following: 4/2 Pulse - 48, 4/11 - 59, 4/12 - 54, 4/24 - 57, 4/25 - 58, 4/29 - 40, 4/30 - 51, 5/1 - 41, 5/7 - 57, 5/10 - 42, 5/17 - 57, and 5/26 - 54. On 6/14/11, the Nurse Consultant confirmed that there were times on the MAR's that the resident's pulse was less than 60 and [MEDICATION NAME] had been given. Review of the facility provided policy titled ""Medication Administration: Oral Medications"" revealed #12 - ""Obtain and record any vital signs as necessary prior to medication administration."" Review of the Nursing Drug Handbook 2005 revealed an alert for excessive slowing of the pulse rate(60 beats per minute or less) may be a sign of [MEDICATION NAME] toxicity and advised to "" ""withhold drug and notify prescriber."" After the facility was advised of the surveyors concern, a statement dated 6/14/11 from the resident's physician was presented. It stated: ""This patient's [MEDICATION NAME] level and pulse have been stable for months. I do not require pulse checks prior to [MEDICATION NAME] dosing and do not want to routinely hold [MEDICATION NAME] for pulse less than 60 BPM (beats per minute)."" There was no previous evidence that the physician was aware of the low pulse or had instructed the staff to administer the medication regardless of the pulse rate. The facility admitted Resident #15 on 3/4/11 with [DIAGNOSES REDACTED]. Record review of the physician's cumulative orders revealed an order to auscultate bruit and palpate thrill every day. Review of the resident's current care plan revealed check bruit and thrill daily. Review of the MAR's and nursing notes for the months of 4/11, 5/11, and 6/11 revealed omissions for checking the resident's bruit and thrill as follows: 4/18, 4/19, 4/20, 4/22, 4/23, 4/24, 4/27, 4/29, 5/2, 5/3, 5/4, 5/6, 5/7, 5/8, 5/12, 5/13, 5/16, 5/17, 5/18, 5/19, 5/21, 5/22, 5/23, 5/26, 5/27, 5/28, 5/30, 5/31. On 6/14/11, the Nurse Consultant and Director of Nursing reviewed the resident's chart with the surveyor related to assessing the resident's shunt for bruit and thrill and verified the findings. Review of the facility policy titled ""[MEDICAL TREATMENT] Patient/Residents"" states in bullet 4. - ""Palpate for thrill and auscultate bruit upon return from [MEDICAL TREATMENT] and document. "" On 6/12/11 at approximately 5:15PM, during medication pass, LPN (Licensed Practical Nurse) # 1 administered one tablet of [MEDICATION NAME] (Klonopin) 1 mg (milligram) to Resident ""A"". During medication reconciliation, the physician's orders for June 2011 read Klonopin 2 mg every PM (5 PM) and the June 2011 MAR indicated [REDACTED]. On 6/12/11 at approximately 5:35PM, the DHS (Director of Healthcare Services) could not find a physician's order for Klonopin 1mg and acknowledged that the June 2011 MAR indicated [REDACTED]. On 6/12/11 at approximately 5:45 PM RN (Registered Nurse) # 1 (the Unit Manager) stated that she wrote Klonopin 2 mg on the June 2011 physician's order sheet but could not find an order for [REDACTED]. On 6/13/11 at approximately 12:10 PM the DHS stated that the facility did not have a policy and procedure on medication order transcription and that it was the responsibility of the Unit Manager or the DHS to make sure that orders were correct. The DHS stated that the physician had been contacted and that the order should have read Klonopin 1mg.",2015-04-01
9506,PRUITTHEALTH ESTILL,425315,252 LIBERTY STREET SOUTH,ESTILL,SC,29918,2011-06-14,322,D,0,1,3QIP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review the facility failed to implement a recommendation offered by the Registered Dietitian resulting in an 18 day delay for 1 of 2 sampled residents reviewed who received tube feedings (Resident #4). The findings included: Resident #4 admitted [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 6/12/11 at approximately 2:15pm revealed resident #4 was receiving [MEDICATION NAME] 1.2 at 40cc (cubic centimeters) per hour (hr) via Gastrostomy tube ([DEVICE]). Observation of the resident's [DEVICE] flush on 6/13/11 at approximately 3:25pm revealed the resident was receiving [MEDICATION NAME] 1.2 at 55cc/hr. Record review on 6/13/11 at approximately 5:30pm revealed a physician's orders [REDACTED]. Further record review revealed that the [DEVICE] had been placed on 5/23/11 due to weight loss and poor intake (less then 25%). A physician's orders [REDACTED]. The ""Registered Dietitian E-Fax Recommendations"" form was faxed to the Registered Dietitian (RD) on 5/24/11. The RD completed the assessment including recommendations and faxed the completed form to the facility on [DATE]. Interview with the RD on 6/14/11 at approximately 10:30am confirmed that the completed assessment/recommendations had been faxed to the facility on [DATE]. The RD had been contacted by the Director of Nursing (DON) approximately 6/8/11 indicating that the facility did not have the completed assessment. The completed assessment was re-sent 6/13/11 as the RD was not able to send the form sooner. This resulted in an 18 day delay in implementation of the recommendations. Interview with Licensed Practical Nurse (LPN) #2 on 6/14/11 at approximately 10:00am indicated that the procedure for obtaining a nutrition consult was to fill out the form, call the RD to inform of the consult, and fax the consult request to the RD. The RD then makes recommendations and faxes the completed form back to the facility - usually within 48 hrs. After the facility receives the recommendations, the nurse who receives the recommendations calls the doctor and if approved, writes the order to implement the recommendations. Interview with the DON indicated that when a fax is received the nurse on duty is responsible for taking the information off the fax and processing accordingly. The delay resulted in the resident receiving 3456 fewer calories and 159g (grams) fewer of protein over the course of the 18 days.",2015-04-01
9507,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2012-03-07,241,D,0,1,9YBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on two observations and interview, the facility failed to care for the residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. A resident was observed being pulled backwards down the hallway in a Gerichair, as well as, a Certified Nurses Assistant (CNA) was observed standing while she was feeding a resident. The findings included: During a random observation on 3/7/12 at 6:15 PM, this surveyor observed a resident being pulled down the hallway of rooms 113-118 backwards in a Gerichair by a CNA. Once the CNA approached the nurses station, she turned the resident around to the forward position and then pushed the resident into the dining room for the evening meal. During an interview with the Director of Nursing (DON) on 3/8/12 at 2:00 PM regarding pulling residents backwards she stated, ""They know they are not supposed to do that. They have been inserviced on that."" On 3/6/12 at 6:40 PM, during a random observation of staff interactions with residents, a Certified Nursing Assistant (CNA) was observed removing a resident from the dining room. The CNA pulled the resident from the dining area to the day room backwards in her Gerichair. The facility admitted Resident #3 on 9/22/11 with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] to the services of Hospice. On 3/6/12 at 12:33, a Certified Nursing Assistant (CNA) was randomly observed standing while feeding Resident #3.",2015-04-01
9508,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2012-03-07,253,E,0,1,9YBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for multiple residents rooms. Numerous rooms were observed with a build-up of dust on the HVAC unit vents and/or grids inside the units of sampled residents (Residents #1, #2 and #6) and non-sampled residents during Initial Tour and throughout the survey (Rooms 113, 115, 118, 116, 114, 106, 110, and 111); multiple wheelchairs were observed with a build-up of debris/spills during random observations throughout the facility; loose/soiled linoleum was observed in the doorway of a resident's bathroom; and an HVAC unit was observed with an inner and exterior wall gap in a sampled resident's room (Resident #3). The findings included: During an tour of the facility's environment on 3/07/12 at approximately 10:00 AM, numerous HVAC units in resident rooms were observed with a build-up of a dusty substance on the unit's air vents. This build-up was observed on the units in rooms 113, 115, 118, 116, 114, 106, 111. The dusty build-up on the outside of the unit vents was readily visible upon observation. In addition, a build-up of dusty substance and/or debris was observed on the grid inside the HVAC units in the following rooms: Rooms 113, 115, 114, 106, and 111. Again, the build-up of dusty substance and/or debris was readily visible upon observation. These environmental concerns were confirmed by the facility's Administrator, Housekeeping Director, and Maintenance Director during an environmental tour of the facility on 3/07/12 at approximately 2:30 PM. During the tour, the Housekeeping Director stated that the facility did not have a schedule for cleaning the HVAC units in resident rooms. However, the Housekeeping Director stated that housekeeping staff was responsible for the cleaning of the HVAC vents. During the initial tour of the facility, which began at approximately 6:40 AM on 3/7/12, for rooms 109-112 there were two rooms (110 and 111) which were found to have debris/dust billed up within the vents of the heating ventilation and air conditioning (HVAC) units. The facility admitted sampled resident #1 on 1/29/10 with [DIAGNOSES REDACTED]. During a tour of the residents room on 3/7/12 at 9:57 AM and 3/8/12 at 10:55 AM it was noted that the debris/dust remained in the HVAC unit. On 3/6/12 at 7:50 AM and again on 3/7/12, during random observations of residents in wheel chairs, 10 chairs were observed to be soiled. The rails under the seats, the seats and the wheels of the chairs had dried food/liquid spills, debris and a thick layer of dust. Initial tour of the facility on 3/6/12 beginning at 6:45 AM, revealed linoleum in the bathroom between rooms 101 and 103 had split in the doorway, with a slightly raised edge and was discolored black. Resident #3 was admitted to the facility on [DATE] from another Skilled Nursing Facility with multiple diagnoses. During an interview with the family of Resident #3, the family voiced concern related to a gap around the HVAC (Heating, Ventilation and Air Conditioning) unit. Observation revealed a loose screw resulting in a gap between the HVAC unit and the wall of approximately 1/8 th inch. Daylight was visible through the gap and cold air could be felt coming through the gap. The family stated that they had informed the facility staff and that maintenance had been in to caulk the gap. They then stated that maintenance had fixed something else on the HVAC unit and had not repaired the gap.",2015-04-01
9509,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2012-03-07,371,F,0,1,9YBX11,"On the days of the survey, based on observations and interviews, the facility failed to store, and serve food under sanitary conditions. Food items were stored in the facility freezer and refrigerator with no labels. Staff were observed touching resident food with their bare hands while assisting resident's with their meals.. The findings included: On 3/6/12 at 6:45 AM, during an observation of the facility's freezer, there was one partial bag of chicken legs (opened), one large bag of hot dog wieners, one large bag of french fries, one bag of pancakes and one package of french toast which were removed from the original boxes with no label to indicate date received or opened. The refrigerator contained 3 large bags of shredded lettuce which was also out of the original box with no label indicating date received. During the observation with a Dietary cook, she identified the items and verified the packages were not labeled or dated. On 3/6/12 at 8:29 AM, a general dining observation for the breakfast meal revealed two Certified Nursing Assistants (CNA) holding residents' toast with their bare hands while spreading jelly on the toast. At 8:41 AM the Assistant Director of Nursing was observed holding a resident's toast with her bare left hand while breaking off a piece with a fork using her right hand. On 3/6/12 at 6:15 PM, a Certified Nursing Assistant (CNA) was observed during the PM meal picking a resident's sandwich up from her plate using her bare hands, and placing it back on the plate multiple times. On 3/7/12 at 1:50 PM, during an interview with the Director of Nursing, she stated that staff should not touch the resident's food with their bare hands.",2015-04-01
9510,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2012-03-07,441,E,0,1,9YBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record reviews, the facility failed to ensure that staff were observing contact precautions as ordered for Resident #3, (1 of 1 residents reviewed with transmission based precautions.) In addition, the facility failed to observe infection control practices while feeding residents simultaneously and did not have available a list of diseases to be reported in accordance with State Laws and Regulations. Furthermore, the facility failed to maintain resident equipment to prevent the spread of infection. The findings included: During Initial Tour of the facility, Resident #3's room was noted to have a sign posted at the doorway for ""handwashing precautions."" At approximately 10:32 AM on 3/6/12 record review revealed a Telephone Order for ""Handwashing precautions. Contact Isolation X (times) 2 days."" During an interview at 10:53 AM, the Assistant Director of Nursing (ADON) stated that Resident #3 was supposed to be on contact precautions. At 11:20 AM the ADON stated the Hospice Nurse had written the order for contact precautions but they (the facility) were doing standard precautions, ""same as we'd do for anybody."" At 12:42 PM, the ADON was asked to explain the facility's policy was for contact precautions. The ADON stated she ""would have to look that up"" but thought it required just gloves. On 3/7/12 at 12:00 N the ADON stated again that the order for contact precautions was a verbal order written by the Hospice Nurse but added that the Hospice Nurse had written the order after speaking to the Physician. She stated that Resident #3 should have been on contact precautions and that PPE (Personal Protective Equipment) should have been available for the staff. She stated the PPE ""are there now but weren't there before."" The ADON verified that she had placed PPE in the room for the staff on the morning of 3/7/12, 2 days after the order had been written for contact isolation. On 3/6/12, during a general dining observation at 8:35 AM, 2 Certified Nursing (CNA) were observed seated at a table with 4 residents needing assistance with eating. The CNAs were observed switching between 2 residents each, using the same hand to feed both residents. Neither CNA was observed using any means of sanitizing their hands between residents. At 8:44 AM, the Director of Nursing was observed also feeding 2 resident simultaneously, using her right hand for both residents and not sanitizing her hands between residents. Review of the Facility's Infection Control Manual on 3/6/12 revealed no DHEC (Department of Health and Environmental Control) List of Reportable Conditions in the Infection Control Manual. At 3:05 PM on 3/7/12, The ADON confirmed this finding and stated that she didn't know if the facility had ever had a copy. During the Initial Tour of the facility on 3/06/12 at approximately 7:00 AM, several resident wheelchairs were observed with cracked/torn arm coverings. A wheelchair in room [ROOM NUMBER] was observed with tears in the covering on the right arm of the wheelchair, and another wheelchair in this room was observed with numerous tears in the covering of both wheelchair arms. In addition, a Geri chair in room [ROOM NUMBER] was observed with numerous tears on both arms and a build-up of food/soil on several areas of the chair. During an observation in the dining room on 3/06/12 at approximately 7:45 AM, a resident was sitting at a table in the same chair. These concerns were confirmed by the facility's Administrator, Housekeeping Director, and Maintenance Director during an environmental tour of the facility on 3/07/12 at approximately 2:30 PM. On 3/6/12 at 12:25 PM, during meal observations, 3 Certified Nursing Assistants (CNAs) were noted to be sitting between 2 residents each feeding each resident. The CNAs fed each of the 2 resident they were assisting with the same hand with out sanitizing their hands between residents. On 3/6/12 at 6:15 PM, 2 CNAs were noted to be sitting at a table with residents. Both CNAs were feeding 2 residents each. The CNAs used the same hand to feed each of the residents without sanitizing their hands between residents. 2 nurses were also noted to be feeding 2 residents each and were also feeding both residents with the same hand without sanitizing between residents. On 3/7/12 at 1:50 PM, during an interview with the Director of Nursing (DON), the surveyor asked if staff should sanitize their hands between residents when feeding 2 residents at the same time? The DON stated they they should use the left hand for the resident to their left and the right hand for the resident to their right or if they could not do that they should sanitize between residents. The DON also stated that the facility had hand sanitizing wipes in dispensers located in various places in the resident dining room. When the surveyor requested a policy related to staff feeding multiple residents, the DON stated the facility did not have a policy related to staff feeding (multiple) residents.",2015-04-01
9511,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,241,E,0,1,8MTR11,"**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 promote an environment that maintains each resident's dignity as evidenced by staff standing to feed residents (Resident #3), non sequential serving of meals within resident rooms, and a delay in the serving of meals in the Spence/Crews dining room. The findings included: Observations on 11/1/11 at approximately 5:40pm in the Spence/Crews dining room revealed there were 24 residents seated at tables. 12 residents were from Spence Place and 12 residents were from Crews Pointe. The residents from Spence Place had been served their meals. The residents from Crews Pointe had not and some were watching the residents of Spence Place eating. There was no food cart in the dining room at this time. At approximately 5:50pm a food cart arrived at the dining room and 9 of the residents from Crews Pointe were served a tray. 3 residents were not served. The food cart was removed from the dining room. At approximately 6:05pm a third food cart was delivered to the dining room and the last resident was served her tray at approximately 6:10pm, a lapse of 30 minutes from the start of the observation. Interview with Certified Nurse Assistant (CNA) #7 at approximately 6:15pm indicated that the Spence Place cart is delivered first then the Crews Pointe carts arrive later. Sometimes the Crews Pointe carts are delivered together and sometimes they are not. Interview with the Director of Food Service on 11/2/11 at approximately 3:45pm indicated that after the Spence Place cart was sent to the floor carts for two other units were loaded and delivered before the first Crews Pointe cart was sent. In addition, there was a cart for another unit sent before the second Crews Pointe cart was sent. This process was creating the delay in the serving of meals in the Spence/Crews dining room. The facility admitted Resident #3 on 10/6/11 with [DIAGNOSES REDACTED]. During the meal observation on 11/1/11 at 12:50 PM, CNA #5 was observed standing at the bedside on the resident's right side, with the bed in the high position, feeding Resident #3. At 5:48 PM on 11/1/11, during the dinner meal observation, CNA #6 was also observed standing at the bedside on the resident's right side, with the bed in the high position, feeding the resident. During an interview on 11/2/11 at approximately 1:40 PM, CNA #5 confirmed that she had been standing while feeding Resident #3. When asked if there was a specific reason that she stood while feeding, CNA #5 stated she was ""just standing."" On 11/2/11 at 3:22 PM, during an interview, Registered Nurse Manager #1 stated the CNA ""should have been sitting at eye level"" with the resident while feeding. Review of the facility's Standard Policy/Procedure No. 05-05 Feeding a Resident dated 11/24/11, under the sub-section ""If resident is unable to feed himself: 3. Seat yourself while feeding the resident so he/she does not feel that he/she is being hurried."" In addition, on 11/1/11 at 12:40 PM, during the lunch observation, the roommate of Resident #11 complained of having to wait a long time after Resident #11 had been served before she, the roommate, was served her meals or that she was served and Resident #11 had to wait along time before being served. The roommate stated that she had been waiting 10 minutes for this meal after Resident #11 had been served.",2015-04-01
9512,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,371,F,0,1,8MTR11,"On the days of survey, based on observation and interview, the facility failed to store and prepare food under sanitary conditions as evidenced by a cracked handle on the meat slicer, hood filters with grease accumulation, an ice machine with part of the gasket missing, accumulation of debris on the floor around the ice machine, a black substance on the floor of the walk in freezer, and a case of food thickener that was opened and exposed to the environment.. The findings included: Observations on 10/31/11, at approximately 2:50pm, revealed the handle on the meat slicer was cracked with a black substance in the crack. The hood filters had an accumulation of grease with streaking. The walk in freezer had a black substance on the floor approximately 6 inches in width. The door of the ice machine had a section of the gasket missing and an accumulation of food debris and a brown substance on the floor by the back legs. Observations on 11/2/11, at approximately 3:30pm with the Director of Food Service present, confirmed that the above conditions continued to exist. In addition, a case of food thickener which was observed beside the floor model Robo Coup was open and exposed to the environment. No staff were in the area at that time using the thickener. Interview with the Director of Food Service at that time verified that the above conditions existed.",2015-04-01
9513,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,441,D,0,1,8MTR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the facility Infection Control Policy (Handwashing) and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. During the observation of a pressure ulcer treatment, the LPN(Licensed Practical Nurse) was observed after cleansing a wound to continue the wound care and contaminate other areas with soiled gloves.(Resident #1) Resident #1 was also observed with conflicting signs on the door and in the room related to what type of transmission based precaution to follow. The findings included: The facility admitted Resident #1 on 10/20/10 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #1 was positive for MRSA(Methicillin Resistant Staphylococcus Aureus) in a pressure ulcer on 5/25/11. Observation of the pressure ulcer treatment on 11/1/11 at 12:00 PM revealed LPN #5 after cleansing the wound, packed the wound with Solosite; placed skin protectant around the area; placed a foam dressing over the area. With contaminated hands, the nurse then reconnected the tube feeding tubing which had come apart and lowered the bed. Review of the facility provided policy for Infection Control stated - ""Handwashing section A. 1 - Wash hands before gloving, after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn."" During an interview on 11/2/11 at 1:40 PM with LPN #5, she did not recognize the above findings. Upon entering the resident's room on 11/1/11 at 12:00 PM, a Droplet Precaution sign was noted on the resident's door. Above the resident's bed, a Contact Precaution sign was posted. During an interview with the Infection Control Nurse on 11/2/11, she stated that the Friday before she had noted the Droplet Precaution sign on the resident's door and that it was a mistake and thought that the staff had removed it.",2015-04-01
9514,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,286,F,0,1,8MTR11,"On the days of the survey, based on record review and interviews, the facility failed to have the Minimum Data Set (MDS) available to the nursing staff at all times for 27 of 27 active records reviewed. The findings included: During record review on 11/01/11 at 10:55 AM Resident's MDS forms were not in the active record. During the days of the survey, further review of active records revealed the MDSs were not present in the active records for 27 of 27 Residents reviewed. Interviews on 11/01/11 at 3:40 PM with Licensed Practical Nurse (LPN) #2 and LPN #4 confirmed that the Residents' MDS's were not available in their active records. Both LPNs revealed that they did not have computer access to review the Residents' MDSs. Interviews with the Director of Nursing (DON), Medical Records Coordinator, and the MDS Coordinator, confirmed the MDS was located on the facility computer and the nursing staff did not have access to review the MDS after business hours. When asked during an interview on 11-1-11 at 3:40 PM, Licensed Practical Nurses #1 and #3 stated that they could not provide the Minimum Data Set (MDS) Assessment data as ""Only the Social Worker and the MDS Coordinators have access to the MDS Assessments in the computer."" When asked about weekend and off-hours access, they stated, ""If they're not here, no one else can get into the computer.""",2015-04-01
9515,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,309,D,0,1,8MTR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide care and services as ordered by the physician for one of four sampled residents with orders for TED (antiembolism) hose. Resident #2 did not have TED hose on as ordered for two days of the survey. The findings included: The facility initially admitted Resident #2 on 10-17-06 and readmitted her on 10-4-11 with [DIAGNOSES REDACTED]. Record review on 11-1-11 at 10:50 AM revealed 10-11 and 11-11 physician's orders [REDACTED]."" The Resident Care Plan last reviewed on 9-2-11 also instructed staff to ""Apply and wear TED hose as directed..."" Multiple observations revealed that TED hose were not on as ordered when the resident was out of bed (on 10-31-11 at 7:20 PM; on 11-1-11 at 8:50 AM, 10:15 AM, 12:10 PM, and 3:45 PM), in the wheelchair, with feet dependent and [MEDICAL CONDITION]. When asked about TED hose during an interview on 11-1-11 at 3:45 PM, a family member stated, ""I haven't seen them on since she came back from the hospital."" Review of the Caughman Way Communication form provided by Licensed Practical Nurse #1 on 11-2-11 at 11:50 AM revealed staff instructions for application of TED hose. During an interview on 11-2-11 at 2:45 PM, Certified Nursing Assistant #1, assigned to Resident #2, stated that she was unaware that the resident had not had the TED hose on. She stated that the Hospice Aide who provided the daily bath had possibly forgotten to put them on.",2015-04-01
9516,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2011-11-02,323,D,0,1,8MTR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide changes in interventions to prevent recurrence of falls for one of five sampled residents reviewed for falls. Resident #2, assessed at high risk for falls, sustained multiple falls without changes in interventions to prevent recurrence. The findings included: The facility initially admitted Resident #2 on 10-17-06 and readmitted her on 10-4-11 with [DIAGNOSES REDACTED]. Review of Fall Risk Assessments (completed from 12-8-10 through 10-25-11) on 11-2-11 at 2:15 PM revealed that Resident #2 scored from 16 to 23 points, with a total score of 10 or above representing high risk for falls. Review of Nurses' Notes on 11-1-11 at 12:50 PM revealed that the resident sustained [REDACTED]. while she was trying to get her w/c moved"". The Falls Incident Report further noted: ""...resident was stooping over + slipped out of w/c and alarm went off."" Review of the Resident Care Plan revealed no entry for the 8-26-11 fall or changes in interventions to prevent recurrence. Nurses' Notes documented a fall on 9-19-11 at 7:30 AM when ""Resident started to go down to floor while being assisted by CNA (Certified Nursing Assistant) to bathroom, CNA assisted resident to floor."" The Resident Care Plan noted the date of the fall, but no changes were made in the interventions/approaches to prevent recurrence. The Caughman Way Communication form instructed staff to assist with transfers, but 1 or 2 person assistance or use of transfer devices was not specified as it was for other residents on the form. Further review of Nurses' Notes revealed that on 10-25-11, ""Pt (Patient) fell on to floor while trying to get into bed."" The Falls Incident Report noted that the resident had been in a recliner prior to the fall. There was no mention of an alarm in use at the time of the fall. Although the Resident Care Plan noted the date of the fall, no changes were made in the interventions/approaches to prevent recurrence. Review of the Quarterly Safety Evaluations dated 3-3-11, 5-20-11, 8-23-11, and 10-25-11 revealed that the resident had fall prevention measures (seatbelt alarm and bed sensor) in use, with no changes made in interventions noted over this entire time period. During an interview on 11-2-11 at approximately 2 PM, the Unit Manager and Licensed Practical Nurse #1 verified that no changes had been made to the resident's plan of care following the falls. They stated that alternative interventions would not be acceptable to the family, though there was no evidence in the record to indicate that staff had discussed alternative interventions with them (risks versus benefits).",2015-04-01
9517,NHC HEALTHCARE - LEXINGTON,425333,2993 SUNSET BLVD,WEST COLUMBIA,SC,29169,2011-07-20,431,D,0,1,93H011,"On the days of the survey, based on observations, interviews, and review of the ""Maintenance Request Form,"" the facility failed to store drugs, and lancets in a locked compartment for 1 of 4 medication carts. The findings include: Observation on 7-18-11 at approximately 3:18 PM on the Jasmine Unit revealed a medication cart placed against a wall approximately 20 feet from the nurses' station. It was also noted that no licensed staff were visible. It appeared as though a drawer on the medication cart was not secured. A tug on the drawer caused the drawer to open. Stored in the drawer was: (one) vial of Novolin R Insulin, a Novolog flex pen, 16 packets of Gluco+Chlor, approximately 6 dozen Unistiks, approximately 5 dozen single packets of 325 mg (milligram) Tylenol and approximately 4 dozen single packets of 500 mg Tylenol. These observations were made by the Pharmacist and one additional member of the State Survey Team. An interview with the Jasmine Unit Manager on 7-18-11 at 3:22 PM confirmed the unsecured drawer and she stated that the drawer may be ""malfunctioning."" She also indicated that the Licensed Practical Nurse (LPN) assigned to the medication cart was aware about the drawer on the morning of 7-18-11 but had failed to mention it to the Unit Manager. Observation on 7-18-11 at 3:55 PM revealed the Unit Manager cleaning out the drawer of the medication cart and placing the medications into other drawers of the same cart. She stated that a part needed to be ordered. At 4:00 PM an interview with the Maintenance Director confirmed a part was ordered and provided a copy of the work order.",2015-04-01
9518,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,160,D,0,1,2LNB11,"**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 convey within 30 days resident funds upon death for 2 of 2 resident accounts reviewed. The findings included: Review of Resident Funds on [DATE] revealed 2 of 2 resident funds not conveyed timely upon death. During an interview on [DATE], the Accounting Coordinator confirmed that the first resident expired [DATE], and the resident's personal funds were not conveyed until [DATE]. The Accounting Coordinator also confirmed that the second resident expired [DATE], and the resident's personal funds were not conveyed until [DATE].",2015-04-01
9519,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,323,E,0,1,2LNB11,"On the days of the survey, based on observations, interviews, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observations revealed hot water temperatures exceeded recommended limits in resident bathrooms in clustered areas on Unit 1, Unit 2, and Unit 3. The findings included: During the Initial Tour of Unit 1 on 4/04/11 at approximately 7:00 PM, the hot water in the bathroom sinks in Room 116, Room 121, Room 139, Room 120, and Room 145 felt hot to the touch. On 4/04/11 at approximately 7:15-7:30 PM, the following hot water temperatures were recorded with the surveyor's thermometer: Room 116 - 121.3 degrees Fahrenheit, Room 121 - 121.5 degrees Fahrenheit, and Room 139 - 122.5 degrees Fahrenheit. On 4/04/11 from approximatley 7:30-8:00 PM, hot water temperatures were measured with the surveyors' thermometers on Unit 2 and Unit 3 with the following measurements recorded: Room 252 - 121.4 degrees Fahrenheit, Room 253 - 121.5 degrees Fahrenheit, Room 254 - 121.3 degrees Fahrenheit, Room 258 - 121.2 degrees Fahrenheit, Room 259 - 120.7 degrees Fahrenheit, Room 333 - 121.5 degrees Fahrenheit, Room 334 - 121.7 degrees Fahrenheit, Room 337 at 122.3 degrees Fahrenheit, Room 330 - 122.2 degrees Fahrenheit, Room 331 - 122.4 degrees Fahrenheit, and Room 335 - 121.4 degrees Fahrenheit. On 4/04/11 from approximately 8:52 PM - 9:15 PM, hot water temperatures were measured with the Maintenance Director's thermometer. The following temperatures were recorded: Room 116 - 121.2 degrees Fahrenheit, Room 139 - 126.7 degrees Fahrenheit, Room 120 - 121.8 degrees Fahrenheit, Room 145 - 126.7 degrees Fahrenheit, Room 259 - 122 degrees Fahrenheit, Room 254 - 124 degrees Fahrenheit, Room 252 - 126.5 degrees Fahrenheit, Room 335 - 124.1 degrees Fahrenheit, Room 337 - 124.1 degrees Fahrenheit, Room 331 - 127.4 degrees Fahrenheit, and Room 334 - 125.2 degrees Fahrenheit. During an interview with the Administrator and Maintenance Director on 4/04/11 at approximately 9:30 PM, the Maintenance Director stated that he would adjust the thermostat on the hot water system and would monitor the water temperatures to ensure temperatures did not exceed acceptable limits. The Maintenance Director produced the Maintenance Water Temperature Checklist for January - March 2011. Review of the log revealed no recorded water temperatures above 109 degrees Fahrenheit. On 4/05/11 the Maintenance Director provided documentation of hot water temperatures recorded on 4/05/11 from 7:46 - 8:15 AM for rooms 116, 120, 121, 139, 145, 252, 254, 258, 259, 331, 333, 334, 335, and 337. Review of the document indicated no hot water temperatures exceeded 114 degrees Fahrenheit. Review of the Maintenance Water Temperature Checklist for January - December 2010 revealed no recorded hot water temperatures exceeding 110 degrees Fahrenheit. Further review of the log revealed the water temperature was recorded for one room on each hall with no documentation indicating which room was tested , the date/time the reading was recorded, and no space for staff to sign-off on the recording. Review of the facility's policy and procedure entitled Water Temperature Checks indicated water temperatures are to be checked monthly in Units 1, 2, and 3 and ""rooms are checked at random on all halls and logged."" The policy did not specify how ""random"" rooms would be chosen and did not specify how many rooms were to be checked monthly on each hall. Record review revealed no cognitively impaired residents could independently access the hot water in the rooms with elevated water temperatures.",2015-04-01
9520,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,366,F,0,1,2LNB11,"During the days of the survey, based on observation and interview, the facility failed to provide a vegetable substitute of similar value to residents for 1 of 2 meals observed. The findings included: On 4/5/11 at 4:16 PM, during trayline observation of the supper meal, it was observed that no alternate vegetable was offered to the residents. The only vegetable available was a vegetable medley with broccoli, carrots, and cauliflower. The cook was observed taking carrots two at a time out of the vegetable medley to give to a resident. The cook did not portion the carrots out to provide a proper serving of carrots. On 4/5/11 at 4:20 PM, an interview with the Certified Dietary Manager (CDM) was conducted. She stated that they do not have an alternate vegetable on the steam table. She stated that the cook can pick out from the vegetable medley if a resident does not want one of the vegetables. The CDM acknowledge that the cook would be unable to provide a proper serving size and also stated that the resident would be able to taste the other vegetables even if the cook only provided the resident with one of the vegetables out of the vegetable medley.",2015-04-01
9521,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,368,F,0,1,2LNB11,"On the days of the survey, based on observation, interview, and review of the meal times effective 2/10/09, the facility failed to provide no more than 14 hours between a substantial evening meal and breakfast. The findings included: On 4/5/11 at 5:30 PM, it was observed that the supper meal was provided to residents on Unit 1. On 4/6/11 at 8:30 AM, it was observed that breakfast was provided to residents on Unit 1. Per review of the facility meal times, it revealed that Unit 3 is provided supper at 5:00 PM and breakfast at 8:00 AM. Unit 2 was provided supper at 5:15 PM and breakfast at 8:15 AM. Unit 1 was provided supper at 5:30 PM and breakfast at 8:30 AM.",2015-04-01
9522,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,371,F,0,1,2LNB11,"On the days of the survey, based on observation and interview and review of the facility policies entitled ""Handwashing"" and ""Single-Use Gloves"", the facility failed to store, prepare, distribute and serve food under sanitary conditions. The findings included: On 4/4/11 at 6:20 PM, during initial tour of the kitchen, it was observed that 2 Styrofoam boxes of employee meal and one employee drink were in the reach in refrigerator with resident food. On 4/5/11 at 11:40 AM, during observation of the lunch meal trayline, the cook was observed leaving from behind the steam table to go to the back of the kitchen to get extra bowls. The cook did not remove her gloves or sanitize her hands before returning back to the steam table to continue trayline service. On 4/5/11 at 2:15 PM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). Two ice scoopers were observed on top of the ice machine not bagged. The CDM stated that they do not bag the ice scoops. The blade of the slicer had a chip in it. It was observed that vanilla wafers in the dry storage had been opened and wrapped but not dated. A prep table was observed with 6 holes on the top of it making the surface uncleanable. In the Walk in Refrigerator in was observed that a box of sweet potatoes was on the bottom shelf with a pan of raw chicken on one side of it, a pan of raw pork on the other side, and a tray of raw pork above it. Fans in the walk in freezer and walk in refrigerator had dust around the guards and on the ceiling. On 4/5/11 at 4:16 PM, trayline for the supper meal was observed. A sanitizer bucket with solution in it was observed next to the steam table with a pan of rolls next to it. The cook was observed leaving the steam table on two occasions and going to the back of the kitchen to retrieve items without changing gloves and washing hands before returning to the steam table and continuing to plate food. On 4/5/11 at 5:15 PM, observation of trays being passed on Unit 2 was conducted. It was observed that the closed tray carts were left at the dining room and trays were walked down the hall by staff. The desserts were not covered on any of the trays. On 4/5/11 at 5:45 PM, observation of dining on Unit 1 was conducted. It was observed that all desserts were left uncovered. Meals were placed on an open tray cart and brought down the halls with desserts and drinks uncovered. On 4/6/11/ at 12:30 PM, review of the HACCP- Based SOPS called ""Washing Hands"" was reviewed. The policy stated that hands should be washed ""when moving from one food preparation area to another"" and ""before putting on or changing gloves"". On 4/6/11 at 12:30 PM , review of the facility policy entitled ""Single-Use Gloves"" was reviewed. The policy states that staff should change gloves ""before beginning a different task"".",2015-04-01
9523,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,456,E,0,1,2LNB11,"On the days of the survey, based on observation and interview, the facility failed to maintain essential equipment in safe operating condition based on the ice machine being dirty and a soiled tray cart. The findings included: On 4/4/11 at 6:48 PM, during a tour of Unit 2 nourishment room, it was observed that a rust colored substance was on the inside guard of the ice machine. On 4/6/11 at 8:15 AM, during test tray observation, it was observed that an open tray cart noticeably soiled and staff still used it to place resident trays in it to pass down the hallway. On 4/6/11 at 9:00 AM, during a random observation, a rust colored substance was observed on the inside guard of the ice machine on Unit 2. On 4/6/11 at 10:22 AM, an interview with the Maintenance Director was conducted. He agreed that there was a rust colored substance on the guard of the ice machine on Unit 2 and stated that the machine needed to be cleaned. On 4/6/11 at 10:25 AM, an interview with the Housekeeping Director was conducted. She stated that her staff does not clean the inside of the ice machine. Her staff wipes down the outside of the ice machine and the inside door of the ice machine. The Housekeeping Director stated that her staff clean the tray cart after every meal but did not know why the tray cart was soiled before the breakfast meal",2015-04-01
9524,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,492,D,0,1,2LNB11,"On the days of the survey, based on review of personnel records and interview, the facility failed to obtain the state required Sled check prior to the date of hire for one Certified Nursing Assistant. (1 of 5 personnel records reviewed for Sled checks.) The findings included: Review of personnel folders on 4/5/11 revealed CNA ""B"" (Certified Nursing Assistant) had a Sled check done on 4/4/11. Her date of hire on the personnel folder reflected a date of 3/4/11. This was confirmed by the Administrator and Personnel Director.",2015-04-01
9525,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2011-04-06,332,E,0,1,2LNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey,based on observations, record reviews and interviews, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 12.2 %. There were 5 errors out of 41 opportunities for error. The findings included: Error #1, Error #2 and Error #3: On 4/5/11 at 4:52 PM, during observation of medication pass on Unit 1, Registered Nurse (RN) #1 was observed to administer one [MEDICATION NAME] 40 mg (milligram) tablet (Error #1), two [MEDICATION NAME] 1 Gram capsules (Error #2) and two Potassium Chloride 10 mEq (milliequivalent) SA (Sustained Action) Capsules (Error #3) to Resident A, followed with water. Review of the current physician's orders [REDACTED]."". The medications were administered at 4:57 PM (with water) and the resident's supper tray arrived at 5:39 PM. During an interview on 4/5/11 at 6 PM, RN #1 stated that she was aware that the medications were ordered to be given with food, but she thought the resident's supper tray would arrive by 5 PM. Error #4 and Error #5: On 4/6/11 at 9:01 AM, during observation of medication pass on Unit 1, RN #2 was observed to administer one [MEDICATION NAME] 125 mcg (microgram) tablet (Error #4) and one [MEDICATION NAME] 40 mg tablet (Error #5) to Resident B. The 2 medications were administered in applesauce and followed with water. The resident had finished her breakfast. Review of the current physician's orders [REDACTED]. During an interview on 4/6/11 at 9:23 AM, RN #2 confirmed that the [MEDICATION NAME] and [MEDICATION NAME] were ordered to be given before breakfast.",2015-04-01
9526,FRANKE HEALTH CARE CENTER,425374,1885 RIFLE RANGE ROAD,MOUNT PLEASANT,SC,29464,2011-12-02,225,D,1,0,EHLW11,"On the day of the complaint inspection, based on review of the facility's investigative documents related to an allegation of misappropriation of resident property, the facility failed to make their initial report of the allegation to the State survey and certification agency within the allowed time frame for 1 of 1 allegation reviewed. The findings included: On 10/30/11, the Responsible Party of Resident #1 reported that he wedding band was missing. The Nurse's Note on that day, at 1 PM said: ""... son of resident was visiting (with) his wife. They stated wedding ban (sic) is missing. (Son's) wife stated she saw it last Sunday. DON (Director of Nurses) notified by CNA (Certified Nursing Assistant) and social worker will address this problem in am. and call son."" On 10/31/11, another allegation of a missing wedding ring was made for Resident #2. Review of the facility's investigation documents revealed the initial report to the State survey and certification agency was made on 11/1/11, which exceeded the twenty-four hour time limit.",2015-04-01
9527,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-12-20,157,D,1,0,PRCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on observations, record review and interview, the facility failed to consult with the resident's physician regarding a significant change for Residents #1 and #2. Resident #1's oxygen saturation levels were in the 80's, he was not using [MEDICAL CONDITION] as ordered, he was attempting to get out of bed and physical therapy increased his oxygen level to 10 liters per minute and Resident #2 had multiple episodes of ""chest pain"", new onset of intermittent confusion and unclear speech. The physician was not notified in a timely manner regarding the changes that occurred with these two residents. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] at 1:30 AM. Review of the Nurses Notes revealed on [DATE] at 8:00 AM, ""Pt (patient) experiencing SOB (shortness of breath). Respirations 24 and shallow. Crackles auscultated in upper lobes bilaterally. O2 sat 88% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Suctioned x 2. Pulled up in bed. Lung sounds clear. O2 sats (increased) to 92%. Respirations 22. Breathing still labored. HOB (head of bed) up 45 degrees. Bed in lowest position, side rails up x 2. Call light in reach."" At 1:00 PM, ""Pt O2 sat 80% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Pt very far down in bed. Respirations 22 and labored. Small amount of thick yellow mucous noted in trach. Suctioned x 1. Crackles heard in upper lobes bilaterally when auscultated. Suctioned x 2. Lung sounds clear. Pulled up in bed. Breathing tx (treatment) c (with) CPT machine in place. O2 sats remain in lower 80's. RT notified. O2 increased to 10 LPM, 40 % FiO2. O2 sats increased to 94%. HOB up 45. Bed in lowest position, side rails up x2, call light in reach."" At 5:25 PM, ""Pt found lying at foot of bed. [MEDICAL CONDITION] removed. Pt immediately placed back at head of bed. [MEDICAL CONDITION] placed back on. O2 sats 88% on 10 LPM, 40 % FiO2. Encouraged to take deep breaths. O2 sats increased to 92%. Pt questioned why he was at foot of bed. He stated that he was trying to get up. Informed pt that he could not get up without assistance. Re-oriented to call light. HOB up 45 degrees. Bed in lowest position, side rails up x 2, call light within reach."" At 6:15 PM, ""Pt experiencing SOB. Using accessory muscles. [MEDICAL CONDITION] found around mouth. [MEDICAL CONDITION] placed back in proper position. Encouraged to take deep breaths, O2 sats 90% on 10 LPM, 40 % FiO2. Before nurse could leave the room, pt was taking [MEDICAL CONDITION]. Pt encouraged not to do so. Informed pt that he really needs to keep oxygen on. Pt given [MEDICATION NAME] 50 mg per PEG for agitation and restlessness. HOB up 45 degrees, bed in lowest position, side rails x 2. Call light in reach."" At 9:00 PM, ""Resident alert lying in bed with both eyes opened pulling [MEDICAL CONDITION], this writer (Registered Nurse #1) instructed resident not to [MEDICAL CONDITION] and given resident instructions on [MEDICAL CONDITION]'s use. Resident verbalized understanding. [MEDICATION NAME] infusing at 75 ml/hr and flushed with 150 ml water. [MEDICAL CONDITION] O2 at 28 % FiO2 infusing without difficulty. Medication given via PEG without difficulty. Head of bed elevated, call light in reach and bed in low position."" At 11:00 PM, ""Resident lying in bed with both eyes opened and no attempt to pull [MEDICAL CONDITION]. Head of bed elevated, call light in reach and bed in lowest position."" ([DATE]) At 1:30 AM, ""Resident lying in bed with both eyes opened, pupils fixed and dilated, no rise and fall noted to chest, unable to palpate carotid pulse. CPR started, EMS notified and resident sent to (ER). Family notified."" At 2:35 AM, ""MD on call notified of resident's condition and transport to the hospital."" During an interview on [DATE] at 2:50 PM, Respiratory Therapist #1 (RT) stated that he was called on Saturday [DATE] related to Resident #1's low sats. He came in and assessed the resident. He stated that [MEDICAL CONDITION] was in the correct position and secured appropriately. He also stated that the resident was able to remove [MEDICAL CONDITION]. RT #1 stated that he never saw [MEDICAL CONDITION] improperly placed. During an interview on [DATE] at 3:15 PM, Licensed Practical Nurse #1 (LPN) stated that she cared for the resident during the 7A-7P shift of [DATE]. She stated that she checked on the resident ""first thing."" She found the resident's sats were in the 80's and she was told to keep an eye on him. She stated that he was slumped down in the bed and ""not looking too well."" LPN #1 stated that his sats were in the 80's, he was SOB and his respiratory rate was increased. She stated that she checked on him every ,[DATE] hours and the resident's family was present most of the day until approximately 4:00 PM. She stated that she called the RT and he came into the building and assessed the resident. She stated that he increased the resident's oxygen to 40% FiO2. LPN #1 stated that the resident's sats increased to the 90's. She stated that after the resident's family left, he started to take [MEDICAL CONDITION] off and attempted to get out of bed. She administered [MEDICATION NAME] and the resident calmed down. LPN #1 stated that during the shift change report she told the oncoming nurse to check on him more frequently, that he slumped down in bed and was removing [MEDICAL CONDITION]. During an interview on [DATE] at 3:35 PM, Registered Nurse #1 (RN) stated that she cared for Resident #1 on the 7P-7A shift on [DATE]-[DATE]. She stated that the resident was trying to swing his legs out of bed and informed the CNA's to check on the resident frequently. RN #1 stated that she checked on the resident at 11:00 PM and he was in bed with [MEDICAL CONDITION] in place and his respirations were ok. She stated that at 1:00 AM, she checked on the resident again and he was not breathing, CPR was initiated and the resident was sent to the hospital. RN #1 stated that during shift change report she was informed that the resident was removing [MEDICAL CONDITION] and had decreased sats. During an interview on [DATE] at 3:30 PM, Certified Nursing Assistant #1 (CNA), stated that she was the lead CNA for Unit. She stated that she informed the CNAs caring for Resident Corley to check on him more frequently, every ,[DATE] minutes. During an interview on [DATE], the Director of Nurses stated that the facility had accepted [MEDICAL CONDITION] residents before and the staff were adequately trained. She stated that the staff responded appropriately to the resident and provided appropriate care. The facility admitted Resident #2 on [DATE] at 1:45 PM with [DIAGNOSES REDACTED]. After multiple episodes of ""chest pain"", onset of intermittent confusion and unclear speech, the facility failed to notify the Physician and / or family of significant changes in the resident's condition in a timely manner. Review of the Daily Skilled Nurse's Notes on [DATE] at 4:45 PM revealed the following: -The resident had new onset of ""intermittent confusion, unclear speech, C/P (chest pain) throbbing constant and falls asleep easily"" on [DATE]. The nurse assessed the resident's heart rate, and the resident denied SOB (shortness of breath). There was no evidence that the Physician or Responsible Party were notified. -The resident again experienced ""intermittent confusion"" on [DATE]. The resident denied chest pain and the nurse assessed the vital signs they were within normal limits. There was no evidence that the Physician was notified. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 5:00 PM, she verified that the Physician or Responsible Party were not notified.",2015-04-01
9528,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-12-20,281,D,1,0,PRCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review, observation, interviews, review of the professional resource of Lippincott Manual of Nursing Practice Ninth Edition the facility failed to provide services that met professional standards of quality for one of ten residents (Resident #1). The facility failed to adequately assess Resident #1's oxygen saturation levels, failed to provide interventions when he removed [MEDICAL CONDITION] and/or attempted to get out of bed and failed to document all physician ordered treatments when administered per CPT vest (chest percussion therapy). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] at 1:30 AM. Review of the Nurses Notes revealed on [DATE] at 8:00 AM, ""Pt (patient) experiencing SOB (shortness of breath). Respirations 24 and shallow. Crackles auscultated in upper lobes bilaterally. O2 sat 88% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Suctioned x 2. Pulled up in bed. Lung sounds clear. O2 sats (increased) to 92%. Respirations 22. Breathing still labored. HOB (head of bed) up 45 degrees. Bed in lowest position, side rails up x 2. Call light in reach."" At 1:00 PM, ""Pt O2 sat 80% on 5 LPM, 28 % FiO2 [MEDICAL CONDITION]. Pt very far down in bed. Respirations 22 and labored. Small amount of thick yellow mucous noted in trach. Suctioned x 1. Crackles heard in upper lobes bilaterally when auscultated. Suctioned x 2. Lung sounds clear. Pulled up in bed. Breathing tx (treatment) c (with) CPT machine in place. O2 sats remain in lower 80's. RT notified. O2 increased to 10 LPM, 40 % FiO2. O2 sats increased to 94%. HOB up 45. Bed in lowest position, side rails up x 2, call light in reach."" At 5:25 PM, ""Pt found lying at foot of bed. [MEDICAL CONDITION] removed. Pt immediately placed back at head of bed. [MEDICAL CONDITION] placed back on. O2 sats 88% on 10 LPM, 40 % FiO2. Encouraged to take deep breaths. O2 sats increased to 92%. Pt questioned why he was at foot of bed. He stated that he was trying to get up. Informed pt that he could not get up without assistance. Re-oriented to call light. HOB up 45 degrees. Bed in lowest position, side rails up x 2, call light within reach."" At 6:15 PM, ""Pt experiencing SOB. Using accessory muscles. [MEDICAL CONDITION] found around mouth. [MEDICAL CONDITION] placed back in proper position. Encouraged to take deep breaths, O2 sats 90% on 10 LPM, 40 % FiO2. Before nurse could leave the room, pt was taking [MEDICAL CONDITION]. Pt encouraged not to do so. Informed pt that he really needs to keep oxygen on. Pt given [MEDICATION NAME] 50 mg per PEG for agitation and restlessness. HOB up 45 degrees, bed in lowest position, side rails x2. Call light in reach."" On [DATE] at 9 PM, ""Resident alert lying in bed with both eyes opened pulling [MEDICAL CONDITION], this writer (Registered Nurse Regina Foster) instructed resident not to [MEDICAL CONDITION] and given resident instructions on [MEDICAL CONDITION]'s use. Resident verbalized understanding. [MEDICATION NAME] infusing at 75 ml/hr and flushed with 150 ml water. [MEDICAL CONDITION] O2 at 28 % FiO2 infusing without difficulty. Medication given via PEG without difficulty. Head of bed elevated, call light in reach and bed in low position."" At 11:00 PM, ""Resident lying in bed with both eyes opened and no attempt to pull [MEDICAL CONDITION]. Head of bed elevated, call light in reach and bed in lowest position."" At ([DATE]) 1:30 AM, ""Resident lying in bed with both eyes opened, pupils fixed and dilated, no rise and fall noted to chest, unable to palpate carotid pulse. CPR started, EMS notified and resident sent to (ER). Family notified."" At 2:35 AM, ""MD on call notified of resident's condition and transport to the hospital."" Review of the Admission physician's orders [REDACTED].#1 was ordered Continuous Oxygen at 28% FiO2 via [MEDICAL CONDITION] (trach) Collar. Resident #1 was also ordered [MEDICATION NAME] 1.2 at 75 ml/hr via PEG (percutaneous endoscopic gastrostomy) with 100 ml water flushes every 4 hours. In addition, the resident was noted to have a permanent pacemaker and was prescribed [MEDICATION NAME] 40 mg subcutaneous daily. The resident was also ordered a CPT vest three times daily with nebulizers. During an interview on [DATE] at 2:50 PM, Respiratory Therapist #1 (RT) stated that he set up all of Resident Corley equipment. He stated that the resident had a size 6 Shiley trach. He stated that he assessed the resident prior to admission to the facility and knew what care needs the resident required. RT #1 stated that he was called on Saturday [DATE] related to the resident' low sats. He came in and assessed the resident. He stated that [MEDICAL CONDITION] was in the correct position and secured appropriately. He also stated that the resident was able to remove [MEDICAL CONDITION]. RT #1 stated that he never saw [MEDICAL CONDITION] improperly placed. During an interview on [DATE] at 3:15 PM, Licensed Practical Nurse #1 (LPN) stated that she cared for the resident during the 7A (AM) -7P (PM) shift of [DATE]. She stated that she checked on the resident ""first thing."" She found the resident's sats were in the 80s and she was told to keep an eye on him. She stated that he was slumped down in the bed and ""not looking too well."" LPN #1 stated that his sats were in the 80s, he was SOB and his respiratory rate was increased. She stated that she checked on him every ,[DATE] hours and the resident's family was present most of the day until approximately 4:00 PM. She stated that she called the RT and he came into the building and assessed the resident. She stated that he increased the resident's oxygen to 40 % FiO2. LPN #1 stated that the resident's sats increased to the 90's. She stated that after the resident's family left; he started to take [MEDICAL CONDITION] off and attempted to get out of bed. She administered [MEDICATION NAME] and the resident calmed down. LPN #1 stated that during the shift change report she told the oncoming nurse to check on him more frequently, that he slumped down in bed and was removing [MEDICAL CONDITION]. LPN #1 also stated that she received training on tracheostomies approximately one month prior to the resident's admission. During an interview on [DATE] at 3:35 PM, Registered Nurse #1 (RN) stated that she cared for Resident #1 on the 7 P-7 A shift on [DATE]-[DATE]. She stated that the resident was trying to swing his legs out of bed and she informed the CNA's to check on the resident frequently. RN #1 stated that she checked on the resident at 11:00 PM and he was in bed with [MEDICAL CONDITION] in place and his respirations were ok. She stated that at 1:00 AM, she checked on the resident again and he was not breathing, CPR was initiated and the resident was sent to the hospital. RN #1 stated that during shift change report she was informed that the resident was removing [MEDICAL CONDITION] and had decreased sats. During an interview on [DATE] at 3:30 PM, Certified Nursing Aide #1 (CNA) stated that she was the lead CNA for the Unit. She stated that she informed the CNAs caring for Resident #1 to check on him more frequently, every ,[DATE] minutes. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on [DATE] at 3:00 PM, the Director of Nurses confirmed the MAR indicated [REDACTED]. Review of the Lippincott Manual of Nursing Practice Ninth Edition Page 17 revealed, ""Failure to communicate or document a significant change in a patient's condition to appropriate professional"" is a Departure from Standards of Care. Review of the Lippincott Manual of Nursing Practice Ninth Edition Page 284 revealed ""Standard of Care Guidelines for Respiratory Disorders"". When caring for patients at risk for respiratory compromise, consider the following assessments and interventions: -Be aware of the status of the patient when assuming care so comparison can be made with subsequent assessments. -Perform thorough systematic assessment, including mental status, vital signs, respiratory status, and cardiovascular status. -Document patient's condition to provide a record for continuity of care. -Evaluate the signs of [MEDICAL CONDITION] when anxiety, restlessness, confusion...... -Notify appropriate health care provider of significant findings of [MEDICAL CONDITION]--cyanosis, abnormal breath sounds.......",2015-04-01
9529,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-12-20,309,D,1,0,PRCO11,"**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 the facility failed to ensure one of ten residents received the necessary care and services to attain or maintain the highest practicable physical well being. Through a lack of coordination between the facility and the [MEDICAL TREATMENT] center the nursing facility failed to implement a fluid restriction ordered for Resident #9 by the [MEDICAL TREATMENT] clinic and failed to monitor the resident's intake as required. The findings included: The facility initially admitted Resident #9 on 9/16/2011 and readmitted her on 10/24/2011 following hospitalization for a cardiopulmonary arrest while at [MEDICAL TREATMENT] for treatment of [REDACTED]. Record review on 12/20/2011 at 11:05 AM revealed that on 10/28/2011, the resident was hospitalized again ""with shortness of breath and chest pain and was found to be volume overloaded and in [MEDICAL CONDITION]... She was dialyzed aggressively for treatment of [REDACTED]. She was found to have bilateral pleural effusions and underwent bilateral thoracentesis..."" Resident #9 was readmitted to the facility on [DATE]. Additional [DIAGNOSES REDACTED]. Based on record review and interviews the facility failed to implement a fluid restriction ordered by the [MEDICAL TREATMENT] clinic and failed to monitor the resident's intake as required. Record review on 12/19/2011 at approximately 6:30 PM revealed that the resident was on [MEDICAL TREATMENT] three times weekly. Review of the [MEDICAL TREATMENT] Communication Sheets revealed that on 11/9/2011, ""Pt (Patient) came in c (with) a 4.7 kg gain. This is to(o) much."" On 11/14/2011, the [MEDICAL TREATMENT] Communication Sheet noted the resident on a ""1200 ml (milliliter) fluid restriction"" and that the resident ""Had wt (weight) gain of 4.1 (kg) from previous post weight. Please make sure Pt only has 1200 ml a day of fluid. This includes ice cream and gelatins."" Review of the clinical record revealed no reference to the resident having been placed on fluid restriction. During an interview on 12/19/2011 at 7 PM, the Assistant Director of Nurses (ADON) stated she was unaware of any residents on fluid restriction. She reviewed the Communication forms and verified the above information. She stated that nursing staff should have reviewed the [MEDICAL TREATMENT] notes upon the resident's return from the clinic and written physician's orders [REDACTED]. The ADON verified that intake was not being monitored for this resident. During an interview at 7:15 PM on 12/19/2011 in the presence of the ADON, the Registered Dietitian stated she had two [MEDICAL TREATMENT] patients, but neither was on fluid restriction. Observations on 12/19/2011 at 4:05 PM and with the ADON at 7:10 PM revealed water readily accessible at the resident's bedside.",2015-04-01
9530,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-12-20,514,D,1,0,PRCO11,"**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 the facility failed to ensure one of one resident clinical records were accurate and complete. Resident #1's Physician order [REDACTED]. Nursing Notes were not timed and the November 2011 Medication Administration Record [REDACTED] The findings included: The facility admitted Resident #1 on 11/4/2011 with [DIAGNOSES REDACTED]. Review of the Physician Telephone Orders revealed five out of nine telephone orders were without dates or times. Review of the Admission Nursing Notes revealed no time was recorded when the resident entered the facility or what time the assessments were completed. Review of the Nursing Admission Evaluation revealed ""Section A: Arrival Time"" was left blank. The resident's history and clinical concerns were not recorded on the Evaluation. Review of the Medication Administration Record [REDACTED]. During an interview on 12/5/2011 at 2:30 PM, the Respiratory Therapist stated that he provided the CPT Vest to the resident on 11/4/2011 and that it wasn't documented. During an interview on 12/5/2011 at 3 PM, the Director of Nurses confirmed the physician's orders [REDACTED]. She also confirmed that the Nurses Notes and Nursing Evaluation did not have times recorded. She stated that the nursing staff should date and time orders and their notes.",2015-04-01
9531,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-12-20,518,F,1,0,PRCO11,"On the days of the Complaint and Extended Survey, the facility failed to ensure the staff was trained on emergency fire procedures as required. There was no documented training for either the 3-11 or 11-7 shifts during the last quarter. The findings included: Review of documented fire drills on 12/20/2011 at 4:30 PM revealed that drills were not conducted quarterly on each shift as required to determine the efficiency, knowledge, and response of facility personnel. The Fire Drill Schedule provided by the facility indicated that drills were scheduled for each shift on a rotating basis. However, review of the drills actually conducted revealed that the 11-7 shift had not had a drill since May 2011 and the 3-11 shift had not had a drill since July 2011. Fire drills were conducted on the 7-3 shift during the months of August, September, and October 2011. When requested, the Maintenance Supervisor was unable to produce any additional information. During an interview on 12/20/2011 at 4:55 PM, in the presence of two maintenance personnel, the Administrator reviewed and confirmed this information. It was pointed out that the Fire Drill Book had dividers for each month that specified the shift on which the drill should have been conducted. The Administrator verified that the fire drills had not been conducted as required.",2015-04-01
9532,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2012-02-08,309,D,0,1,OP6411,"**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 provide the necessary care to maintain the highest practicable physical wellbeing for one of one sampled residents reviewed with sliding scale insulin. The Medication Administration Record [REDACTED]. The findings included: Resident #7 admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review on 2/8/12 at approximately 10:30 am revealed on the January 12 thru 31, 2012 cumulative physician's orders [REDACTED].= 0 units; 121-150 = 3 units; 151-200 = 4 units; 201-250 = 6 units; 251-300 = 9 units; 301-350 = 12 units; 351-400 = 16 units. Finger Stick Blood Sugars (FSBS) at 0700, 1200, 1700."" Review of the January 2012 MAR indicated [REDACTED] For 1700 ( or 5 PM)- 1/16/12 FSBS - 145, no insulin given, should have been given 3 units 1/17/12 FSBS - 127, no insulin given, should have been given 3 units 1/19/12 FSBS - 127, no insulin given, should have been given 3 units 1/20/12 FSBS - 125, no insulin given, should have been given 3 units Review of the February 2012 MAR indicated [REDACTED] For 1700 ( or 5 PM)- 2/1/12 FSBS - 124, no insulin given, should have been given 3 units An interview was conducted on 2/8/12 at approximately 11:00 am with the Director of Nursing (DON). The DON was shown the above documentation and asked if the correct amount of insulin was provided in each instance. The DON stated no, the nurse should have given insulin according to the sliding scale provided.",2015-04-01
9533,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2012-02-08,164,D,0,1,OP6411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, the facility failed to ensure that resident #1 received personal privacy during a wound care treatment to the buttocks. ( 1 of 2 sampled residents reviewed for privacy during treatments.) The findings included: The facility admitted Resident #1 on 9/12/2011 with the following Diagnosis: [REDACTED]. During observation of wound care on 2/7/12 at 1:35 PM Licensed Practical Nurse (LPN) # 1 pulled the curtain in the middle of the room, separating only the two beds. Resident # 1 was in the bed by the door and the bathroom door was at the foot of the residents bed. The bathroom was a shared with an adjoining room. The curtain did not provide privacy from the view of the bathroom. During the treatment, LPN # 1 dropped the dressing on the floor and had to leave the room to obtain another dressing for the wound. She pulled the curtain around the end of the bed, leaving approximately two feet opened facing the entrance door to the room. She opened the door, spoke to another staff member in the hall, left the room and closed the door. The resident was laying on his side with the buttocks exposed. The curtain was not pulled all the way around to block the view of the exposed resident from the door to the room. The LPN returned to the room and opened the curtain back to only blocking the other bed, and continued with her treatment. During a interview with LPN # 1 after the treatment was completed, she stated when ask about providing privacy: "" I guess I should have pulled the curtain all the way"".",2015-04-01
9534,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2012-02-08,441,D,0,1,OP6411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the policy provided by the facility entitled ""Hand Washing and Use of Gloves"", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to wash hands appropriately before during and after a wound treatment. The findings included: The facility admitted Resident #1 on 9/12/2011 with the following Diagnosis: [REDACTED]. During the wound care observation on 2/7/12 at 1:35 PM Licensed Practical Nurse (LPN) # 1 knocked on the door, entered and spoke with the resident. She then washed her hands very briefly (not timed), turned the faucet off with her bare hand and donned gloves. She then set her table up with supplies, pulled the residents pants down, unfastened the brief and removed her gloves. The LPN washed her hands for 3 seconds (timed) and again turned the faucet off with her bare hand. She donned gloves, removed the soiled dressing and her gloves and washed her hands for 2 or 3 seconds (timed) and without a barrier turned the faucet off. She donned gloves, opened the dressing package and dropped it on the floor. The LPN left the room to get another dressing. When she returned she donned gloves without washing her hands. LPN # 1 then cleaned the wound, removed her gloves, immediately donned another pair of gloves and stated "" I should wash my hands again, but it's not open anymore"". She then applied skin prep to the surrounding skin tissue. LPN # 1 removed her gloves, donned another pair of gloves (without washing her hands) and applied the [MEDICATION NAME] dressing to the buttocks. She again removed her gloves, donned another pair (without washing her hands) and dressed the resident. The LPN washed her hands again 2-3 seconds and did not use barrier to turn the faucet off. She removed all of the trash from the room and washed her hands again using her previously observed process. During an interview after the treatment was completed the LPN stated when ask about hand washing training or inservices "" All nurses know how to wash their hands"". When ask about washing hands thoroughly, she stated she washes her hands for a least 30 seconds at home, then confirmed that she did not do that here. The facilities policy for hand washing stated under the procedure to Wet hands and wrist thoroughly and apply soap, vigorously rotate hands to assure that friction is applied with the soapy water between the fingers and the back of the hands for approximately 15-30 seconds, rinse the hands and wrists well, dry hands thoroughly with the paper towels and turn the water off by using the paper towel.",2015-04-01
9535,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2012-02-08,367,D,0,1,OP6411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide adequate supervision for a resident at risk for aspiration. Resident #1 was ordered by the physician to receive a pureed diet. He received regular fruit cut in approximately one inch pieces. The resident ate a piece of cantaloupe and was observed to start coughing and drooling. The findings included: The facility admitted Resident #1 on 9/12/2011 with the following Diagnosis: [REDACTED]. The medical record review on 2/7/12 revealed a order for a pureed diet with nectar thick liquids. Further review revealed that the resident had a history of [REDACTED]. During observation of the evening meal on 2/7/12 at 5:15 PM the Certified Dietary Manager (CDM) was plating food and the Certified Nursing Assistants (CNA) were assisting by placing the dessert and drinks on the trays. The dining room had 2 to 4 staff present at all times during the meal. The resident received a pureed meal and a cup of fruit cut in approximately one inch pieces. The resident picked up a piece of cantaloupe with his fork and put it in his mouth, he immediately started coughing and drooling. He held the cantaloupe in his mouth 8 to 10 minutes and then swallowed it. The staff was observed walking around, asking other residents if they needed anything, but did not acknowledge resident # 1's coughing episode, his drooling or that he had a fruit cup. When this surveyor ask the CDM what is the dessert for the pureed diet, she stated ice cream or sherbet. When ask about resident # 1's dessert, a CNA stated "" Oh no, he should not have that."" She removed the fruit and the resident was given ice cream. During a interview with the CDM she stated "" this is all new (bringing the food to the dining room to be plated) and we are working it all out, but we have a way to go yet"". The Director of Nursing stated during a interview on 2/8/12 - "" Meals are being brought up to the unit for about a week now and it's not organized well at this point"".",2015-04-01
9290,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2012-01-17,225,D,1,0,WZUA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure residents were protected during an investigation, failed to conduct a thorough investigation and failed to report a potential incident of neglect. Resident #1's CNA (Certified Nursing Assistant) was suspended 5 days after the allegation of neglect. The allegation of neglect was not thoroughly investigated or reported to the State Certification Agency. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 12/14/2011 Registered Nurse (RN) Supervisor documented: ""This Elder was found in the floor sitting upright with blood on head, face and on the floor. She did not make any noise the companion just happen to walk to the front of the common area and saw her on the floor. The laceration to the back of her head measured 1.5 cm superficial. Site was cleansed by Primary Nurse. Neuro checks started per policy. Corrective action: Place tab alert to Elder to be worn anytime she is out of bed."" On 12/15/2011 at 3:21 AM, Licensed Practical Nurse (LPN) #1 documented, ""Regarding 12/14/2011 at (8:05 PM), this nurse was called to this cottage from (another cottage) by the CNA, stating there had been a fall. Upon arriving, elder was sitting upright on her buttocks on the tile area at the back of the cottage. There was blood present on elder in multiple small pools on the floor. Upon assessment, elder was noted to be alert and upset about the blood present on her hands and her clothes. One injury on back of head present; 1.5 cm x 0.2 cm in width. Site is superficial. No other apparent injuries. Approximate amount of blood lost: 40 ml. Assisted elder to lie down on pillow. Called RN supervisor and assisted with complete assessment. ROM of all extremities unchanged as compared with elder's prior ability. Pupils equal and round. Elder responds to verbal stimuli. Cleansed [MEDICAL CONDITION] site and assisted elder to change clothes and wash blood off skin. Gait belt and 3 person transfer was used to place elder in recliner. GS (geriatric services) contacted and received orders for neuro checks per policy and monitor and cleanse skin laceration to back of head Q shift and PRN until healed. IDON (Interim Director of Nursing) notified by RN supervisor. Family notified ...CNA's in cottage at time of incident report that they walked to the front of the cottage and saw elder sitting on the floor in the previously explained condition and called this nurse at that time. They were not alerted to the elder's condition by any noise. Elder currently has a pressure alarm and alarming seatbelt present while in w/c; tab alert to be added."" Review of the CNA Documentation revealed CNA #2 documented at approximately 9:35 PM that the resident consumed 51-60% of her supper and was incontinent. No other documentation for Resident #1 was located for the 3-11 shift on 12/14/2011. Review of the Incident Report dated 12/17/2011 revealed ""Elder was found sitting up on floor in front of the exit doors to cottage. Alarming seatbelt had not alarmed, but had been alarming earlier. CNA #1 not cooperating with investigation. Elder sustained a mild superficial [MEDICAL CONDITION]."" Review of the 5 Day Report revealed the resident's condition prior to the incident was ""Elder was having a usual day in the cottage rolling around in her w/c. Self releasing alarming seatbelt on. Elder frequently opens the seatbelt causing repeated alarms."" Details of the incident were ""elder was found sitting up on floor in front of the exit doors of cottage. Elder wears an alarming seatbelt that had been alarming earlier but did not alarm when elder fell . CNA #1 is suspected of removing/disconnecting her alarm d/t frequent alarms. Elder also had not been toileted x 4 hours prior to her fall. At shift change at 11:30 PM elder was found in her recliner and smelled of feces. Elder taken to the BR and was found with a saturated brief with dried feces. Elder was toileted, showered and prepared for bed. Care plan not followed r/t toilet and reposition elder every 2 hours."" Interventions taken by the facility: ""CNAs suspended for neglect. CNAs disciplined for neglect of elder in their care..."" The facility substantiated neglect. CNA #1 was suspended on 12/15/2011. CNA #2 was suspended on 12/19/2011 for one day and then allowed to return to work. No disciplinary action was located in CNA #2's employee file. There was no evidence the allegation of neglect was thoroughly investigated and no evidence CNA #2 was disciplined for neglect of Resident #1. CNA #1 was allowed to return to work following the completion of the investigation, however, he failed to show up for his assignment and was terminated on 12/25/2011 for a ""no call, no show."" Review of the facility obtained statement by CNA #1 revealed: ""I was on my to start charting when I found Resident #1 sitting upright on the floor bleeding, I then called over my co-worker (CNA #2) and to her to contact the nurse. We then waited for the nurse to arrive."" Another interview was conducted on 12/19/2011 with CNA #1 and the IDON. ""What times did you toilet (Resident #1) from 3 PM to 10:30 PM? At 4 PM and 8 PM. Why did you two not toilet her since 8 PM? Silence... Silence... I don't know why we didn't toilet her again."" ""Are you telling me you disconnected her alarm on purpose to quiet the alarm and did not turn it back on or forgot to turn it on? Yes."" ""Explained to Eric I had received a report in the past of incontinent care not being done on another elder and I should have brought it forth when I found out about it. I asked him has this been occurring? He reluctantly stated yes. I explained to him he must do the care, it is not an option. Review of time card revealed CNA #1 clocked in at 3 PM on 12/14/2011 and clocked out at 11:38 PM. Review of the assignment sheet revealed CNA #1 and CNA #2 were assigned to the Tea Olive Cottage from 3-11 on 12/14/2011. During a telephone interview on 1/17/2012 at 4:20 PM, CNA #1 stated that both he and (CNA #2) were caring for the residents together, however, (CNA #2) was ""assigned"" to Resident #1. He stated that the resident constantly was opening and closing her alarming seatbelt. CNA #1 stated that either he or (CNA #2) failed to reset the alarm prior to her fall so no alarm sounded to alert them to her standing. CNA #1 stated that all residents were to be toileted every two hours at least. When asked when Resident #1 was toileted during the shift he stated that he didn't know because he was ""taking care of my side."" Review of the facility obtained statement from CNA #2 revealed she ""was her (Resident #1's) CNA (on 12/14/2011, 3-11 shift). ""No alarm went off not her self release belt or her chair alarm, and both were cut on."" ""When was the last time elder was toileted before occurrence? Right before supper around 4:15/4:30 PM."" ""When was the last time you observed elder before occurrence (last rounding)? During supper because I fed her."" During a telephone interview on 1/17/2012 at 3:15 PM, CNA #2 stated that the resident's alarms were working earlier in the shift. She stated that the resident was toileted at approximately 4:30 PM and then was toileted again after her fall at 8:30 PM. She stated that CNA #1 found the resident when she had fallen and that no alarm was sounding. CNA #2 stated that she checked on the resident at 10:15 PM and the resident's brief was dry. Review of the facility obtained statement from Licensed Practical Nurse (LPN) #1 revealed: ""Has alarming seatbelt and elder keeps taking seatbelt off to where it alarms 90% of time. Feels staff may have been ignoring it..."" During a telephone interview on 1/17/2012 at 3:15 PM, LPN #1 stated she last interacted with Resident #1 around dinnertime. She stated that her seatbelt alarm was on and working at that time. LPN #1 reported that she was notified of the fall by CNA #1. She stated that neither alarm was sounding at the time of the fall. LPN #1 stated that the resident was last toileted around 4:30 PM. Review of the facility obtained statement from LPN #2 revealed: ""Elder was on a recliner and was trying to get out of it when I came in to get report at 2330 (11:30 PM). I explained to the 3-11 nurse that the recliner will tip over (Resident #1) if we don't get her out of it. (Resident #1) is used to being on the ""go"" and having her on the recliner is like a restraint for her. When we transferred the elder to her wheelchair we smelled feces odor. We took her to her bathroom and her diaper was saturated with urine and drying stool. After the elder finished voiding in the commode, I gave her a warm shower to clean her up and then we assisted elder to bed."" LPN #2 was unavailable for interview during the survey. During an interview on 1/17/2012 at 5 PM, the Interim Director of Nurses confirmed CNA #2 was not suspended until 12/19/2011 (5 days after the incident) and was suspended for one day. The IDON also confirmed that the allegation of neglect related to incontinent care was not thoroughly investigated and stated that since everything was under CNA #1 nothing else was done.",2015-05-01
9291,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2012-01-17,226,D,1,0,WZUA11,"On the day of the complaint inspection based on record review, interview and review of the facility's policy on Abuse, the facility failed to assure their policy was implemented related to the investigation of neglect, and protection of residents. The findings included: The facility failed to thoroughly investigate an allegation of neglect for Resident #1 related to incontinent care. The facility also failed to suspend CNA #2 following the allegation of neglect. During an interview on 1/17/2012 at 5 PM, the Interim Director of Nurses confirmed CNA #2 was not suspended until 12/19/2011 (5 days after the incident) and was suspended for one day. The IDON also confirmed that the allegation of neglect related to incontinent care was not thoroughly investigated and stated that since everything was under CNA #1 nothing else was done. Review of the facility's policy on Abuse and Neglect revealed the following: ""Any staff member implicated in an incident where they may have committed abuse or neglect of a guest/elder will be placed on suspension pending the outcome of an investigation."" ""All elder/family concerns/grievances and occurrences will be investigated and appropriately reported to the appropriate authorities. Events such as but not limited to falls ...are investigated for possible abuse."" Cross Refer to F 225 as it relates to the facility's failure to protect residents, thoroughly investigate and report allegations of neglect.",2015-05-01
9292,THE COTTAGES AT BRUSHY CREEK,425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2012-01-17,280,D,1,0,WZUA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview the facility failed to ensure 1 of 3 resident's care plans were updated with new and appropriate interventions after a fall with injury on 12/14/2011. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the CNA Care Plan revealed Resident #1 was to have a ""bed alarm, matt, lo bed, seat belt, anti-tipper w/c."" The resident was also to be ""toileted and repositioned every two hours while in seat belt."" Review of the Nursing Care Plan date 4/21/2011 revealed a problem area of ""I need assistance for transfers and ambulation. I have a hx of falls."" Approaches included: ""I have been evaluated by PT (physical therapy) on 10/23/2011, I need extensive assist of 1 for transfers, I can ambulate short distances with my walker and 1 assist. High fall risk. Provide for my safety. Make sure my call light is within reach, my walking path is free of clutter and I'm wearing non skid foot wear. Provide bed alarm in bed and out and floor matt."" The care plan was updated on 12/7/2011 to include ""I use a Sara Lift for transfers and my safety devices include bed alarm in bed/chair, matt, low bed and alarming seat belt."" The care plan had not been updated to reflect the residents fall on 12/14/2011 and no new interventions were included. Review of the Nurse's Notes revealed on 12/14/2011 the RN (registered nurse) Supervisor documented: ""This Elder was found in the floor sitting upright with blood on head, face and on the floor. She did not make any noise the companion just happen to walk to the front of the common area and saw her on the floor. The laceration to the back of her head measured 1.5 cm superficial. Site was cleansed by Primary Nurse. Neuro checks started per policy. Corrective action: Place tab alert to Elder to be worn anytime she is out of bed.""",2015-05-01
9293,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,250,D,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on observation, record review and interviews, the facility failed to ensure that the residents who were visually impaired received the medically related social services to meet those needs for 1 of 14 sampled residents reviewed for social services. The findings included: The facility admitted Resident #6 on 10/07/02 with a [DIAGNOSES REDACTED]. During the resident interview on 12/12/11 at 2:12pm, the resident stated she was unable to see the television and could not see to read. The surveyor asked the resident if she had glasses that could help improve her vision. The resident denied having glasses. The surveyor observed Resident #6 remove a photo of her daughter from her purse with her left hand and bring it to her face to see the picture. The resident brought the photo approximately 8-10 inches from her face and was able to see the photo of her daughter and commented on how beautiful she was. During the record review on 12/13/11 at 10:00am, the annual MDS with an Assessment Reference Date (ARD) of 02/03/11 (B1000) coded the resident as 1-visually impaired. The quarterly MDS with an ARD of 10/27/11 (B1000) was coded as 2-moderately impaired. According to the care plan, the resident was to receive an annual eye exam from the on-site physician who had been at the facility in September, 2011. There were no records found indicating that the resident was seen for the annual eye exam. Review of 11/2/11 Social Services notes revealed that the resident stated she could not see television or see to read. During an interview on 12/13/11 at 11:00am, the surveyor asked the Social Services Director (SSD) and Social Services Assistant (SSA) if the resident had been seen for her annual eye exam, which was on her care plan. The SSD was unable to locate documentation in the chart that the resident had been seen for the on-site annual eye exam. The SSD did provide, however, documentation that Resident #6 was seen on 1/21/2009 by a physician for an eye exam. At that time, the physician offered Resident #6 magnifiers, but the resident declined. The SSD called the on-site physician's office and they were unable to provide documentation that the resident was seen by the physician in September, 2011 for an annual eye exam. Review of the care plan on 12/12/11 reflected that Resident #6 had glasses. As stated during the interview, the resident denied having glasses. There were no glasses seen on the bedside table. During an interview on 12/13/11 at 9:45am, the resident's roommate stated she had never seen the resident wear glasses. When asked if she could get a pair of glasses if she would wear them, the resident responded, ""Oh, yes ma'am!"".",2015-05-01
9294,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,281,K,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of facility provided policies related to Hyper/[DIAGNOSES REDACTED], SSI (sliding scale insulin), Procedure For Diabetic Monitoring and the Glucometer Skills Check List , facility nursing staff failed to ensure that approved germicidal wipes were used for the disinfecting/cleaning of 3 of 4 multiple-resident use glucometer's prior to use and or failed to clean glucometer's between residents. Thirty- nine residents in the facility received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. Resident #11, 1 of 3 residents reviewed for Sliding Scale Insulin did not receive Insulin as ordered for 5 doses. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that appropriate and effective disinfecting wipes were used to clean multiple-resident use glucometers prior to use. On [DATE] at 3:37 PM, Registered Nurse (RN) #4 was asked by the surveyor to demonstrate how she cleans a glucometer. RN #4 removed a glucometer from her medication (MED) cart and alcohol wipes from a caddy on her cart. She then cleaned the meter using the alcohol wipes and stated that she cleans the glucometer between each resident using alcohol wipes. At 3:42 PM Licensed Practical Nurse (LPN) #3 was asked how she cleans the glucometer. She stated that she did not know anything about cleaning a glucometer and that she does not clean it. She acknowledged she has residents who have Finger Stick Blood Sugars (FSBS) done on her shift. When interviewed, LPN #4 stated that he cleans the glucometer using alcohol wipes. On [DATE] at 1:55 PM, both the Director of Nursing and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly until they were informed by the surveyor. During a telephone interview on [DATE] at 2:35 PM with the Medical Director, he stated that he would expect the facility nurses to clean the glucometers with a sodium Hypochlorite solution and was not aware that they did not. He also stated that he approved the new policy which included cleaning with a approved germicidal product and checking for expiration dates on those products. Review of the facility policy entitled Procedure For Diabetic Monitoring revealed ""...15) glucometers that are used for more than one resident must be cleaned and disinfected between residents. 16) Check the expiration date of the approved germicidal wipe before using. 3. To clean the meter: Disinfect the meter after it is turned off. Gently wipe the surface with approved germicidal wipe. Do not put meter under water or spray any cleaning or disinfectant directly onto the meter. Set meter aside on a clean piece of paper and allow the germicidal to dry."" Review of the facility's Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List all stated to ""..Cleanse meter after each resident use..."" Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident use. CFR 483.20 F-281 was identified at a scope and severity of ""K"". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean glucometers used for multiple residents with an appropriate cleansing agent. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of ""E"". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. The facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at 2:15 PM revealed a [DATE] Documentation Record for Resident #11. One entry stated ""Regular Insulin SS (Sliding Scale) Before Meals, Less Than 150=0 Unit, ,[DATE]=0 Unit, ,[DATE]=2 Units, ,[DATE]=4 Units, ,[DATE]=6 Units, ,[DATE]=8 Units..."". Further review revealed documentation that 4 units of Insulin had been given for a blood sugar of 241 on [DATE] at 11:30 AM . According to the order, 2 units of Insulin should have been given instead of 4 units. Review of Resident #11's ""Fingerstick Blood Sugar Record"" for [DATE]- 11:30 AM also documented 4 units of Insulin had been given for the blood sugar of 241. An entry dated [DATE] at 4:30 PM documented 6 units of Insulin had been given for a blood sugar of 352. According to the order, 8 units of Insulin should have been given. The resident's ""Fingerstick Blood Sugar Record"" also documented 6 units of Insulin had been given for the blood sugar of 352 on [DATE] at 4:00 PM. The above findings were verified by Registered Nurse (RN) #2 after reviewing the record. Continued record review on [DATE] at 9:50 AM revealed Documentation Records and Fingerstick Blood Sugar Records for Resident #11 for October and [DATE]. The October and [DATE] Documentation Records contained entries for ""Regular Insulin SS (Sliding Scale) Before Meals, Less Than 150=0 Unit, ,[DATE]=0 Unit, ,[DATE]=2 Units, ,[DATE]=4 Units, ,[DATE]=6 Units, ,[DATE]=8 Units..."". The following entries were reviewed which indicated Resident #11 received the incorrect dosages of Insulin: On [DATE] at 11:30 AM, 4 units of Insulin had been documented as having been given for a blood sugar of 245. According to the order, 2 units of Insulin should have been given. On [DATE] at 4:00 PM, 2 units of Insulin had been documented as having been given for a blood sugar of 266 on the Fingerstick Blood Sugar Record. According to the order, 4 units of Insulin should have been given. Review of the Documentation Record for the same date and time ([DATE] at 4:30 PM) revealed documentation that no Insulin had been given for the blood sugar of 266. On [DATE] at 4:30 PM, 2 units of Insulin had been documented as having been given for a blood sugar of 272. According to the order, 4 units of Insulin should have been given. These findings were verified with RN #2 after reviewing the record.",2015-05-01
9295,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,323,E,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, review of facility's policy entitled Procedure for safe smoking and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Resident #13, 1 of 1 residents known to smoke was given a cigarette lighter by a facility staff member. The facility failed to provide adequate nursing supervision for a Certified Nursing Assistants (CNA) related to monitoring and documenting resident safety devices and restraint release every 2 hours. Resident #15 had repeated (12) falls without additional preventive measures added. Resident #16's fall assessment was incorrect. The findings included: The facility admitted Resident # 13 on 11/3/1998 and readmitted him on 12/31/2007 with [DIAGNOSES REDACTED]. His BIMS (Brief Interview for Mental Status) score on 5/12/11 was 5 and on 11/10/11 was 6. A score of 0-7 indicates severe impairment. On 12/12/2011 at 3:25 PM, a male staff member was observed to give Resident #13 a small green disposable cigarette lighter. The resident placed the lighter in a fanny pack,which was secured to his waist. The resident then zipped the pack and cover himself to his chest with a blanket. At 4:00 PM, review of the resident's smoking assessment indicated that he was not safe to smoke without dropping it on himself. Review of the care plan for Resident #13 stated that he had been assessed as ...."" unsafe to smoke independently, provide 1:1 supervision during smoking activity and nursing is to keep cigarettes and lighter in a safe place."" Review of the facility's policy entitled Procedure for safe smoking indicated""...5). Residents will not be allowed to have cigarettes or lighters/matches on their person or in their room at any time..."" On 12/12/2011 at 4:11 PM, during an interview with the Business Office Manager (BOM), he stated that he had given the resident the lighter and had given them to him ""in the past"" when the resident stated his was not working. He stated that the resident would send another resident to the business office to tell him he needed a lighter or would stop him on the unit. The BOM stated he had never given the resident cigarettes. He also stated that he was unaware that the residents could not have smoking materials and that he does not recall being in-serviced on smoking safety for the residents. The facility admitted Resident #15 on 2/17/2011 with [DIAGNOSES REDACTED]. Review of the December 2011 physician's orders [REDACTED]."" Review of the facility provided Incident Reports revealed the following: On 2/23/11, Resident #15 fell out of her wheelchair. A low bed and fall mats were already in place, wheelchair and bed alarms were in place prior to the fall. New interventions: none. On 2/28/1, the resident fell from her wheelchair again. Per the incident report the new intervention was to ""walk with resident when agitated."" However, the intervention were not passed to the nursing staff nor documented on the care plan. Resident #15 had an OT evaluation done 3/1/11. On 3/10/11, Resident #15 fell from the wheelchair. The new intervention was for a med (medication) review and an alarm for the geri-chair. However, a tab alert alarm was already ordered for the wheelchair. On 3/31/11, the resident fell from her wheelchair. The intervention was ""anti lock wheelchair brakes."" However, the anti lock brakes were ordered prior to the resident's fall. On 4/16/11 the resident fell twice, no incident report was located for the fall. A criss cross seat belt was ordered. On 4/24/11 the resident fell from the wheelchair, only one side of the criss cross belt was attached. The intervention was criss cross seat belt and OT for restraint reduction. On 8/3/11 Resident #15 fell from bed while trying to use the restroom. No new interventions were put in place. On 8/22/11 the resident fell out of bed and the bed alarm did not sound. The intervention was for the CNA to assure the alarm was in place. On 8/28/11 the resident fell out the wheelchair because the criss cross belt was alleged to have been removed by another resident. The intervention was to assure the resident was not alone. On 9/12/11 the resident's criss cross belt was discontinued and a self release belt was ordered. On 9/15 the resident fell from the wheelchair. The intervention was for OT to re-evaluate the resident. However the resident was already on OT's case load. On 9/20 the resident's criss cross seat belt was reordered for 24 hours. No other restraint was ordered and the criss cross belt was not renewed. As of the survey the resident continued to use the criss cross seat belt. Review of the Nurses Notes revealed on 11/1/11 the resident attempted to slide out from underneath the criss cross seat belt. During an interview on 12/12 at 5:30 PM, the Assistant Director of Nurses (ADON) confirmed the 12 falls. She also confirmed that the resident did not have a new intervention put in place after each fall. She confirmed that interventions put in place prior to the fall were not effective if the resident fell again. The ADON also confirmed that some of the interventions put in place per the incident reports did not get passed to the nursing staff or documented anywhere else. The facility admitted Resident #16 on 9/6/2005 with [DIAGNOSES REDACTED]. Observation of the resident on 12/12/11 at 10:45 AM revealed the resident sitting up in a wheelchair with a lap cushion secured to the wheelchair. The resident was unable to remove the lap cushion. Observation of the resident's room revealed the resident had a defined parameter mattress. Record review of the December 2011 Cumulative physician's orders [REDACTED]. The resident was also prescribed a raised edge mattress. Review of the Medication Administration Records from October, November and December revealed no indication that the resident was checked on every thirty minutes or that the restraint was released every two hours. Review of the Minimum (MDS) data set [DATE] revealed the resident was coded as having long term and short term memory problems and was severely disabled in daily decision making abilities. The resident was also coded as totally dependent for all activities of daily living. Review of the Care Plan revealed the resident's ""lap cushion"" was included as an ""enabler."" No interventions were included related to the resident's restraint. Review of the CNA (certified Nursing Assistant) care plan revealed the Lap-n-Loc was included on the care guide. An Incident Report dated 10/16/2011 at 7 PM stated: the ""Resident fell out of wheelchair while in redirect (small dining room on Unit II). Orientee (LPN #1) heard the fall, responded and came and notified this nurse (RN #5). Resident was on the floor on her left side, blood was dripping from her head. I gently applied pressure to area and assessed resident for other injuries...CNA remained c (with) resident until EMS arrived. MD was notified and ordered transfer to ER for eval. Family notified and met resident at ER. Review of the 5 Day report revealed the resident sustained [REDACTED]. Further review revealed CNA #3 was ""dismissed on 10/17 for not following care plan and applying lap n lock."" Also, ""incident could have been avoided if lap n lock cushion had been placed as ordered. Lap n lock was ordered on care plan and personal care sheet."" Review of the facility obtained statement from Registered Nurse (RN) #5 revealed: ""Resident was found on the floor in redirect. No lap n lock present on w/c. Forehead (L) was bleeding. I applied gentle pressure to area to assess extent of bleeding. Assessed for other injuries- none apparent. Assisted CNA and LPN to transfer resident via sling lift to her bed. Called MD-ordered to send to ER for eval. Called daughter- will meet at ER. Called EMS and ER for report. Resident remained conscious the entire time of finding to transport."" During a telephone interview on 12/12/11 at 11:35 AM, RN #5 stated that she was assigned to the resident on 10/16/2011 during the second shift. She stated that she was passing medications and did not witness the fall. She stated that the resident was in the redirect dining room. She stated that the resident was gotten up out of bed at approximately 4 PM. She stated that she saw the resident during the dinner meal, however she was pushed up to the table and was unable to tell if the lap n lock was in place. RN #5 stated that LPN #1 informed her the resident had fallen. When RN #5 arrived, no lap n lock was in place. She stated that the CNA was a new CNA and did not put the lap n lock on the resident. RN #5 stated that she usually would check to make sure the lap n lock was in place. She also stated that she knew she was supposed to supervise the CNAs but stated that she couldn't because she had ""other things to do."" RN #5 stated that CNAs have an extensive orientation and they were supposed to know what to do and she couldn't ""be on them."" Review of the facility obtained statement from LPN #1 revealed: ""I was in the redirect room giving medications. (Resident #16) was sitting in her wheelchair. I went down the hall to give out more medicines, I heard a thump and a resident say she fell . I went back into the redirect room and saw (Resident #16) laying on the floor with blood dripping from her head, I went to get help."" During an interview on 12/12 at 2:30 PM, LPN #1 stated that he was assigned to Resident #16 on 10/16 during the second shift. He stated that he was in orientation at the time of the incident. LPN #1 stated that he was passing medications. He left the redirect room and heard a thump. He stated that the resident did not have anything fastened to her wheelchair. LPN #1 stated that he was aware he was to supervise the CNAs and stated that the nurses should check to make sure the ordered devices were in place. Review of the facility's obtained statement from CNA #3 revealed: ""I was on break and (another CNA) called by over the intercom to ring my location. I walk out of the break room into redirect and (Resident #16) was in the floor and ( RN #5) was sitting with her with a towel against her heard. I helped with the lift and got her in bed and took her vitals and they were normal. I kept a close eye on her until the EMS got here to get her. CNA #3 was unavailable for interview. Review of the Exit Interview for CNA #3 revealed: ""On Sunday October 16, 2011 my resident had been put in her wheelchair by myself with the help of another aide. Both of us got side tracked in order to get other residents up on time for supper and forgot about her lap cushion. However, she was pushed up all the way to the table in the dining room. Around 7 or 7:30 PM, I was called to ring my location. Since I was on break in the break room, I kindly stepped out into the hall and followed the nurse to the dining room. When I got in there my resident had fallen out her wheelchair and hit her head on the floor. I got yelled at by the nurse who was in the floor with her and all the blame was on me! However, nobody was in there when it happened and a nurse in training said he had just walked through the dining room and as soon as he got back onto the hall at the cart, he heard a thump. He walked back through and found she was in the floor....I thought back on it, the only possible way she got away from the table would've been by the nurse to give her her meds and left her in the middle of the floor. My question is, why didn't anyone bring it to my attention before it happened?..."" Review of the Assignment Sheet for 10/16/2011 revealed CNA #3 was assigned to Resident #16. No Time Card was located for the resident for 10/16/2011. (Terminated employees are purged from the system and no logs are kept.) Review of the Resident Personal Care Sheet revealed the CNAs were to document the care given to the residents. Devices were not recorded on the sheets for initials. The nurses were to initial each shift under ""Nursing Accountability."" Review of Resident #16's Personal Care Sheet revealed 24 blanks on the Nursing Accountability space. However, on 10/16/2011 all shifts were initialed. During an interview on 12/12 at 12:35 PM, the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) stated that the CNAs documented on the Personal Care Sheets that the care had been performed to the residents. Both stated that the Nursing Accountability meant the nurses were initialing the CNAs documented and were initialing accountability for the care. Both stated that there was no documentation for devices or restraints. Alarms were documented every shift in a separate book. Both the DON and ADON stated that the nurses were responsible for supervising the CNAs, however, there was no documentation or evidence of the supervision. During an interview on 12/12 at 12 PM, the Medical Director stated that the nurses were ultimately responsible for the residents and were responsible for following up on the CNAs. He also stated that any device should be documented and nursing should check to make sure the devices were in place.",2015-05-01
9296,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,441,K,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled ""Procedure For Diabetic Monitoring"" , ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" and ""Hand Washing"" the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect 3 of 4 glucometers between each resident use were approved germicidal wipes. Concerns were identified with 39 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. The connector tip of Resident #8's Feeding tube was placed uncovered, on a soiled towel during treatment observation for 1 of 2 residents reviewed for feeding tube flushes. The findings included: On [DATE] at 3:37 PM, Registered Nurse (RN) #4, was asked to demonstrate the procedure for cleaning glucometers. The RN removed a glucometer from her Medication (Med) Cart, removed alcohol wipes from a caddy sitting on her cart and cleaned the meter with the alcohol wipes. At 4:42 PM on 12//,[DATE], Licensed Practical Nurse (LPN) # 3 was asked how she cleaned her glucometer. LPN #3 stated she did not know anything about cleaning the glucometer. In an interview with RN #4, she stated that she had not been inserviced on cleaning glucometers and that she vaguely remembered something about wipes but always cleaned with alcohol wipes. LPN #1 was asked how he cleaned his glucometer, he stated that he cleaned with alcohol wipes. He stated he had worked at the facility for 2 months and always cleaned with alcohol wipes. During an interview on [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) #1 was asked to demonstrate how to clean a glucometer. He stated that once the blood sugar reading was done, he would throw the test strip and lancet into the sharps container. He then demonstrated cleaning the glucometer by using gloved hands and an alcohol pad to wipe the glucometer all over. When asked, he stated he had been using an alcohol pad to clean the glucometer ever since he had started working at the facility a couple of months ago. During an interview on [DATE] at 5:28 PM, LPN #1 was asked if he had ever received training from the facility on using a disinfectant wipe instead of alcohol to clean the glucometer. He stated ""If they told me to use disinfectant wipes I don't remember. He stated he had recently put Gluco-Chlor wipes onto the cart and showed the surveyor the wipes which were in date. He stated there had been a few of the wipes in the drawer, but he had never seen them so he didn't know to use them. During an interview on [DATE] at 4:22 PM, Registered Nurse (RN) #1 was asked if she had received any training on using the disinfectant wipes to clean the glucometer. She stated during her orientation to the facility a couple years ago she was told to use Clorox wipes to clean the glucometer. She stated that approximately ,[DATE] weeks ago she was told to use the Gluco-Chlor wipes. She stated she read the package to find out how to use the Gluco-Chlor wipes. On [DATE] at 4:42 PM, during observation of Med pass, LPN #3 gathered supplies for a Finger Stick Blood Sugar (FSBS) to be drawn. The LPN did not clean the meter in the presence of the surveyor prior to entering the room. After checking the resident's FSBS, the nurse returned to her med. cart, drew up the ordered dose of insulin correctly and returned to administer the medication. LPN #3 then returned to the med. cart, again entered the room to do a FSBS on the resident's roommate in the same room. She did not clean the glucometer prior to re-entering the room. After washing her hands and donning gloves, she cleaned the second resident's finger with a alcohol wipe, stuck the resident and placed a strip in the glucometer. At that point the surveyor stopped the LPN and asked her to return to the cart. The surveyor then informed the nurse that she could not let her complete the FSBS due to the nurse not cleaning the glucometer after using it on the previous resident. LPN #3 stated that she had been working at the facility since August and had not been told to clean the glucometer. The nurse then took a Gluco Chlor wipe from her caddy and cleaned the glucometer and stated, ""it takes a long time for this to dry."" In an interview with the Registered Pharmacist on [DATE] at 4:30 PM, she stated that the pharmacy did not in-service on specific wipes to clean the glucometers but that during medication pass check off they did informed the nurses to clean the glucometers. Review of a (purchase) Order Acknowledgement revealed that on [DATE], 5 boxes of Gluco Chlor (containing 100 wipes per box per box) had been ordered by the facility. The purchase had been approved by the Administrator on [DATE]. No information as to when the product arrived at the facility was provided prior to the survey team exiting the facility. Review of the facility's ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" (not dated) on [DATE] provided by the Director of Nursing stated ""...20. Cleanse meter after each resident use..."" An updated ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" also provided by the DON on [DATE] stated ""...Cleanse meter with Gluco chlor swabs after each resident use..."" On [DATE] at 1:55 PM, both the Director of Nursing (DON) and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly or not cleaning them between residents until they were informed by the surveyor. When asked who monitored the nurses to ensure that the glucometers were cleansed properly with the appropriate cleanser, the DON stated that Nursing Administration should have been monitoring. The DON was asked if any of the residents in the facility had any known blood borne diseases such as Hepatitis or HIV (Human Immunodeficiency Virus). She provided a note stating that ""No residents in the facility as of ,[DATE] have known HIV or Hepatitis or any other blood borne pathogen"". During an interview on [DATE] at 2:35 PM, The Medical Director stated that he agreed that the nurses should be using an approved germicidal wipe for cleaning glucometers. Review on [DATE] of [DATE] Medication Administration Records revealed 39 residents had received FSBS monitoring in the month of December. These 39 residents had FSBS done from 1 time daily in the month to up to 4 times daily. Review of the facility Infection Control Logs from [DATE] to the present along with the Monthly Nosocomial Infection Report for 2011 revealed no incidents of residents with blood borne infections. Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident FSBS. This systemic practice placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of ""K"". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that glucometers used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. There were 39 residents residing in the facility who received blood glucose testing with the use of the glucometer in [DATE]. The systemic failure of the facility to effectively clean the glucometers placed the residents at risk for serious harm. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of ""E"". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. . On [DATE] form 8:05 AM to 8:40 AM, RN #3 was observed administering medications to 2 resident's. The RN failed to wash/sanitize her hands at any time during the observation. A hand sanitizer dispenser was noted to be on the wall in the hallway where the nurse had placed her medication cart while giving the resident's their medications. On 12//,[DATE] at 11:00 AM, in an interview with RN #3, she verified that she did not wash her hands the prior day when administering medications while the surveyor observed. The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Observation of a tube flush on [DATE] at 3:20 PM revealed RN #1 unhooked the tube feeding from the Gastrostomy tube to perform the flush. After she unhooked the feeding tube, she placed the tubing onto the resident's abdomen with the tip of the feeding connector touching the towel draped around the gastrostomy tube. The tubing remained there until she was finished with the procedure. When finished, the nurse did not remove the towel from around the gastrostomy tube. During an interview on [DATE] at 5:02 PM, she verified she had placed the tip of the feeding connector onto the towel. She stated she usually kept the tip between her fingers. After reviewing the record, it was noted that the resident was to be seen on consult because her gastrostomy tube was leaking. Later on when asked, RN #1 verified the towel that was around the gastrostomy tube was there because the tube had been leaking.",2015-05-01
9297,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,490,K,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled ""Procedure For Diabetic Monitoring"" , ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" and ""Hand Washing"" the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers. The findings included: During the days of the survey, it was identified based on observation and interview that facility licensed staff were failing to clean multi use resident glucometers. Interviews revealed that either staff was either not aware of the need to clean the glucometers and or not aware of the proper procedure. There were 39 residents residing in the facility who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE] who had the potential to be affected. Review of a (purchase) Order Acknowledgement revealed that on [DATE], 5 boxes of Gluco Chlor (containing 100 wipes per box per box) had been ordered by the facility. The purchase had been approved by the Administrator on [DATE]. No information as to when the product arrived at the facility was provided prior to the survey team exiting the facility. Review of the facility's ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" (not dated) on [DATE] provided by the Director of Nursing stated ""...20. Cleanse meter after each resident use..."" An updated ""Hyper/[DIAGNOSES REDACTED],SSI,Glucometer Skills Check List"" also provided by the DON on [DATE] stated ""...Cleanse meter with Gluco chlor swabs after each resident use..."" On [DATE] at 1:55 PM, both the Director of Nursing (DON) and the Nursing Home Administrator stated that they were not aware that the nurses were not cleaning the glucometers correctly or not cleaning them between residents until they were informed by the surveyor. When asked who monitored the nurses to ensure that the glucometers were cleansed properly with the appropriate cleanser, the DON stated that Nursing Administration should have been monitoring. During an interview on [DATE] at 2:35 PM, The Medical Director stated that he agreed that the nurses should be using an approved germicidal wipe for cleaning glucometers. Immediate Jeopardy was determined to exist on [DATE] at 5:45 PM after staff were identified as not using an approved germicidal wipe and/or not cleansing the glucometer between resident FSBS. This systemic practice placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. An Allegation of Compliance was submitted by the facility on [DATE]. During interviews on [DATE] at approximately 2:30 PM, 4 nurses on Unit 1 verbalized and/or demonstrated the proper way to clean a glucometer using appropriate disinfectant wipes and checking the expiration date prior to use. Interviews of 12 licensed nurses on [DATE] at approximately 4:30 PM revealed nursing staff were knowledgeable on using the germicidal wipes and checking for expiration before using them to clean glucometers. Review of staff education on the policy of FSBS and checking expiration dates revealed nursing staff had either been called and informed of the new policy on FSBS and checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for three had been contacted; and a message had been left for the nurses that she would not be allowed to work until she had received information relative to the new policy on FSBS and checking supplies for expiration dates prior to use. Observations, interviews, and review of policy education and signature sheets on [DATE] revealed the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the new policy requiring staff to use and check germicidal wipes prior to disinfecting glucometers to ensure they had not expired. The Administrator was informed of this on [DATE] at 3:45 PM. The citations at F-281, F-441, and F-490 remained at a lower scope and severity of ""E"". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction. .",2015-05-01
9298,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,502,E,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide lab services as ordered for 3 of 14 residents reviewed for lab services. (Resident #8, Resident #11, and Resident #12) The facility failed to remove multiple expired lab tubes from supplies currently available for use on the lab cart. The findings included: The facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a ""Nursing Home Readmit History and Physical"" dated [DATE], which stated that Resident #8 had been ""admitted from the nursing home with reported acute gastrointestinal (GI) bleed. She had blood in her stool. Apparently, she remained stable...They recommended to monitor her hemoglobin every other day. The patient has a history of GI bleeding and other causes includes [DIAGNOSES REDACTED]..."". Under ""Plans"" was written ""We will get an H&H (Hemoglobin and Hematocrit) every other day as recommended by Dr. --- at least for 2 weeks, and then decide..."". Review of Readmission Physician order [REDACTED]. Review of lab reports in the chart revealed a Hemoglobin was drawn on [DATE], an H&H was drawn on [DATE], [DATE], [DATE], and [DATE]. The labs were not drawn every other day as ordered, and the last one should have been obtained on [DATE]. During an interview on [DATE] at 12:45 PM, RN #2 and LPN #2 verified the lab orders and the lab reports found in the chart. LPN #2 stated she would try to locate the missing labs, but later stated she was unable to find any additional information. The facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 3:15 PM revealed [DATE] cumulative orders which included lab orders for ""A1C every 3 months, Electrolytes every 2 months..."". Continued review on [DATE] revealed all cumulative physician's orders [REDACTED]. Review of lab reports in the chart revealed a Hemoglobin A1C had been drawn [DATE] and [DATE]. There were no Hemoglobin A1C results noted for April or [DATE] as ordered. Continued review of lab reports in the chart revealed electrolytes had been drawn in May, August, and November of 2011, every 3 months instead of every 2 months. During an interview on [DATE] at approximately 11:00 AM, Licensed Practical Nurse (LPN) #2 verified the above findings. She stated that according to their lab book, the A1C was due every 6 months. She also stated that the Electrolytes were scheduled to be done on the third month, skipping 2 months and doing the lab on the third. The facility admitted Resident #12 on on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a Physician's Telephone Order dated [DATE] which stated ""Hepatic function panel and CBC on [DATE]"". Continued review revealed a Pharmacy recommendation to the physician dated [DATE] which stated ""(Resident) receives [MEDICATION NAME] Sodium and does not have a hepatic function panel or complete blood count (CBC) evaluation documented in the resident record within the previous 6 months. Please consider monitoring a complete blood count (CBC) and hepatic function panel on the next convenient lab day and every six months thereafter..Rationale for Recommendation- The manufacturer's prescribing information includes a BOXED warning describing the potential increased risk for serious hepatotoxicity and/or pancreatitis associated with this medication's use"". The Physician accepted the recommendation and signed the bottom of the report on [DATE]. Review of lab reports in the chart on [DATE] revealed there were no CBC or Hepatic Function Panel results for [DATE]. LPN #2 verified the Physician order [REDACTED]. She stated the lab request had been placed in the lab book to be done, but she did not know why the lab service personnel did not get the lab. When asked, she stated there was no documentation that the resident had refused and the resident was not able to tell. According to LPN #2, the labs had been rescheduled to be drawn [DATE]. Review of the Unit 2 Lab book on [DATE] at 9:26 AM revealed an entry dated [DATE] which documented Resident #12 was to have a CBC and Hepatic Function Panel drawn on [DATE]. However, the boxes for ""Specimen Obtained"" and ""Report at (facility)"" was blank. Continued review of the Lab book revealed another entry for Resident #12 which indicated a ""CBC"" and ""Hepatic"" was to be drawn [DATE]. There was no indication the labs had been drawn [DATE]. Out to the side was handwritten ""Do ,[DATE]"". During an interview on [DATE] at 9:53 AM, Registered Nurse (RN) #2 stated that the lab comes in twice a week on Tuesdays and Thursdays to draw labs. She stated they draw the labs ordered in the lab book. If a lab is ordered on a day the lab doesn't come, then the nurses would have to draw the lab. She stated that the ADON and LPN #2 were responsible to make sure the labs are drawn. On [DATE] at 9:50 AM, during a random observation of the facility's laboratory cart, there were 162- 0.6 milliliter red top lab tubes which had expired on ,[DATE]. The expiration date was verified at that time by Registered Nurse #1. In an interview with the Director of Nursing, she stated that the facility did not have a policy/procedure related to monitoring laboratory supplies.",2015-05-01
9299,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,363,D,0,1,8N3011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review, the facility failed to provide Resident #11 with fortified foods at meals and Resident #20 with a puree vegetable. (2 of 12 residents reviewed for nutritional needs) The findings included: Resident #20 was admitted on [DATE] with the [DIAGNOSES REDACTED]. It was observed on 12/13/11 at 11:45 AM, during trayline observation, that Resident #20 did not receive a pureed vegetable with her meal. He tray consisted of pureed hamburger, pureed potatoes, and pureed cobbler. The vegetable for the day was pureed tomatoes. There were no other pureed vegetables available on the trayline. On 12/13/11 at 2:00 PM, review of the resident's tray card documented the residents meal was Pureed, No Added Salt, No Seeds or Nuts. The residents dislikes were milk, tea, broccoli, tossed salad, and grits. On 12/13/11 at 2:30 PM, review of the physician orders [REDACTED]. The resident's care plan dated 11/23/11 stated ""Resident at nutritional risk related to end-stage dementia AEB (as evidenced by) requires puree diet, non-significant weight loss in past year"". Approaches for care plan included providing substitutes. On 12/14/11 at 10:15 AM, an interview was conducted with the CDM (Certified Dietary Manager) who stated that she did not know why the resident was not provided with a vegetable at the meal. The facility admitted Resident #11 on 6/9/00 with [DIAGNOSES REDACTED]. Review of the Care Plan on 12/12/11 at 2:42 PM revealed an entry dated 10/13/11 which stated ""Res(ident) at nutrition risk RT (Related To) dementia, low intake, wound, AEB (As evidenced by) 13.6 % wt (weight) loss in 6 months, new wound"". The Approaches listed included ""...Diet: LGD (Liberalized Geriatric Diet), NCS (No Concentrated Sweets), pureed. Fortified Foods Program...Give Medpass and Prostat as ordered for wound healing and weight loss prevention. Nutrition Alert Team monitoring..."". Record review on 12/12/11 at approximately 3:15 PM revealed cumulative physician's orders [REDACTED]. Observation on 12/12/11 at 5:20 PM revealed Resident #11 being fed a pureed dinner of pork, bread, beets, blackeyed peas, oranges, tea, water, and cranberry juice. Throughout the meal there was no soup observed on her tray and there was no observation of soup being offered the resident. Review of her dinner tray card revealed a notation on the bottom to ""add bowl of soup"". There was no notation on her tray card of the resident receiving fortified foods. Record review on 12/13/11 at 10:12 AM revealed a ""Quarterly Nutrition Review"" dated 10/11/11 which documented Resident #11's diet/supplement/nourishment order was ""Pureed, NCS, Fortified Foods Program, MedPass, Prostat"". Observation on 12/13/11 at 12:55 PM revealed Resident #11 was served a pureed diet. However, there was no soup observed on her tray. During an interview on 12/13/11 at approximately 4:45 PM, the Certified Dietary Manager was advised that soup had not been observed on the Resident #11's tray for supper the day before and lunch that day. She stated the resident should have received the soup since it was noted on the bottom of her tray ticket. When asked about the Fortified Food Program and what it entailed, she stated that some residents with weight loss would be on this program and that Dietary staff fortified foods by adding margarine or brown sugar and butter to foods. When asked how the dietary staff knew which residents had fortified foods, she stated this information would be documented on the tray card. When told that Resident #11's tray card did not include this information, she pulled up an application on her computer which detailed the information on Resident #11's tray card. After reviewing this information, she stated that according to her records, there was no indication Resident #11 was to receive fortified foods. She pulled the most recent information she had from a binder and revealed a Physician's Telephone Order dated 11/2/11 which stated ""Diet (change) to puree, NCS and thin liquids"" which was written by the Speech Therapist. She stated this was the most current information she had related to the resident's diet. The surveyor attempted to show her the December cumulative physician's orders [REDACTED]. The Registered Dietician who joined the interview was asked if Resident #11 was supposed to be on fortified foods. After reviewing the resident's Nutrition Care Progress Notes (9/29/11- 12/8/11), she stated that the resident was currently monitored by the Nutrition Alert Team due to weight loss and should be receiving fortified foods.",2015-05-01
9300,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,492,D,0,1,8N3011,"On the days of the survey, based on review of personnel files and interview, the facility failed to perform a background check timely for 1 of 5 newly hired employees. The findings included: Review on 12/14/11 of the facility New Hire Report Form revealed Licensed Practical Nurse (LPN) #1 had an ""Adjusted Hire Date"" of 10/5/11. Review of his personnel record revealed information that his ""DOH"" (Date of Hire) was listed as 10/5/11. Review of the Criminal Background Check for LPN #1 revealed a copy of the report had been printed on 10/6/11. Review of the Time Detail report for October 2011 revealed LPN #1 had punched in for work on 10/5/11 for 7.5 hours. During an interview on 12/14/11 at 11:55 AM, the Human Resource Manager verified the above findings. She stated that the date of hire was not accurate, but did not provide any additional information related to this. She was asked to provide any documentation that the Criminal Background Check for LPN #1 had been reviewed prior to 10/6/11 but was unable to provide any before exit.",2015-05-01
9301,ELLEN SAGAR NURSING HOME,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2011-12-14,371,F,0,1,8N3011,"On the days of the survey, based on observation, interview, and review of the facility policies entitled ""Uniform Dress Code"" revised on 1/02 and ""Hand Hygiene"" revised on 11/09, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The findings included: On 12/13/11 at 11:00 AM, observation of the trayline was conducted. Dietary Aid #1 was observed serving food with the front of her hair not covered by a hairnet. Dietary Aid #1 was observed placing hamburger buns on top of sliced cheese and placing them on top of a serving tray containing desserts. Ten serving trays had metal exposed on the rims and were observed being used for residents. Three staff members were observed entering the kitchen next to the trayline to get employee meals. The staff was not observed to wash their hands after entering and did not wear hairnets. One staff member, who was not wearing a hairnet and had not washed their hands, was observed to walk to the trayline to get silverware. On 12/13/11 at 11:45 AM, a staff member entered the kitchen with a residents tray that had already been delivered to the unit and stated it needed to ""go in the hot box."" The tray was brought into the kitchen a placed on a cooler and then placed in the hot box. Dietary Aid #2 was observed entering the kitchen and going straight to the dish machine without sanitizing his hands. He touched the robo coupe and used the sprayer to rinse it. He was observed pulling up his pants and then went directly to the clean dishes and began removing clean plates and placing them on top of other clean plates. He did not sanitize his hands at any time during this process. On 12/14/11 at 9:55 AM, a tour of the kitchen was conducted with the CDM (Certified Dietary Manager). A pink substance was observed on the guard of the ice machine along the bottom rim. A prep table being used to prep food was observed with three holes on the top that had been partially filled in and could not be sanitized properly because food was observed around the holes. The bin of flour had a black trash bag in it with holes observed on the inside of the bin. On 12/14/11 at 9:50 AM, a review of the facility policy entitled ""Uniform Dress Code"" revised on 1/02 was conducted. It stated that employees should ""wear the approved hair restraint when on duty"". On 12/14/11 at 9:50 AM, a review of the facility policy entitled ""Hand Hygiene"" revised on 11/09 was conducted. It stated that all employees should wash hands ""before handling food or clean/dishes/equipment; after touching hair, skin, beard or clothing; after any other activity that may contaminate the hands"". On 12/14/11 at 10:15 AM, an interview was conducted with the CDM. She stated that when resident trays go out to the units they usually do not place them back in the hot box once they leave the kitchen. All findings were shared and not disputed.",2015-05-01
9302,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,157,D,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview, the facility failed to ensure 1 of 6 sampled residents' responsible party or interested family member was notified when there was an accident/incident or when there was a change in treatment. Resident #1's responsible party was not notified of a medication error until 3 days after the error. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Medication Error Investigation Worksheet dated 1/17/2012 revealed on 1/15/2012 at 8 PM, Resident #1 reported that ""the new nurse (RN #1) that worked at night this weekend, gave her a shot last night in her left arm, last night would have been 1/15/2012. Resident said she asked her what the shot was for and she said for her blood sugar. Resident said she told nurse she doesn't get a shot for her blood sugar and the nurse said 'You do tonight.'"" The Findings/Analysis were: ""...the Director of Nurses(DON) called the nurse (RN #1) and she didn't remember giving resident this shot but knew the resident across the hall was suppose to get an insulin injection. (Resident #1) described the nurse as the new white nurse that has worked a couple of weekends at night. Resident may have received 12 units of Insulin this one time. Resident tolerated it well s (without) adverse effects noted."" The Follow up Steps Taken were: ""Reviewed with (RN #1) to always check for the right med, right dose, right patient, right time, right site. If an alert and oriented resident tells you they don't usually receive a particular med to recheck all of the steps again."" At the conclusion of the investigation the ""resident's health condition"" at 8 PM on 1/16/2012 was: ""FSBS (finger stick blood sugar) 132."" Further review of the Worksheet revealed the resident's physician was notified at 2:30 PM on 1/16/2012. The resident's responsible party was not notified of the medication error until 1/18/2012 at 11:45 AM. During an interview on 1/31/2012 at 1:15 PM, RN #1 stated that she misidentified Resident #1 and gave the resident Insulin. She stated that the resident did not have a bracelet on at the time. RN #1 stated that she administered the Insulin at approximately 9 PM on 1/15/2012. During an interview on 1/31/2012, the DON confirmed that Resident #1's Responsible Party was not notified of the medication error until 1/18/2012 at 11:45 AM.",2015-05-01
9303,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,224,D,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure two of six sampled residents received the necessary goods and services to avoid physical harm. Registered Nurse (RN) #1 administered 12 units of insulin to Resident #1 in error on 1/15/2012. Resident #5 had a history of [REDACTED]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 10/15 (out of a possible 15) on her BIMS (brief interview for mental status) assessment. Observation of the Resident on 1/31/2012 at 6 AM, revealed the resident sitting up in her wheelchair. The resident was alert and answered questions appropriately. Resident #1 was noted to have an aphasic speech pattern and was noted to struggle completing sentences, however, given time the resident was able to complete her thoughts and sentences. Review of Resident #1's Physician order [REDACTED]. No insulin was prescribed for the resident. Review of the Medication Administration Record [REDACTED]. The next recorded blood sugar was 1/18/2012 at 6 AM. Review of the Nurse's Notes revealed no entries were made related to the resident's blood sugars or the administration of Insulin. Review of the Medication Error Investigation Worksheet dated 1/17/2012 revealed on 1/15/2012 at 8 PM, Resident #1 reported that ""the new nurse (RN #1) that worked at night this weekend, gave her a shot last night in her left arm, last night would have been 1/15/2012. Resident said she asked her what the shot was for and she said for her blood sugar. Resident said she told nurse she doesn't get a shot for her blood sugar and the nurse said, 'You do tonight.'"" The Findings/Analysis were: ""...(the Director of Nurses, DON) called the nurse (RN #1) and she didn't remember giving resident this shot but knew the resident across the hall was suppose to get an insulin injection. (Resident #1) described the nurse as the new white nurse that has worked a couple of weekends at night. Resident may have received 12 units of Insulin this one time. Resident tolerated it well s (without) adverse effects noted."" The Follow up Steps Taken were: ""Reviewed with (RN #1) to always check for the right med, right dose, right patient, right time, right site. If an alert and oriented resident tells you they don't usually receive a particular med to recheck all of the steps again."" At the conclusion of the investigation the ""resident's health condition"" at 8 PM on 1/16/2012 was: ""FSBS 132."" Further review of the Worksheet revealed the resident's physician was notified at 2:30 PM on 1/16/2012. The resident's responsible party was not notified of the medication error until 1/18/2012 at 11:45 AM. No further investigation was conducted and the incident was not reported to the State Survey and Certification Agency. Review of RN #1's personnel file revealed RN #1 was hired on 12/27/2011. Her license was checked on 12/22/2011 and was noted to have the ""prior terms of order complete-in good standing."" Review of the terms of the order dated 3/22/2010 revealed she had approximately nine documentation and medication administration errors, for which she was disciplined. Review of an Affidavit dated 12/16/2011 revealed RN #1 successfully complied with the terms placed upon her and her license was reinstated. Review of RN #1's time card revealed that beginning 1/4/2012 she routinely worked evening and night shifts on Fridays, Saturdays and Sundays. RN #1 clocked in on 1/15/2012 at 6:45 PM and clocked out on 1/16/2012 at 7:22 AM. RN #1 was noted to work the weekend of 1/20/12-1/22/12 and 1/27/12-1/29/12. During an interview on 1/31/2012 at 1:15 PM, RN #1 stated that she worked the night shift of 1/15/2012 and stated that she was working the unit by herself. She confirmed again that no other nurse was with her on the unit. RN #1 also stated that she has continued to work weekend nights by herself. RN #1 stated that she misidentified Resident #1 and gave the resident Insulin. She stated that the resident did not have a bracelet on at the time. RN #1 stated that she administered the Insulin at approximately 9 PM on 1/15/2012. RN #1 stated that the resident did ask her about the injection but she had already administered the Insulin before the resident finished her statement. RN #1 also stated that she did not check Resident #1's blood sugar during the night. RN #1 stated that she realized her error ""the next day"" and stated that it was an ""honest mistake."" RN #1 stated that the DON called her and provided an ""in-service"" via the telephone regarding the five rights of medication administration. RN #1 confirmed that her license was suspended previously for medication errors. During an interview on 1/31/2012, the Director of Nurses (DON) confirmed RN #1 made the medication error on 1/15/2012. She also stated that she was ""not aware"" of RN #1's previous medication errors resulting in suspension until after the incident on 1/15/2012. The DON stated that since RN #1's license was reinstated and there were no restrictions on her license. The DON stated that RN #1 was in orientation, and stated that another nurse was on the unit with RN #1 during her shift. The DON was informed of RN #1's statement that no other nurse was with her on the unit. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #5 had four falls from 12/2/2011-12/15/2011. On 12/16/2011 at 2:30 PM, ""resident placed on toilet per staff. Resident attempted to get off toilet s (without) assist. States I was going to bed. Found face down in front of toilet..."" Review of the Resident's Fall Assessment revealed he was assessed as High Risks for falls. He was also noted to remove his alarms and stand unassisted. Review of the Minimum Data Set revealed the resident scored a 6/15 on the BIMS assessment and was noted to require two person extensive assist with transfers. During an interview on 1/31/2012, the Director of Nurses (DON) was asked when it was not acceptable for staff to leave a resident unattended on the toilet. The DON stated that a disoriented resident should not be left alone or a resident with a history of falls should not be left unattended on the toilet. The DON confirmed that Resident #5 had a history of [REDACTED]. The DON also confirmed that the resident should not have been left unattended.",2015-05-01
9304,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,225,E,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview the facility failed to thoroughly investigate a fracture; failed to identify, investigate and report an incidence of neglect and a medication error. Registered Nurse #1 administered Insulin in error to Resident #1. Resident #5 was left unattended on the toilet resulting in a fall, the incident was not investigated or reported as neglect. Resident #2's fracture of unknown origin was not thoroughly investigated. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Medication Error Investigation Worksheet dated 1/17/2012 revealed on 1/15/2012 at 8 PM, Resident #1 reported that ""the new nurse (RN #1) that worked at night this weekend, gave her a shot last night in her left arm, last night would have been 1/15/2012. Resident said she asked her what the shot was for and she said for her blood sugar. Resident said she told nurse she doesn't get a shot for her blood sugar and the nurse said, ""You do tonight."""" The Findings/Analysis were: ""...(the Director of Nurses (DON) called the nurse (RN #1) and she didn't remember giving resident this shot but knew the resident across the hall was suppose to get an insulin injection. (Resident #1) described the nurse as the new white nurse that has worked a couple of weekends at night. Resident may have received 12 units of Insulin this one time. Resident tolerated it well s (without) adverse effects noted."" The Follow up Steps Taken were: ""Reviewed with (RN #1) to always check for the right med, right dose, right patient, right time, right site. If an alert and oriented resident tells you they don't usually receive a particular med to recheck all of the steps again."" At the conclusion of the investigation the ""resident's health condition"" at 8 PM on 1/16/2012 was: ""FSBS 132."" Further review of the Worksheet revealed the resident's physician was notified at 2:30 PM on 1/16/2012. The resident's responsible party was not notified of the medication error until 1/18/2012 at 11:45 AM. No further investigation was conducted and the incident was not reported to the State Survey and Certification Agency. Review of RN #1's personnel file revealed RN #1 was hired on 12/27/2011. Her license was checked on 12/22/2011 and was noted to have the ""prior terms of order complete-in good standing."" Review of the terms of the order dated 3/22/2010 revealed she had approximately nine documentation and medication administration errors, for which she was disciplined. Review of an Affidavit dated 12/16/2011 revealed RN #1 successfully complied with the terms placed upon her and her license was reinstated. During an interview on 1/31/2012 at 1:15 PM, RN #1 stated that she worked the night shift of 1/15/2012 and stated that she was working the unit by herself. RN #1 stated that she misidentified Resident #1 and gave the resident Insulin. She stated that the resident did not have a bracelet on at the time. RN #1 stated that she administered the Insulin at approximately 9 PM on 1/15/2012. RN #1 stated that the resident did ask her about the injection but she had already administered the Insulin before the resident finished her statement. RN #1 also stated that she did not check Resident #1's blood sugar during the night. RN #1 stated that she realized her error ""the next day"" and stated that it was an ""honest mistake."" RN #1 stated that the DON called her and provided an ""in-service"" via the telephone regarding the five rights of medication administration. RN #1 confirmed that her license was suspended previously for medication errors. During an interview on 1/31/2012, the DON confirmed RN #1 made the medication error on 1/15/2012. She also stated that she was ""not aware"" of RN #1's previous medication errors resulting in suspension until after the incident on 1/15/2012. The DON confirmed that RN #1 was hired at the facility from November 2010 through April 2011. She stated that RN #1 was in orientation and did not provide care to residents. The DON stated that RN #1's license was reinstated and there were no restrictions on her license. The DON stated that RN #1 was in orientation, and stated that another nurse was on the unit with RN #1 during her shift. The DON was informed of RN #1's statement. The DON also confirmed the incident was not further investigated and the incident was not reported to the State Survey and Certification Agency. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #5 had four falls from 12/2/2011-12/15/2011. On 12/16/2011 at 2:30 PM, ""resident placed on toilet per staff. Resident attempted to get off toilet s (without) assist. States I was going to bed. Found face down in front of toilet..."" Review of the Falls Care Plan dated 11/23/2011 indicated the following falls and interventions: ""12-2-11 Fall - no injury; intervention ""Use call light"" 12-9-11 Fall - no injury; intervention ""Canary Alarm"" 12-11-11 Fall - no injury; intervention ""Assist with toileting - Bed Alarm"" 12-15-11 Fall - no injury; intervention ""Re-educated to use call light"" 12-16-11 Fall - no injury; intervention ""Staff to stay with resident while on commode..."" During an interview on 1/31/2012, the Director of Nurses (DON) was asked when it was not acceptable for staff to leave a resident unattended on the toilet. The DON stated that a disoriented resident should not be left alone or a resident with a history of falls should not be left unattended on the toilet. The DON confirmed that Resident #5 had a history of [REDACTED]. The DON also confirmed that the resident should not have been left unattended. The incident had not been investigated and had not been reported to the State Survey and Certification Agency. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 7/15 (7 out of a possible 15) on her BIMS assessment. The resident was also coded as requiring two person total dependence for transfers. Review of the Nurse's Notes revealed on 1/2/2012 at 7 PM, ""Res(ident) seen by NP (nurse practitioner) c new order for d/c (discontinue) [MEDICATION NAME], when Narco becomes available. Also order for [MEDICATION NAME] cream to right knee- all these orders r/t right leg pain."" On 1/3 at 10:45 AM, ""Res c/o (complained) R (right) knee and R leg pain. R knee warm to touch and redness noted to her R leg. The resident stated a girl was putting her in the bed and dropped her yesterday. Will cont to monitor."" At 11:25 AM, ""NO (nurses order) X-Ray to R thigh and R knee r/t pain, warmth and redness."" At 4 PM, Res has order for [MEDICATION NAME] inj (injection) and knee immobilizer for R leg r/t fx (fracture) of R knee and F femur as described by x-ray today..."" On 1/4 at 2:15 PM, ""Res LOA (leave of absence) to hospital per family request."" Review of the Care Plan dated 7/1/2011 revealed a problem area related to falls. The care plan was updated on 1/2/2012 for ""Resident had c/o rt knee and rt leg pain-interventions included, new pain medication ordered. Review of the Progress Note dated 1/3/2012 revealed, ""The patient has had less than a day's worth of right knee pain. Pain is constant and she is unable to scale it on a verbal analogue scale. The patient reported that someone dropped her... Nursing is unaware of any fall or other incident. She does have some contracture to the right knee... X-Ray shows non displaced impacted distal femur fracture...We will place her on [MEDICATION NAME] 20 mg every 12 hours and [MEDICATION NAME] 10 mg as needed. Immobilize the knee and initiate [MEDICAL CONDITION] with [MEDICATION NAME] will monitor her for further symptoms and plan on re x-ray later. This should heal without surgical intervention. Orthopedic consult can be obtained if we later determine it is necessary."" Review of the Medication Administration Record [REDACTED]. That order was discontinued on 1/3/2012 after the 6 AM dose. The resident was also assessed for pain three times daily. No pain was recorded for the resident for the month of January. Further review revealed the resident received 1 dose of the [MEDICATION NAME] at 10 PM on 1/3 and received one dose of Narco 10/325 at 8:30 PM. The resident received one dose of [MEDICATION NAME] on 1/4 at 8 AM. On 1/5 the resident received 2 doses of Narco at 7:10 AM and 2:20 PM and received her scheduled [MEDICATION NAME] at 8 AM and 8 PM. Review of the facility obtained statement from Certified Nursing Assistant #2 dated 1/3/12 revealed: ""I asked (CNA #2) if she had assisted in the transfer of (Resident #2) on the previous night 1/2/2012-11-7 shift. (CNA #2) stated no that she was assigned to the other hall and had never gone into (Resident #2's) room that night."" The statement had not been signed by the CNA. During an interview on 1/31/2012 at 6:45 PM, Certified Nursing Assistant (CNA) #2 stated that she was working on the same unit as CNA #1 on the night shift of 1/2/2012. CNA #2 stated that CNA #1 did not ask for assistance with any transfers that night. She stated that she was not aware of any resident falling or injuring herself. Review of the facility obtained statement from Licensed Practical Nurse (LPN) #1 dated 1/3/2012 revealed: ""(LPN #1) worked Station 4 11-7 1/1/2012. I asked her if anything unusual had happened or had she received any complaints from (Resident #2). She stated no. I then told her that (Resident #2) had been dropped by the CNA and had fractured knee and hip. (LPN #2) stated that she was unaware of any incident."" During an interview on 1/31/12 at 7 AM, Licensed Practical Nurse #1 stated that she was assigned to the resident on the night of 1/2/12. She stated that the resident was in bed all shift. She stated that the resident did not complain of any pain. LPN #1 also stated that the Certified Nursing Assistants (CNAs) did not report any fall or anything abnormal. During an interview on 1/31/2012 at 9:10 AM, CNA #3 stated that she was assigned to the resident on 1/3/2012 from 7-3. She stated that the resident was still in the bed when she arrived on shift. CNA #3 stated that the resident complained of pain that morning. She stated that she and CNA #1 tried to get the resident up and the resident was ""screaming in pain."" CNA #3 stated that she did not ""remember reporting"" the pain to anyone that morning. CNA #3 stated that she could not remember if she got the resident up or not. No statement had been obtained by the facility from CNA #3. Review of the facility obtained statement dated 1/3/2012 from Restorative Aide #1 revealed: ""(Resident #2) is in the restorative feeding program. (RA #1) stated that on Monday (Resident #2) had no complaints. On Tuesday 1/3/2012 while in the dining room, (Resident #2) needed to be repositioned in her wheelchair. When the CNA attempted to reposition her, she stated that her knee was hurting her. (RA #1) immediately notified (RN #2)."" During an interview on 1/31/2012 at 12:10 PM, Restorative Aide (RA) #1 stated that the resident was up in her wheelchair when she was brought to the dining room for breakfast around 7:15 AM. RA #1 stated that the resident complained to her right leg. She stated that the resident didn't eat because she was in so much pain. RA #1 stated that after breakfast she took the resident back to her room and the resident was still complaining of pain to the right leg. RA #1 stated that at that point she notified the nurse of the pain. During an interview on 1/31/2012 at 12:15 PM, RN #2 stated that she was assigned to Resident #2 on 1/3 from 7-3. RN #1 stated that she also cared for the resident on 1/2 during the first shift and the resident did not have any complaints of pain. RN #2 stated that RA #1 reported to her between 9:30 -10 AM of the resident's knee/leg pain. RN #2 stated that she typically would not have seen the resident prior to 9:30 AM, after she had eaten breakfast. RN #2 also stated that she did not receive any reports of pain from the third shift nurse. No statement had been obtained by the facility from RN #2. Review of CNA #1's statement written on 1/12/2012 revealed: ""I didn't drop (Resident #1) and am being falsely accused of it and I'm also being coerced into confessing to it. On several occasions of having her as a patient she would complain of leg and back pains and on numerous occasions I told this. She was a 3rd shift get up and I would say 80% of the time I dressed her and left her in bed..."" CNA #1 was not available for interview during the survey. CNA #1 was assigned to Resident #2 from 11-7 on 1/2-1/3/2012. CNA #1 was suspended on 1/3/2012 for failure to obtain assistance with transferring a resident. She was terminated on 1/13/2012. There was no evidence that the resident was dropped or had fallen on the night of 1/2/2012. The resident had new complaints of right knee and leg pain on 1/2/2012 and was assessed by the provider with a change in orders. The resident continued to complain of knee/leg pain on the morning of 1/3/2012. Facility staff failed to timely report the resident's pain. The facility's investigation was not thorough and did not include sufficient interviews to substantiate the resident had been dropped or had fallen. Statements obtained during the survey were contradictory. During an interview on 1/31/2012, the Director of Nurses confirmed the resident had complained of pain in her right leg on 1/2/2012. She also confirmed that the facility had not obtained statements from CNA #3 or RN #2. She also confirmed statements had not been obtained from staff prior to the night shift of 1/3/2012. She stated that because Resident #2 told staff she had been dropped yesterday by a white CNA, the facility did not investigate any further. The DON also confirmed that Resident #2 was not alert and oriented.",2015-05-01
9305,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,226,E,1,0,CHOM11,"On the day of the complaint inspection based on record review, interview and review of the facility policy on Abuse Prohibition the facility failed to follow their policy related to investigations and reporting. Registered Nurse #1 administered Insulin in error to Resident #1. Resident #5 was left unattended on the toilet resulting in a fall. The incident was not investigated or reported as neglect. Resident #2's fracture of unknown origin was not thoroughly investigated. The findings included: Review of the facility's policy on Abuse and Neglect revealed ""Reporting: All alleged violations concerning abuse, neglect, misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies according to state law including the State Survey and Certification Agency."" Further review revealed ""Investigation: the facility maintains that all allegations of abuse, neglect, misappropriation of property etc are thoroughly investigate and appropriate actions are taken... Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions."" Cross Refer to F 225 as it relates to the facility's failure to identify, thoroughly investigate and report allegations of abuse and neglect.",2015-05-01
9306,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,280,G,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview, the facility failed to ensure 4 of 6 sampled residents' care plans were periodically reviewed and revised. Resident #3, #4 and #5 had multiple falls, new and appropriate interventions were not put in place to prevent recurrence. Resident #1's care plan was not updated related to the resident's non compliance with the required foot rests. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes and Care Plan revealed Resident #3 sustained 20 falls between 9/13/2011 and 1/12/2012. The resident sustained [REDACTED]. The resident did not have new and appropriate interventions put in place after each fall to prevent recurrence of a similar fall. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed the care plan was updated with 3 of the resident's 4 falls. No new and appropriate interventions were put in place after each fall to prevent recurrence. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed Resident #5 sustained 11 falls from 12/2/11 through 1/5/2012. No new and appropriate interventions were updated to prevent recurrence. The care plan also had not been updated to reflect the resident's non compliance with the fall prevention devices. During an interview on 1/31/2012, the Director of Nurses confirmed that a new intervention needed to be put in place after each fall. The DON confirmed Resident #3, #4 and #5's multiple falls. The DON agreed that encouraging the use of a call light was not an appropriate intervention. She also confirmed that Resident #5 removed his devices and continued to stand up and transfer himself. The DON agreed that continuing the current interventions was not an appropriate intervention. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed on 12/13/11 at 1 PM, ""Resident was being pushed in wheelchair from therapy to nurses station and fell forward out of chair. Resident hit head on R(ight) side and lying on right side of body. Abrasion noted to R upper arm...Bruise and swelling noted to right side of forehead. Family and doctor informed of fall and condition..."" At 3 PM, ""Cushion for chair or other intervention requested to physical therapy to prevent falls."" On 12/16 at 11 AM, ""...Resident's right foot drags occasionally while in w/c (wheelchair). Foot rests on w/c required to elevate foot off floor but resident refuses foot rest d/t complaints that it's not comfortable. Different foot rests tried by therapy and resident still refuses. Family informed of this."" Observation of Resident #1 on 1/31/2012 at 6 AM, 9 AM and 3 PM revealed no foot rests were attached to the resident's wheelchair. A pair of foot rests was observed under the resident's vanity in her room. The resident stated that she did not want the foot rests on her wheelchair and stated that she can use her feet to propel herself around her room. Review of the Care Plan dated 2/22/2011 revealed a problem area related to impaired physical mobility related to left [MEDICAL CONDITION] (the resident has right sided paresis), approaches included ""make sure foot rests are in place on w/c whenever resident is in it."" The care plan had not been updated with the resident's non compliance with the foot rests. During an interview on 1/31/2012, the Director of Nurses confirmed that foot rests were not in place on the wheelchair. She also confirmed the resident's care plan and stated that the resident did not have to have the foot rests in place. She stated that the foot rests were required only when the resident left the building with a transfer service. Cross Refer to F-323 as it relates to the facility's failure to provide each resident with the necessary supervision and assistance devices to prevent accidents.",2015-05-01
9307,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,281,D,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review, interviews and review of Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing: Concepts, Process, and Practice, 4th ed. St Louis: Mosby-Year Book, Inc., 1997. Registered Nurse (RN) #1 failed to administer medications in compliance with Professional Standards of Practice to one of six sampled residents. RN #1 failed to identify the resident and administered 12 Units of Insulin to the wrong resident. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] coded Resident #1 as a 10 out of a possible 15 for the BIMS (Brief Interview for Mental Status). Review of the Medication Error Investigation Worksheet dated 1/17/2012 revealed on 1/15/2012 at 8 PM, Resident #1 reported that ""the new nurse (RN #1) that worked at night this weekend, gave her a shot last night in her left arm, last night would have been 1/15/2012. Resident said she asked her what the shot was for and she said for her blood sugar. Resident said she told nurse she doesn't get a shot for her blood sugar and the nurse said, 'You do tonight.'"" The Findings/Analysis were: ""...(the Director of Nurses, DON) called the nurse (RN #1) and she didn't remember giving resident this shot but knew the resident across the hall was suppose to get an insulin injection. (Resident #1) described the nurse as the new white nurse that has worked a couple of weekends at night. Resident may have received 12 units of Insulin this one time. Resident tolerated it well s (without) adverse effects noted."" The Follow up Steps Taken were: ""Reviewed with (RN #1) to always check for the right med, right dose, right patient, right time, right site. If an alert and oriented resident tells you they don't usually receive a particular med to recheck all of the steps again."" At the conclusion of the investigation the ""resident's health condition"" at 8 PM on 1/16/2012 was: ""FSBS (finger stick blood sugar) 132."" During an interview on 1/31/2012 at 1:15 PM, RN #1 stated that she worked the night shift of 1/15/2012 and stated that she was working the unit by herself. RN #1 stated that she misidentified Resident #1 and gave the resident Insulin. She stated that the resident did not have a bracelet on at the time. RN #1 stated that she administered the Insulin at approximately 9 PM on 1/15/2012. RN #1 stated that the resident did ask her about the injection but she had already administered the Insulin before the resident finished her statement. RN #1 also stated that she did not check Resident #1's blood sugar during the night. RN #1 stated that she realized her error ""the next day"" and stated that it was an ""honest mistake."" RN #1 stated that the DON called her and provided an ""in-service"" via the telephone regarding the five rights of medication administration. RN #1 confirmed that her license was suspended previously for medication errors. During an interview on 1/31/2012, the DON confirmed RN #1 made the medication error on 1/15/2012. The DON also confirmed that the Board of Nursing had previously disciplined RN #1 for medication errors. Review of Potter and Perry, Fundamentals of Nursing: Concepts, Process, and Practice, revealed: ""To ensure adequate medication administration and prevent errors...the 5 rights of medication administration: right dosage, right medication, right time, right patient, and right route. This system is a stopgap measure for effective medication administration to each client.""",2015-05-01
9308,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,309,D,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview, the facility failed to ensure one of six sampled residents received the necessary care and services. The facility staff did not adequately assess resident #1's tongue lesion. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Progress Note dated 10/13/2011 revealed: ""Chief Complaint... lesion on tongue. She (Resident #1) wanted me to look at that... She tells me today that she had a lesion on the left side of her tongue which she shown me today. She states she thinks it started maybe a week or two ago. She is not sure but she indicates it does not hurt but does get in the way when she chews... She has noted [MEDICAL CONDITION] of the tongue, vascularity changes, significant shininess to tongue surface or appears to be some mild varicosities. She also has a large pedunculated lesion in the left lateral tongue somewhat vascular in appearance and she has what appears to be almost a verrucous type [MEDICAL CONDITION] those areas along the lateral aspect of the right side of the tongue... We will make a referral to oral surgery associated with the lesion. She certainly may need to have this removed just for functional purposes as well as possible diagnosis..."" On 10/21/2011 the Ear Nose and Throat Physician saw Resident #1 and prescribed Magic Mouthwash twice daily, [MEDICATION NAME] 5 times daily for 14 days. The treatment was again ordered on [DATE] and again on 12/20/2011. The resident's mouthwash was discontinued on 1/13/2012. Review of the Nurse's Notes between 9/2011 and 11/20/2011 revealed no assessment or documentation of Resident #1's tongue [MEDICAL CONDITION]. On 11/21/2011 at 1:30 PM, ""Resident with small amount of bleeding to lesion on tongue. Gauze placed to area and pressure held for 2 minutes. Bleeding subsided. (Ear, Nose and Throat Physician) to see resident this afternoon for lesion on tongue."" At 11 PM, ""No bleeding noted from mouth, ate supper today..."" Review of the Nurse's Notes from 11/22/2011 through 1/31/2012 revealed no other assessment or documentation of Resident #1's tongue lesion. Review of the Weekly Body Audits revealed no documentation related to the [MEDICAL CONDITION] on the resident's tongue. Review of the Care Plan revealed a problem area related to the [MEDICAL CONDITION] on the resident's tongue was dated 10/21/2011. The care plan had been lined through and discontinued at an unknown date. However, there was no indication that the two other treatment episodes were updated on the care plan. During an interview on 1/31/2012, the above information was shared with the Administrator and Director of Nurses (DON). Both confirmed that the Ombudsman had investigated some concerns related to Resident #1. However, he stated that he had not received the Ombudsman's findings. He also stated that the plan was to sit down with the responsible party and discuss her concerns. As of the survey that had not been done. In addition, the DON stated that she expected the nurses to have assessed and documented the resident's tongue lesion.",2015-05-01
9309,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-01-31,323,G,1,0,CHOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review and interview, the facility failed to ensure 3 of 6 sampled residents' received the adequate supervision and assistance devices to prevent accidents. Resident #3, #4 and #5 had multiple falls; timely and appropriate interventions were not put in place to prevent recurrence. Resident #3 sustained 20 falls in 4 months with several minor injuries; appropriate interventions were not put in place after each fall. Resident #4 sustained 4 falls in a 3 month period resulting in head injuries and skin tears timely and appropriate interventions were not put in place. Resident #5 sustained 11 falls in one month. The resident was known to remove/disconnect his alarms and attempt to stand up. Timely and appropriate interventions were not put in place. The last fall on 1/5/2012 resulted in a hip fracture. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set revealed the resident scored a 6/15 on the BIMS (brief interview for mental status) assessment and was noted to require two person extensive assist with transfers. Review of the Resident's Fall Assessment revealed he was assessed as High Risks for falls. He was also noted to remove his alarms and stand unassisted. Review of the Nurse's Notes revealed Resident #5 had 11 falls from 11/9/2011 through 1/5/2012. The resident was noted on 11/14/2011 to remove his canary alarm. Further review revealed his canary alarm was to be ""in use at all times."" The falls are as follows: 12/2-fell , intervention was to use call light; 12/9-fell , intervention was a canary alarm (already in use); 12/11-fall, intervention was a bed alarm; 12/15-fell while attempted to go to the bathroom, the resident was encouraged to use his call bell. On 12/16/2011 at 2:30 PM, ""resident placed on toilet per staff. Resident attempted to get off toilet s (without) assist. States I was going to bed. Found face down in front of toilet..."" The intervention added was for ""staff to stay c (with) resident while on commode."" On 12/22-fell , intervention was to continue physical therapy (PT was discontinued on 12/23/2011); 12/23 ""Resident observed on the floor sitting on his bottom in front of his w/c canary alarm taken off..."" The intervention was for a chair mat alarm (the chair mat alarm was d/c'd on 12/30/11); 12/24-fall-the resident was encouraged to stay close to the nurses station; 12/27""Resident found sitting in floor in front of w/c. No injuries noted... Resident conts (continues) to remove tab alert from clothing...""; 12/30-fall-a self release belt was ordered. On 1/5/12 the resident removed his self release belt and fell backwards sustaining a hip fracture. The resident was sent to the hospital. Review of the Physician's Progress Notes revealed a 1/2/2012 note that stated, ""...Nursing staff reports that he attempts to get up and walk. He unfastened his alarmed seatbelt with is a soft release..."" Review of the Falls Care Plan dated 11/23/2011 indicated the following falls and interventions: ""12-2-11 Fall - no injury; intervention ""Use call light"" 12-9-11 Fall - no injury; intervention ""Canary Alarm"" 12-11-11 Fall - no injury; intervention ""Assist with toileting - Bed Alarm"" 12-15-11 Fall - no injury; intervention ""Re-educated to use call light"" 12-16-11 Fall - no injury; intervention ""Staff to stay with resident while on commode"" 12-22-11 Fall - skin tear; intervention ""Continue PT (physical therapy) with safety training"" 12-24-11 Fall - no injury; intervention ""Bring to NS (nurses station) to socialize with other residents"" 12-27-11 Fall - no injury; intervention ""Brought to NS to be supervised"" 12-30-11 Fall - no injury; intervention ""Self release belt"" 1-5-12 Fall - possible fx left hip; intervention ""To __Regional Medical Center"" The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #3 scored a 14/15 on her BIMS assessment. The resident was also noted as requiring limited one person assistance with transfers and walking in her room. Review of the Nurses Notes and Care Plan revealed Resident #3 sustained 20 falls between 9/13/2011 and 1/12/2012. The resident sustained [REDACTED]. The resident was noted to receive physical therapy between 11/25 and 12/16/2011. The resident was then placed in a restorative ambulation program. On 9/1/11 a canary alarm was ordered. The falls are as follows: 9/13-fall from wheelchair, sustained skin tears- autolock brakes to wheelchair, 9/14, fall from wheelchair- self release belt ordered, 9/20, fall from wheelchair-self release belt replaced, 10/14, fall-continue with belt, 10/19, fall, sustained abrasions-continue interventions, 10/22, fall, sustained skin tears-therapy and maintenance to follow up on autolock brakes, 10/25, fall-canary alarm discontinued and bed mat alarm ordered, 11/4, fall-blue belt to wheelchair (soft belt restraint), 11/10, fell while transferring self-no new intervention listed, 11/15, fell while squatting-sustained skin tears-no new intervention listed, 11/17, fall, sustained skin tears-discontinued restraint and encouraged to use call light, 11/18, fall from wheelchair-Nurse Practitioner to address falls (no progress note noted), 11/25-fell while walking, sustained skin tears-therapy to evaluate and treat (picked up on caseload until 12/16/2011), 12/14, fall from wheelchair-skin tears-1: 1 discussion with resident, 12/21, fall from bed-Nurse Practitioner to evaluate medications (no changes made), 12/25, fall from wheelchair-no interventions listed, 12/30, three falls one from the wheelchair and two from the bed-on 1/2/12 changed rooms to be closer to nurses station, 1/12, fall from wheelchair, sustained skin tears-continue current interventions. The resident did not have appropriate interventions put in place after each fall to prevent recurrence of a similar fall. Review of the Progress Notes revealed no notes related to the resident's multiple falls. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident coded a BIMS of 15/15; required one person extensive assistance with transfers and bed mobility. Resident #4 ambulated with the assistance of a walker or wheelchair. Review of the Nurse's Notes revealed on 10/22/2011 the resident fell and sustained skin tears. The intervention put in place was to encourage resident to use his ""reacher."" On 11/18/2011 the resident fell again and sustained skin tears to his hand, no new interventions were put in place. On 1/6/2012 the resident fell going to the bathroom, hit his head and sustained skin tears, the intervention was to encourage him to use his call bell. On 1/16/2012 the resident again fell going to the bathroom, he hit his head resulting in a hematoma, the interventions put in place was a bed mat alarm ordered on [DATE]. Review of the Care Plan dated 9/30/2011 listed the following falls with interventions: ""10-22-11 fell from leaning forward in w/c (wheelchair) 1/6/12 Fall with skin tear; intervention ""use call light and wear fitted clothes"" 1/16/12 Fall hit head; intervention ""Bedmat alarm ordered..."" During an interview on 1/31/2012, the Director of Nurses confirmed that intervention needed to be put in place after each fall. The above information was shared with the DON and Administrator. The DON confirmed Resident #3, #4 and #5's multiple falls. The DON agreed that the encouraging the use of a call light was not an appropriate intervention. She also confirmed that Resident #5 removed his devices and continued to stand up and transfer himself.",2015-05-01
9310,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,333,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews and interviews, the facility failed to follow a procedure to ensure that residents are free of significant medication errors. Resident C received two doses of an expired medication. The findings included: On [DATE] at approximately 2:30 PM, inspection of the SCU (Skilled Care Unit) medication room revealed the following: -One amber-colored plastic zip-loc bag belonging to Resident C labelled by United Pharmacy Service with an ""EXPIRATION DATE [DATE], RX # 71, [DATE], QTY: 15, [MEDICATION NAME] 1 MG(milligram)/ ML (milliliter) PLO, APPLY 1 ML (1 MG) TOPICALLY THREE TIMES DAILY AS NEEDED FOR ANXIETY"". This plastic bag was found inside the medication refrigerator on the top shelf and contained 13 unlabelled syringes each of which contained approximately 1 ml of a yellow substance. RN (Registered Nurse) # 2 on [DATE] at approximately 2:40 PM confirmed that the medications were expired. A review of Physicians Orders, Medication Administration Records and Controlled Drug Records (,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]) conducted on [DATE] at approximately 3:20 PM revealed that Resident A is still in the facility and has an active order for [MEDICATION NAME] 1 mg/1 ml. This review revealed that since [DATE] Resident A received two doses of expired [MEDICATION NAME] 1 mg/1 ml. The first dose on [DATE] (46 days after expiration) and the second dose on [DATE] at 3:30 PM (106 days after expiration).",2015-05-01
9311,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,425,D,0,1,CVJ911,"On the days of the survey based on observations, record reviews and interviews, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 1 of 2 medication rooms. The findings included: On 8/15/11 at approximately 2:30 PM, inspection of the SCU (Skilled Care Unit) medication room revealed the following: -One amber-colored plastic zip-loc bag belonging to Resident C labelled by United Pharmacy Service with an ""EXPIRATION DATE 4/2/11, RX # 71, 3/18/11, QTY: 15, LORAZEPAM 1 MG (milligram)/ ML (milliliter) PLO, APPLY 1 ML (1 MG) TOPICALLY THREE TIMES DAILY AS NEEDED FOR ANXIETY."" This plastic bag was found inside the medication refrigerator on the top shelf and contained 13 unlabelled syringes each of which contained approximately 1 ml of a yellow substance. RN (Registered Nurse) # 2 on 8/15/11 at approximately 2:40 PM confirmed that these medications were expired and stated that nurses are supposed to check for expired medications when doing controlled substance counts (lorazepam is a controlled substance) at each shift change and that the Consultant Pharmacist is supposed to check for expired medications monthly. A review of the facility's ""Medication Storage in the Healthcare Centers"" policy and procedure on 8/16/11 at approximately 4:30 PM revealed that ""Nurses are required to check all medications for deterioration and expiration before administration."", ""Nurses are also required to inspect medication storage facilities, including medication carts, routinely."" and ""The Consultant Pharmacist will monitor storage of medications by performing a review of storage areas at least quarterly.""",2015-05-01
9312,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,431,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews and interviews, the facility failed to follow a procedure to ensure that medications were locked in 1 of 4 medication carts and that medications were improperly labelled in 1 of 2 medication rooms. The findings included: On [DATE] at approximately 11:30 AM a random observation during initial tour revealed an unattended and unlocked medication cart on the URS (UniHealth Recovery Suites) outside room [ROOM NUMBER]. This observation was also witnessed by another state surveyor. Continuous observations between approximately 11:30 AM and 11:55 AM revealed that the medication cart remained unlocked and unattended. At approximately 11:35 AM, a resident in a wheelchair stopped at the medication cart, touched medication drawers and then removed several straws and plastic spoons from a box on the left side of the cart. At approximately 11:55 AM, RN (Registered Nurse) # 1 stood by the cart for approximately 2 minutes, then locked the cart. RN #1 confirmed during an interview on [DATE] at approximately 11:58 AM that the cart had not been locked. On [DATE] at approximately 2:30 PM, inspection of the SCU (Skilled Care Unit) medication room revealed the following: -One amber-colored plastic zip-loc bag belonging to Resident C labelled by United Pharmacy Service with an EXPIRATION DATE [DATE], RX # 71, [DATE], QTY: 15, LORAZEPAM 1ML (1MG) PLO, APPLY 1ML (1MG) TOPICALLY THREE TIMES DAILY AS NEEDED FOR ANXIETY"". This plastic bag was inside the medication refrigerator on the top shelf and contained 13 unlabelled syringes, each of which contained approximately 1 ml (milliliter) of a yellow substance. On [DATE] at approximately 4:10 PM, the Consultant Pharmacist confirmed, from facility made photocopies of the findings, that the syringes were expired, unlabelled and that the syringes should have been properly labelled as to content and expiration date. A review of the facility's ""Medication Storage in the Healthcare Centers"" policy and procedure on [DATE] at approximately 4:30 PM revealed that ""The medication supply is accessible only to licensed nursing personnel and pharmacy personnel."", and ""Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access."" A review of the monthly Consultant Pharmacist Activity Reports (,[DATE] through ,[DATE] and ,[DATE] through ,[DATE], ,[DATE] was missing) on [DATE] at approximately 11:55 AM revealed repeated findings of improper drug storage and unlocked medications in the facility along with recommendations for correction. Observation on [DATE] at 5:40 PM on Unihealth Recovery Suites revealed a treatment cart stationed near the nurses station, unattended and with no nursing staff in the immediate area. Interview with the Director of Nursing (DON) at 5:50 PM on [DATE] confirmed this surveyors findings and she stated that the treatment cart should be secured at all times unless being used. An interview at 10:33 AM on [DATE] with the DON and Licensed Practical Nurse (LPN) #2 revealed that it was unknown how long the treatment cart was unlocked and/or broken. The DON went on to say that all drawers to the treatment cart could not be repaired. Review of the contents of the treatment cart included but was not limited to: Santyl ointments, Mometasone Furoate, Clotrimazole and Dipropionate cream, a bottle of Nyamyc, Triamcinolone Acetonize cream, Vitamin A and D ointment, Cavilon spray, Surgical lubricant and 2 pair of blunt scissors. Review of the facilities policy related to ""Medication Storage in the Healthcare Centers"" states: ""Medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier.""",2015-05-01
9313,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,441,E,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews, interviews, review of the facility policies entitled ""Handwashing Techniques"" (Revised 8/11) and ""Contact Precautions"" (2/08), and review of the CDC (Centers for Disease Control) 2007 Guideline for Isolation Precautions, the facility failed to follow effective infection control procedures for three of three sampled residents reviewed on contact precautions. The facility failed to provide dedicated patient care equipment for Resident #3 (on contact isolation) and failed to disinfect the stethoscope following use and removal from the isolation room. A Certified Nursing Assistant (CNA) failed to wash her hands and change gloves between care of Resident #4 (on contact precautions for infection with a multi-drug resistant organism) and Resident #13 who was at increased risk of infection due to presence of indwelling devices. The facility also failed to implement symptomatic precautions for Resident #9 admitted with symptoms of Clostridium Difficile (C-diff) and continued precautions for approximately two weeks after treatment was complete and the resident asymptomatic. The findings included: Prior to observation of catheter care for Resident #4 on 8-16-11 at 2:50 PM, CNA #2 stated that the resident was ""on contact precautions for MRSA (Methycillin-Resistant Staphylococcus Aureus) of the wound"". She proceeded to don personal protective equipment and provide the treatment. The urine in the tubing was visibly bloody and had a large amount of bloody strings/sediment. When the condition of the urine was brought to the attention of the CNA, she stated, ""I think he has a UTI (Urinary Tract Infection)."" After the treatment was complete, the CNA removed her isolation gown. The surveyor asked about routine use of a catheter strap for this resident as well as for the roommate who also had a catheter. Without removing her gloves and washing her hands, she went to Resident #13's bedside, touched the siderail, laid back the covers, raised the resident's gown and checked the resident. Resident #13 had a Gastrostomy tube as well as a Foley catheter and was at high risk for transmission of bacteria. Review of the facility policy entitled ""Handwashing Techniques"" (Revised 8/11) provided by the acting Director of Nursing (DON) on 8-17-11 at 12:25 PM revealed the following: ""1. Hands should be washed before and after patient/resident contact and as necessary during patient/resident care."" Review of the facility policy entitled ""Contact Precautions"" (2/08) revealed no reference to restriction of room placement with a resident at high risk for transmission due to the presence of indwelling devices. The facility admitted Resident #9 on 4-28-11 with multiple comorbidities following Left Above-Knee Amputation with Complications, including Chronic Diarrhea. Record review and interview revealed that the facility failed to implement symptomatic precautions for Resident #9 admitted with symptoms of Clostridium Difficile (C-diff) and continued precautions for approximately two weeks after treatment was complete and the resident asymptomatic. Record review on 8-16-11 at 9 AM revealed that the resident was transferred to a rehabilitation unit ""after a prolonged hospitalization for chronic ulcer and cellulitis of the left lower extremity"" which resulted in an above-knee amputation. She experienced chronic diarrhea at the rehabilitation (rehab) center. Records revealed that Resident #9 was treated with multiple antibiotics during her hospital and rehab stay and was discharged to the facility with continued intravenous antibiotic therapy via a peripherally inserted central line catheter (PICC line). There was no evidence in the transfer records to indicate that the resident was ever checked for[DIAGNOSES REDACTED] toxin prior to admission. Review of Medication Administration Records and Daily Skilled Nurse's Notes revealed that Resident #9 had documented episodes of diarrhea beginning on 4-30-11 which required treatment with [MEDICATION NAME] on 4-30-11, 5-3, 5-4 X 2, 5-5 X 2, 5-6, 5-7 X 2, 5-8, 5-9, 5-10, 5-11, and 5-12-11. There was no evidence that the physician was notified until a Physician's Interim Order was received on 5-4-11 to check the stool for[DIAGNOSES REDACTED]. There was no evidence that any type of transmission based precautions were implemented until the laboratory results were received and noted to be positive. Treatment with [MEDICATION NAME] for 10 days and Contact Precautions were implemented on 5-7-11. [MEDICATION NAME] was completed on 5-17-11 and no further diarrhea was noted after 5-12-11. Contact Precautions were not discontinued until 6-1-11. During an interview on 8-17-11 at 11 AM, the DON stated that the previous DON had been responsible for implementation of infection control policies. She verified that symptomatic precautions had not been implemented: ""I'm sure the staff were waiting for tox(in) results."" The DON also stated that Resident #9 should have been taken off contact precautions as soon as the treatment was completed and she was asymptomatic. Review of the CDC 2007 Guideline for Isolation Precautions page 21-22, related to C.difficile revealed the following: ""Important factors that contribute to healthcare-associated outbreaks include...exposure of patients to frequent courses of antimicrobial agents...Prevention of transmission focuses on syndromic application of Contact Precautions for patients with diarrhea..."" Page 71, related to Syndromic and empiric applications of Transmission-Based Precautions, states: ""[DIAGNOSES REDACTED]. Since laboratory tests, especially those that depend on culture techniques, often require two or more days for completion, Transmission-Based Precautions must be implemented while test results are pending based on the clinical presentation and likely pathogens."" Appendix A, page 96, noted that contact precautions should be discontinued following the duration of the illness. The facility admitted Resident #3 on 08-12-11 with [DIAGNOSES REDACTED]. On 08-16-11 at approximately 10:05 AM, observation revealed Licensed Practical Nurse (LPN) #4 clothed in Isolation attire of gown, gloves, and shoe covers in Resident #3's room to perform a Gastroscopy (G) Tube Flush. After completion of the [DEVICE] Flush, LPN #4 auscultated Resident #3's lungs, disposed of the trash and linen in the appropriate containers in the resident's room, washed her hands, and exited the room with the stethoscope used for auscultation. During an interview on 08-16-11 at 10:23 AM with LPN #4, she verified she had not cleansed the stethoscope after auscultation of Resident #3's lungs and should not have removed it from the room. Review of the facility's ""Infection Control Program Overview"" revealed Section 1. Scope of the Infection Control Program stated ""Prevention of Infections...Policies, procedures, and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment"". Review of the facility policy titled ""Contact Precautions"" revealed Section Patient/Resident Care Equipment #2 stated ""If use of common equipment or items is unavoidable, the items should be adequately cleaned and/or disinfected before use for another patient/resident"".",2015-05-01
9314,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,152,D,0,1,CVJ911,"On the days of survey, based on record review and staff interviews, the facility failed to ensure that 1 of 16 sampled resident's (Resident #9, ) rights were exercised appropriately. Residents #9 was alert and oriented on admission, however advance directives were signed by a family member. The findings included: The facility admitted Resident #9 on 4-28-11 with multiple comorbidities following Left Above-Knee Amputation with Complications. Record review and interviews revealed that Resident #9 was not afforded the right to formulate her own advance directive. Record review on 8-16-11 at 9 AM revealed that a family member had signed the information on advance directives provided at the time of admission, though there were no physician certifications of the resident's inability to make her own health care decisions. The Advance Directives Checklist had ""Full Code"" written in with a request for additional information. Social Progress Notes dated 5-2-11 stated,""(Daughter) is RP (Responsible Party)-looking into POA (Power of Attorney). Desires DNR (Do Not Resuscitate)."" Review of the 5-5-11 Admission Minimum Data Set Assessment on 8-16-11 at approximately 11 AM revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8-16-11 at 6 PM and on 8-17-11 at 9 AM, the resident stated that she did not recall anyone talking to her about advance directives. The resident wanted her daughter to make decisions for her whenever she became unable to do so, ""but right now I certainly can."" During an interview on 8-17-11 at 11:10 AM, Social Services verified that the facility should have discussed advance directives with the resident as she was alert and oriented at the time of admission.",2015-05-01
9315,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,157,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to notify the family and physician of allegations of abuse and misappropriation of funds for two of three residents reviewed for reportable allegations of abuse/neglect. (Residents A & B) The findings included: Reportable allegations of abuse/neglect to the State Agency were reviewed on 8-16-11 at approximately 5 PM. Review of Resident A's investigative file revealed that on 7-19-11, while crying, he reported to a Licensed Practical Nurse that he had been struck in the stomach three times by the Certified Nursing Assistant (CNA) assigned to him. Further review of this file as well as the medical record on 8-17-11 revealed that there was no evidence that the physician or family was notified of the incident. There was no entry in the Nurse's Notes for the date the incident was reported. On 7-20-11, an entry for ""A(M)/P(M) (shift)"" noted: ""Res(ident) tearful this AM & anxious. Called MD office re: restarting [MEDICATION NAME] routinely..."" There was no mention of the allegation of abuse. Review of Social Progress Notes revealed that the Social Services Director was notified by the Administrator of the incident on 7-20-11. During an interview with the resident, Social Services documented that the resident again began crying as he repeated the details of the incident. At 9 AM on 8-17-11, the surveyor requested any incident/accident report that had been completed regarding the allegation of physical abuse. During an interview on 8-17-11 at 11 AM, the acting Director of Nurses (DON) stated that she had spoken with the Administrator and there had been no incident report completed. She stated that she had reviewed the medical record and could find no evidence of family or physician notification. Review of Resident B's investigative file and medical record on 8-16-11 revealed that on 7-20-11, he reported to the Dietary Manager that he was missing money from his drawer. Social Services spoke with the resident and determined that this had occurred between 7-18-11 and 7-19-11. Further review of this file as well as the medical record on 8-17-11 revealed that there was no evidence that the physician or family was notified of the incident. There was no entry in the Nurse's Notes for the date the incident was reported. Review of Social Progress Notes revealed no reference to physician/family notification about the incident. At 9 AM on 8-17-11, the surveyor requested any incident/accident report that had been completed regarding the allegation of misappropriation. During an interview on 8-17-11 at 11 AM, the acting Director of Nurses (DON) stated that she had spoken with the Administrator and there had been no incident report completed. She stated that she had reviewed the medical record and could find no evidence of family or physician notification.",2015-05-01
9316,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,221,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the facility policy entitled ""Restraints: Physical Restraints"" (Revised 3/06), the facility failed to conduct a restraint assessment for one of one sampled residents with an abdominal binder in use (Resident#13). The findings included: The facility admitted Resident #13 on 9-26-08 with multiple comorbidities including, but not limited to, [MEDICAL CONDITION] with Dysphagia, Severe Dementia, Status/Post Gastrostomy, and [MEDICAL CONDITION]. Observation with Certified Nursing Assistant (CNA) #1 on 8-16-11 at 3:45 PM revealed that the resident had an abdominal binder in place and was grabbing at the covers in his suprapubic area. He had both a Foley catheter and a Gastrostomy tube in place. The CNA stated the binder was in place ""so he won't pull his stomach tube out."" Record review on 8-16-11 at 4 PM revealed that there was a current Physician's Order for ""Abdominal binder on @ all times except for care to prevent resident from pulling on leg tube."" Review of the only restraint assessment in the medical record (1-5-10 Initial/Annual Assessment for a Physical Device) revealed no reference to the use of an abdominal binder. Review of Section P of the 12-16-10 Annual Minimum Data Set (MDS) Assessment and of the most recent Quarterly MDS (5-20-11) revealed no restraint use coded. During an interview on 8-16-11 at 5:25 PM, when asked what the purpose of the abdominal binder was, the Unit Manager stated, ""To keep him from pulling on the tube. It has come out multiple times."" She verified that the binder's use limited his access to his body, but stated that no restraint assessment had been completed. ""We didn't consider it a restraint."" During an interview on 8-17-11 at 11 AM, the acting Director of Nursing (DON) stated that an abdominal binder does limit access to the body but, ""If not on the assessment, they didn't look at it as a restraint."" Review of the facility policy entitled ""Restraints: Physical Restraints"" (Revised 3/06) provided by the DON on 8-17-11 at 12:25 PM revealed the following: ""Physical restraints may only be utilized when the following criteria have been met and there is supportive documentation present in the patient/resident's clinical record: -A completed Physical Restraint Assessment."" The definition of a physical restraint in the policy included ""Any manual method or physical or mechanical device, material or equipment...which restricts...normal access to one's body.""",2015-05-01
9317,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,241,D,0,1,CVJ911,"On the days of the survey, based on observation, review of the facility's policy entitled ""Catheters: Care and Anchoring, Changing of"" (Revised 7/07), review of the South Carolina Nurse Aide Candidate Handbook (April 2010), and interview, the facility failed to promote dignity during treatments for one of two residents reviewed for catheter care. Certified Nursing Assistant (CNA) #2 left Resident #4 uncovered from waist to feet during provision of catheter care. The findings included: During observation of catheter care for Resident #4 on 8-16-11 at 2:50 PM, CNA #2 told the resident about the procedure to be performed and the surveyor requested and was granted permission to observe. The privacy curtain was pulled between the residents in the two beds in the room, but was not pulled around the foot of the bed to the door, thus allowing ready visibility to anyone in the hall should the door be opened for any reason. Resident #4 was in the bed nearest the door. The CNA uncovered the resident to his feet and placed a towel across the resident's chest. She detached the disposable brief and proceeded to perform incontinent/catheter care. The resident remained exposed from waist to toes during the entire procedure. Review of the facility's policy entitled ""Catheters: Care and Anchoring, Changing of"" (Revised 7/07) revealed under Procedure: ...6. Drape patient/resident..."" The South Carolina Nurse Aide Candidate Handbook (April 2010), page 35, in reference to provision of catheter care, states: ""6. Exposes area surrounding catheter while avoiding overexposure of client."" During an interview on 8-17-11 at 11 AM, the acting Director of Nursing stated, ""The CNA should only expose the part she is working with.""",2015-05-01
9318,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,281,E,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to ensure professional standards of care were met for 3 of 14 residents reviewed for acceptable standards of practice (Resident #1, #9, #13). Multiple omissions/blanks were found on the Medication Administration Record [REDACTED]. Resident #13, with a known allergy to Zinc, had applications of a product containing Zinc applied to a Gastroscopy (G) Tube site for 3 months. The findings included: The facility admitted Resident #1 on 04-19-11 with [DIAGNOSES REDACTED]. Record review on 08-15-11 at 4:05 PM of the Physician's Orders dated 06-01-11 to 06-30-11 and 07-01-11 to 07-31-11 revealed an order for [REDACTED]. Additional record review on 08-15-11 at approximately 4:05 PM of Resident's #1's MAR indicated [REDACTED] 06-07-11, 06-22-11, 06-25-11, and 06-28-11: no documentation of [MEDICATION NAME]-SC Disc administered. Further record review on 08-15-11 of the MAR indicated [REDACTED] 07-25-11: no documentation of [MEDICATION NAME]-SC Disc administered. During an interview on 08-16-11 with the Director of Nursing, she, after record review, verified the blanks/omissions on the June and July 2011 MAR. The facility admitted Resident #13 on 9-26-08 with multiple comorbidities including, but not limited to, [MEDICAL CONDITION] with Dysphagia, Severe Dementia, Status/Post Gastrostomy, and [MEDICAL CONDITION]. Record review on 8-16-11 at 4 PM revealed a red allergy sticker in the front of the medical record which noted that the resident was allergic to zinc. The 1-2-10 hospital History and Physical and the 8-11 Physician's Orders also noted the allergy to zinc. Review of the current (8-11) Physician's Orders revealed that the resident had been receiving a treatment with zinc oxide ointment to the ""peg site and skin on abdomen three times daily"" since 5-23-11. During an interview on 8-16-11 at 5:40 PM, Licensed Practical Nurse (LPN) #2 verified the Physician's Order for the ointment. She stated that the zinc that had been used for ""at least a couple of months"" excoriated the resident's abdomen and had been changed to [MEDICATION NAME] this month. LPN #2 verified the information on the allergy sticker and stated she was unaware that the resident was allergic to zinc. Review of Clinical Nursing Skills and Techniques, 7th Edition (2010), page 523 related to medication allergies [REDACTED]."" The facility admitted Resident #9 on 4-28-11 with multiple comorbidities following Left Above-Knee Amputation with Complications. Record review on 8-16-11 at 9 AM revealed that the resident was admitted from the hospital with a PICC (Peripherally Inserted Central Catheter) line for administration of antibiotic therapy. Physician's Interim Orders were not written for care of the PICC line until 5-9-11, eleven days after admission. Review of the 5-11 Treatment Record revealed that the PICC line dressing was not changed until 5-9-11 and that the injection cap was not changed until 5-12-11. Review of the facility policy entitled ""PICC Infusion Access Device Maintenance"" (Revised 12/09) provided by the acting Director of Nurses (DON) on 8-17-11 revealed the following: ""3. Weekly schedule for maintenance is as follows: -Change dressing on Monday and Thursday, -Change injection cap...every Thursday."" During an interview on 8-17-11 at 11 AM, the DON verified the 5-9-11 Physician's Order and stated that the facility policy for care of the PICC line should have been implemented upon admission.",2015-05-01
9319,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,315,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, review of Assisting in Long Term Care, Second Edition, review of the South Carolina Nurse Aide Candidate Handbook (April 2010), and review of the facility policy entitled ""Catheters: Care and Anchoring, Changing of"" (Revised 7/07), the facility failed to provide appropriate care and services to prevent trauma and/or infection for two of two sampled residents reviewed for incontinent/catheter care. Resident #4's penis was not cleansed appropriately during catheter care, his catheter was unsecured, and his urinary drainage tubing was threaded through the siderails, applying tension on the tubing. Resident #13's catheter was not secured and was not anchored during catheter care to prevent tension on the tubing. The findings included: Upon entering the room to observe catheter care for Resident #4 on 8-16-11 at 2:50 PM, the catheter drainage tubing was noted to be positioned through the right siderail. The urine in the tubing was bloody and had a large amount of bloody strings/sediment. During observation of catheter care, Certified Nursing Assistant (CNA) #2 raised and lowered the siderail a total of four times, applying tension to the catheter tubing which was pinned between the mattress and siderail. The resident had no catheter strap in place to secure the catheter from pulling at the insertion site. With any stimulation, the resident experienced jerky movements. While providing catheter care, CNA #2 cleansed around the meatus but failed to cleanse the penile shaft. Following the procedure, the bloody urine was brought to the attention of the CNA who stated,""I think he has a UTI (Urinary Tract Infection)."" She also noted that the resident was on contact precautions for Methacillin-Resistant Staphylococcus Aureus infection of a sacral wound. When asked about use of a catheter strap, CNA #2 stated, ""I had one on him yesterday. I don't have him today."" She left the room and the drainage tubing remained through the siderail. CNA # 2 stated she would obtain and apply the catheter strap. The facility admitted Resident #13 on 9-26-08 with multiple comorbidities including, but not limited to, [MEDICAL CONDITION] with Dysphagia, Severe Dementia, Status/Post Gastrostomy, and [MEDICAL CONDITION]. Upon entering the room to observe catheter care on 8-16-11 at 3:45 PM, the resident was noted to be scratching/grabbing at the covers in his suprapubic area. Certified Nursing Assistant (CNA) #1 checked and found that a catheter strap was not in place to prevent tugging/tension on the tubing. During the catheter care, the CNA failed to anchor the tubing while cleaning it to prevent tension at the insertion site during the procedure. Immediately after the treatment, CNA #1 verified that she had held onto the resident's penis while she cleaned the catheter tubing, instead of securing the tube. During an interview on 8-17-11 at 11 AM related to the catheter care provided for Residents #4 and #13, the acting Director of Nurses stated that it was facility policy to use catheter straps/legbands to prevent trauma, staff should not have put the catheter tubing through the rails for the same reason, the catheter should have been anchored to prevent pulling, and the penile shaft should have been cleaned. Assisting in Long Term Care, Second Edition, Section 5, page 390, states: ""Secure the tubing in such a way that there is no strain on the catheter or tubing. A catheter strap should be applied to the leg to secure the tubing."" Page 389, regarding catheter care for the male resident, states: ""...cleanse the glans from meatus toward shaft for approximately four inches."" The South Carolina Nurse Aide Candidate Handbook (April 2010), page 35, in reference to provision of catheter care, states: ""8. While holding catheter near meatus without tugging, cleans at least four inches of catheter nearest meatus, moving...away from meatus..."" Review of the facility policy entitled ""Catheters: Care and Anchoring, Changing of"" (Revised 7/07), provided by the Director of Nurses on 8-17-11, revealed the following: ""In order to avoid mucosal damage, catheter tubing will be anchored to prevent tension on the Foley insertion site."" Under Procedure, it stated: ""10. For the male patient/resident...cleanse the meatus outward...11. Use a new section of the washcloth, cleanse catheter from insertion site to four (4) inches outward.""",2015-05-01
9320,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,367,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to provide therapeutic diets as prescribed by the physician for two of four sampled residents. Resident # 12 recieved ketchup with the meal wbich was not allowed within the physician ordered diet restriction. Resident # 9 recieved milk which was noted as a disliked food by the resident and the resident received salt on her tray for two of three meals observed. The planned menu for the resident's dietary restrictions was not followed for two of three meals observed. The findings included: The facility admitted Resident # 12 on 8/11/09. The resident's [DIAGNOSES REDACTED]. Observation of the resident's meal on 8/16/11 at 1:30 PM revealed the resident had received ketchup which was placed on the meatloaf. Record review on 8/16/11 at 1:30 PM revealed a physician order [REDACTED]. Review of the Menu as provided by the facility indicated the resident should not have received ketchup with the meal. On 8/17/11 at 9:30 AM, during an interview with the Certified Dietary Manager, she stated ""I don't know what happened, we should not have served ketchup on the meatloaf."" The facility admitted Resident #9 on 4-28-11 with multiple comorbidities following Left Above-Knee Amputation with Complications. [DIAGNOSES REDACTED]. Record review and interview revealed that this resident received salt on her tray for two of three meals observed and that the planned menu for the resident's dietary restrictions was not followed for two of three meals observed. Record review on 8-16-11 at 9 AM revealed that the resident was transferred from the hospital on an 1800 calorie American Diabetic Association diet with a snack at bedtime. The diet was changed/clarified on 5-17-11 to provide ""Liberal diabetic NAS (No Added Salt) c (with) HS (hour of sleep/bedtime) snack"". Observation of the breakfast tray and resident intake at 8:50 AM on 8-16-11 revealed an open salt packet on the tray. The resident stated she had received and consumed grits, eggs, bacon, coffee, orange juice and a pecan spin wheel. She noted that she did not like the milk left on the tray. The tray card noted the diet as ordered and milk as a dislike. When asked, the resident stated she had used the salt on the grits and eggs. ""Without it, there's not much taste. If they send it, I use it."" Observation of the evening meal revealed that the resident received an egg salad sandwich, vegetable soup, cucumber/onion salad, cobbler, tortilla with salsa, and tea. Again, an open salt packet was noted on the tray. The resident stated she had used it in the soup. Review of the planned menu for the liberalized diabetic diet revealed that the resident should have received black bean soup instead of the vegetable soup. Upon entering the resident's room on 8-17-11 at 8:50 AM, the surveyor asked how she was doing. The resident seemed upset and responded, ""Not so good."" When questioned about any concerns, the resident stated that she had not received any meat on her breakfast tray and that she always got meat for breakfast. She stated that she had asked a nurse and a Certified Nursing Assistant (CNA) to get her some meat. ""The CNA went to the kitchen and came back and said I couldn't have the ham because I was on a no added salt diet. I have been getting meat all along. I don't know why it's changed now."" Review of the planned breakfast menu revealed that Resident #9 should have received the ham. During an interview on 8-17-11 at 12 PM, the Dietary Manager stated that she was unaware that the resident was receiving salt on her trays. She stated, ""I don't know if it's coming from dietary or from nursing."" When questioned about the menu not being followed for the resident's therapeutic diet order related to specific food items, she stated that she had been following the ""low sodium"" diet instead of providing no salt packet. She stated she had spoken to her consultant and was now aware of the difference.",2015-05-01
9321,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,280,D,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to review and revise the Comprehensive Care Plan to reflect Range of Motion (ROM) with Activity of Daily Living (ADLs) for 2 of 7 sampled residents. (Resident #1, #10) The findings included: The facility admitted Resident #1 on 04-19-11 with [DIAGNOSES REDACTED]. Record review on 08-15-11 at approximately 4:05 PM of the Physician's Interim Orders dated 07-01-11 revealed an order to ""Discharge from Restorative Nursing. Certified Nursing Assistants (CNAs) to perform passive ROM with ADL care"". Record review on 08-16-11 at approximately 9:30 AM of Resident #1's Plan of Care, undated, for ""Problem: Impaired mobility related to (r/t) decreased bilateral lower extremities"" revealed it had not been updated to reflect discontinuing Restorative Nursing and beginning passive ROM with ADL care. Further record review on 08-16-11 at 9:30 AM of the 04-26-11 Admission Minimum Data Set (MDS) and the 06-20-11 Significant Change MDS revealed Resident #1 had limited ROM in both upper and lower extremities. Review of Resident #1's ADL Care Plan Record dated 04-25-11 revealed section ""Mobility"" relating to contractures had not been updated to reflect passive ROM with ADL care. During an interview on 08-17-11 at 8:45 AM with CNA #4, she verified the resident's ADL Care Plan had not been updated and stated, ""If it's not there then I wouldn't know to do it. Yes, I'd expect it to be there"". During an interview on 08-17-11 at 9:45 AM, the MDS Coordinator, after record review, verified Resident #1's undated Plan of Care and the ADL Plan of Care had not been updated to reflect discontinuation of Restorative Nursing and to begin passive ROM with ADL care."" The facility admitted Resident #10 on 9/26/08 and readmitted her on 8/2/11, with [DIAGNOSES REDACTED]. On 8/16/11 at 9:00am, Resident #10 was observed laying in bed on her back with bilateral heel protectors on and side rails up. Multiple observations of the resident during the survey on 8/16/11 and 8/17/11 revealed that the resident kept both hands closed with no devices to prevent further decline of contractures. Review of the 4/24/10, 4/1/11 and 6/17/11 Minimum Data Set (MDS) Assessments on 8/16/11 at 12:00pm in Section G, revealed ""Functional limitation in Range of Motion impairment of both sides"". Section O, revealed no ""Restorative Nursing Programs"" for each MDS assessment for the previous dates mentioned. Review of the 8/2/11 ""Admission/ Nursing Evaluation Form"" indicated that the resident had contractures to both hands. Further review revealed an ""Interdisciplinary Referral to Rehab Screening"" was done on 6/24/10 for ""Range of Motion/ Contractures to both hands"". The rehab screening results and recommendations stated ""No changes in status noted; skilled therapy currently not warranted"". The Occupational Therapy (OT) notes, dated 6/24/10, stated ""Pt. (Patient) with hypersensitivity to touch and sound.....Pt. would not tolerate splints at this time....Pt also with wound on Left D (Digits)5 + D4 and Left palm secondary to nails....No OT at this time"". Review of the Resident Care Plan (last updated 6-28-11) on 8/16/11 at 3:35pm, revealed no reference to provision of restorative service or measures to prevent further contracture development. During interview on 8/17/11 at 8:45am, the Minimum Data Set (MDS) Coordinator confirmed that the resident was assessed for limitation in ROM to all extremities and bilateral hand contractures. She verified that the Care Plan had not been updated to address limited ROM or contractures.",2015-05-01
9322,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,318,E,0,1,CVJ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and record review, the facility failed to ensure that the resident with limited Range of Motion (ROM) received services to prevent further decline in ROM for 3 of 7 sampled residents reviewed with contractures (Resident #1, #8, and #10). The findings included: The facility admitted Resident #10 on 9/26/08 and readmitted her on 8/2/11, with [DIAGNOSES REDACTED]. On 8/16/11 at 9:00am, Resident #10 was observed laying in bed on her back with bilateral heel protectors on and side rails up. Multiple observations of the resident during the survey on 8/16/11 and 8/17/11 revealed that the resident kept both hands closed with no devices to prevent further decline of contractures. Review of the 4/24/10, 4/1/11 and 6/17/11 Minimum Data Set (MDS) Assessments on 8/16/11 at 12:00pm in Section G, revealed ""Functional limitation in Range of Motion impairment of both sides"". Section O, revealed no ""Restorative Nursing Programs"" for each MDS assessment for the previous dates mentioned. Review of the 8/2/11 ""Admission/ Nursing Evaluation Form"" indicated that the resident had contractures to both hands. Further review revealed an ""Interdisciplinary Referral to Rehab Screening"" was done on 6/24/10 for ""Range of Motion/ Contractures to both hands"". The rehab screening results and recommendations stated ""No changes in status noted; skilled therapy currently not warranted"". The Occupational Therapy (OT) notes, dated 6/24/10, stated ""Pt. (Patient) with hypersensitivity to touch and sound.....Pt. would not tolerate splints at this time....Pt also with wound on Left D (Digits)5 + D4 and Left palm secondary to nails....No OT at this time"". During an interview on 8/16/11 at 3:30pm, Licensed Practical Nurse (LPN) #3 stated that Certified Nursing Assists (CNA) had an ""Activities of Daily Living (ADL) Care Plan Record"" that informed them of the resident's Mental Status, Impairments, Bowel/ Bladder, Mobility, Special Equipment, Personal Hygiene, Nutrition, and Pressure Sore. LPN #3 stated that the CNA's document their care for the residents on the charting kiosk. Upon observation of the kiosk with the nurse, she comfirmed there was no evidence of ROM provided for Resident #10. The facility admitted Resident #1 on 04-19-11 with [DIAGNOSES REDACTED]. Record review on 08-15-11 at 4:05 PM of the Physician's Interim Orders dated 07-01-11 revealed an order to ""Discharge from Restorative Nursing. Certified Nursing Assistants (CNAs) to perform passive Range of Motion (ROM) with Activity of Daily Living (ADLs) care"". Review of Resident #1's Restorative Minutes Minimum Data Set (MDS) 3.0 on 08-16-11 at 12:10 PM revealed there was no documentation for 38 of 41 days for passive ROM with ADLs for dates of 07-01-11 to 08-10-11. During an interview on 08-16-11 at 12:10 PM with the MDS Coordinator, she, after review of the Restorative Minutes MDS 3.0 from 07-01-11 to 08-10-11, confirmed there was no documentation for 39 days to reflect Resident #1 received passive ROM with ADL care. The facility admitted Resident #8 on 01-15-09 with [DIAGNOSES REDACTED]. Record review on 08-15-11 at 2:40 PM of the physician's orders [REDACTED].#8 had limited ROM in the upper and lower extremities. Additional record review of the Restorative Minutes MDS 3.0 for dates of 07-01-11 through 08-17-11 revealed there was no documentation for 39 days to reflect Resident #8 received Restorative Nursing bilaterally to the lower extremities (ROM). During an interview on 08-16-11 at approximately 12:10 PM with the MDS Coordinator, she, after record review, confirmed the above findings. During an interview on 08-17-11 at 8:55 AM with Certified Nursing Assistant (CNA) #5, she stated, ""I do treatments three times a week for this resident but I've been out sick. When I'm not here another CNA does them. Sometimes they forget to chart, but yes, if it's not charted, it means and looks like it's not done"".",2015-05-01
9323,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,492,D,0,1,CVJ911,"On the days of survey, based on review of personnel files and interview, the facility failed to check licensure for 2 of 2 newly hired Licensed Practical Nurses (LPN) prior to employment. The findings included: Upon review of the newly hired employee folders on 8/16/11 at 1:20pm, there was no evidence of licensure check from the Board of Nursing prior to employment dates for 1 of 2 LPN's. During an interview on 8/17/11 at 10:20am, the Financial Manager stated the license checks were kept in a binder, however the binder was misplaced. She then confirmed after looking through the employee folders that the licensure checks were missing and that she would continue to look for the binder and/or obtain the checks. At 10am on 8/17/11, the Financial Manager presented a copy of the licensure check for one of the LPN's dated 8/17/11 (hire date 5/10/11). The second LPN licensure check was completed on 6/16/11 and date of hire was 6/8/11.",2015-05-01
9324,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2011-08-17,496,D,0,1,CVJ911,"On the days of survey, based on record review and interview, the facility failed to obtain registry verification prior to hire for 1 of 3 staff members performing the duties of Certified Nursing Assistants (CNA). The findings included: On 8/16/11 at 1:20pm, a review of the facility abuse/ neglect policy revealed screening would include contacting registries to ensure a potential employee was current and in good standing. On 8/17/11 at 10am, a review of personnel files revealed 1 CNA had been hired prior to being verified as in good standing with the abuse registry. During an interview on 8/17/11 at 10am, the Financial Manager confirmed no registry check was in the employee's folder. The Financial Manager presented a copy of the ""South Carolina Nurse Aides"" search for the CNA dated 8/17/11.",2015-05-01
9325,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,332,E,0,1,VY3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to ensure that it was free of medication error rates of 5 percent or greater. The medication error rate was 9.7 percent. There were 4 errors out of 41 opportunities for error. The findings included: Error #1- Observation of medpass on 10/24/11 at 4:08 PM revealed Licensed Practical Nurse (LPN) #5 checking a Finger Stick Blood Sugar (FSBS) on Resident A. The blood sugar result was 340 mg/dl (milligrams per deciliter). Observation of the Medication Administration Record [REDACTED]. The nurse was observed as she drew up 6 units of [MEDICATION NAME] R and took the syringe to the resident's bedside. She washed her hands and started to put on gloves when the surveyor stopped her and asked her to check the order for the medication again. She went back to the cart and checked the medication record for the dosage ordered. When asked, she stated she would have given the insulin (6 units) if the surveyor had not stopped her. She stated the resident was supposed to get 4 units. She then drew up 4 units of [MEDICATION NAME] R and administered this to the resident. Record review on 10/24/11 at 5:00 PM revealed cumulative Physician Order(s) for October 2011 for Resident A which included an entry for ""[MEDICATION NAME] R Insulin Sliding Scale FSBS before meals and at bedtime...301-350 = 4 units..."". Error #2- Observation of medpass on 10/24/11 at 5:24 PM revealed LPN #5 drawing up medications to administer to Resident B. She administered the resident's medications which included Klorcon M10, 10 meq. (millequivalents) 3 capsules to Resident B at approximately 5:30 PM. Review of the Medication Administration Record [REDACTED]. The resident had not received his meal at the time of the medpass. Review of physician's orders [REDACTED]. Observation by a surveyor revealed Resident B did not receive his meal tray until 6:20 PM. During an interview on 10/25/11 at 4:22 PM, LPN #5 was told that the Potassium had not been given with a meal. She stated she was aware the order for the medication stated to give with meals or after. She stated she had spoken to the Pharmacy related to the medication administration time not matching with dinner. She stated the resident usually ate anytime between 5:15 PM and a quarter to six. Error #3- Observation of medpass on 10/25/11 at 9:12 AM revealed LPN #6 drawing up [MEDICATION NAME] drops for Resident C. She drew up .22 ml (milliliters) in a syringe. Observation of the Medication Administration Record [REDACTED]. Before the nurse squirted the medication into the cup of orange juice, the surveyor asked her to verify the dosage with another nurse. LPN #6 then took the syringe to Registered Nurse (RN) #2 who stated the measurement on the syringe should be between the 2 and 3 (.2 and .3). LPN #6 then drew up .24 ml of the medication. When the surveyor questioned whether that was the correct dosage, she stated she would ask the Pharmacist. The Pharmacist Consultant told the nurse that the measurement should be between the 4 and the 6 (.24 and .26). The nurse then drew up .26 ml of the medication. The surveyor again questioned the nurse about the dosage and reviewed the markings on the syringe with the nurse. The nurse then drew up .25 ml of the medication and squirted it into the cup of orange juice. Review of Physician order [REDACTED]. Error #4- Observation of medpass on 10/25/11 at 10:18 AM revealed RN #2 drawing up medications to administer to Resident D. She administered the resident's medications which included a Mi-acid tablet (1) at approximately 10:30 AM. The medications had been crushed and/or emptied from the capsule and mixed in pudding. The resident took a bite out of a spoonful offered and swallowed at least one bite, but subsequently spit out and refused the majority of the medication. Review of Physician order [REDACTED]. Observation revealed the resident was offered and drank some of a cola drink at 10:48 AM. During an interview on 10/25/11 at 10:50 AM, Certified Nursing Assistant (CNA) #2 stated the resident's breakfast tray had been removed at 9:45 AM that morning. Observation at 10:57 AM revealed the resident sitting in the activity/dining room drinking her cola. She did not have a meal at the time of the medication administration. During an interview on 10/25/11 at 11:00 AM, RN #2 verified the Telephone Order stated that the Gas X should be given with meals. She stated that this resident's medications were usually given at 9:00 AM and were given late today. When asked why the medication had to be given with meals, she stated that it was given with meals related to the resident's upset stomach. During an interview on 10/25/11 at 10:53 AM, the Consultant Pharmacist was asked what she would expect related to medications being ordered to be given with meals. She stated it would depend on the medication, but in general, she would expect the medication to be given with a substantial snack/with a full stomach or with a meal or immediately after. She stated that she would include it if the medication had been given within an hour of a meal.",2015-05-01
9326,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,241,E,0,1,VY3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random meal observations and interviews, the facility failed to promote care for residents in a manner that enhanced their dignity and respect . Two of two dining rooms were observed with concerns related to meal delivery, crowding, and care of residents during feeding. The findings included: The facility admitted Resident #4 on 1/22/03 with [DIAGNOSES REDACTED]. Random observation on 10/24/11 at approximately 1 PM revealed Resident #4 being fed by a family member while 5 other residents were seated in the day room near 200 Unit and were not served or eating. One resident seated near Resident #4 asked the family member - Where was her food? Resident #4 had completed the meal before the other residents were served. Additional information provided by the facility revealed Resident # 4's family frequently fed the resident and an early tray was sometimes requested to accommodate the family schedule. It ws not disputed that the resident was fed in front of other residents who were waiting for their meals to arrive. While the five other residents were eating in the day area, staff were noted bring multiple residents from the main dining room and crowding them into the day room where the five residents were eating. Staff were noted stepping over residents to get in and out of the day room. Random observation on 10/25/11 at approximately 12:50 PM revealed a staff member feeding Resident #4 without identifying themselves or informing the resident what foods were being placed in his mouth. Resident #4 was heard asking the staff, ""Who are you and what are you doing?"" The resident was also heard telling the staff to not to put food in his mouth with him knowing what it was. The resident heard telling the staff to ""just stop"", he did not want anything. Random observation on 10/25/11 at approximately 12:55 PM revealed 5 to 6 residents eating the day room with multiple residents seated around them not eating. Staff were observed transporting residents who had eaten in the main dining and placing them in the day room around the residents who were just getting there food to eat. An interview on 10/25/11 at approximately 1 PM with CNA (Certified Nursing Aide) #1 confirmed the day area was congested with multiple residents while 5 to 6 residents in the day area were trying to eat. An interview on 10/25/11 at approximately 1:10 PM with the DON (Director of Nursing) confirmed the day area was crowd with residents who had already eaten in the main dining room while 5 to 6 residents were trying to eat. The DON further stated the residents who eat in the day area like eating in the day room to watch television. The DON acknowledged the residents who reportedly eat in the day room to watch television were positioned further away from the television than the other residents. On 10/25/2011 during observation of a meal at 12:05 PM in the Grace Cottage dining area, a resident was observed sitting at a table with 6 other residents. She remained at the table for 10 minutes while the other residents were eating before being served her lunch.",2015-05-01
9327,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,280,E,0,1,VY3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, care plans were not reviewed or revised related to the discontinuation of a Watchmate for Resident # 1; multiple episodes of [MEDICAL CONDITION] ( [MEDICAL CONDITION]) for Resident # 5; new falls and/or new interventions for Residents # 2 and #7; and [MEDICAL CONDITIONS] upon re-admission for Resident #2. ( 4 of 13 sampled residents reviewed for revision of care plans.) The findings included: The facility admitted Resident # 1 on 10/14/10 and readmitted the resident on 10/5/11 with [DIAGNOSES REDACTED]. Record review on 10/14/11 revealed a care plan for risk of leaving facility unattended related to exit seeking behavior. An intervention was listed as ""provide safety by using watchmate."" Further record review revealed no physician order for [REDACTED].# 7 (Licensed Practical Nurse) at 10:30 AM on 10/25/11 revealed the resident had had a hospitalization and returned to the facility on [DATE]. Upon return to the facility the resident was no longer able to get up or self propel without assistance and had no exit seeking behavior. No order was obtained for the continuation for a Watchmate; therefore the Watchmate was not reapplied. The nurse verified the resident did not have a Watchmate and that the care plan had not been updated to reflect the change. The facility admitted Resident # 5 on 4/19/10 and readmitted the resident on 9/12/11 with [DIAGNOSES REDACTED]. Record review on 10/24/11 revealed a care plan problem onset date of 2/28/10 for History of [MEDICAL CONDITIONS] with recurrent episodes of diarrhea. Further record review and interviews with the Nurse Consultant and MDS (Minimum Data Set) Coordinator on 10/25 and 10/26/11 revealed the resident had in fact had episodes of [MEDICAL CONDITION] on admission 2/28/10, 3/11/10, 4/7/10, 5/24/10, and 8/11/10. The care plan had not been updated to reflect the repeated episodes and treatment for [REDACTED]. The Coordinator stated she left the problem as it was because of the resident's history and that she had not added the reoccurring episodes to the care plan.. The facility admitted Resident #2 on 8/10/2011 and readmitted her on 9/23/2011 with [DIAGNOSES REDACTED]. Review of the resident's Nurses' Notes on 10/24/2011 at 3:40 PM, revealed the resident had fallen on 10/19/2011 at 9:31 PM from her bed. Resident #2's September Physician's Order Form (POF) indicated that she had no safety devices ordered for the month of September. Her October POF contained orders for ""Chair Alarm to wheelchair to alert staff of attempts to get up unassisted related to poor safety awareness secondary to [MEDICAL CONDITION] Encephalitis. Review of the resident's Care Plan revealed no update related to the fall nor further interventions to prevent falls . Additionally, review of Resident #2's record revealed that on 10/16/2011, she had positive test results for [MEDICAL CONDITION] (MRSA). Review of the resident's Care Plans indicated that her Care Plan had not been updated to [MEDICAL CONDITION]. In an interview with Licensed Practical Nurse (LPN) #4 on 10/25/2011 at 2:30 PM, she stated that the facility incident report does not include alarms. She also showed this surveyor the POF in the computerized charting. The Bed Alarm/ Chair Alarm had been stopped on 10/17/2011. When a copy of these orders were requested, the surveyor was told by the Corporate Consultant that they would not print as seen on the screen, a copy of the October POF was provided. The Bed Alarm was re-started on 10/25/2011 per LPN #4. The facility admitted Resident #7 on 7/7/2010 and readmitted him on 9/28/2011 with [DIAGNOSES REDACTED]. The resident's Nurses' Notes revealed that on 7/23/2011 he was ""noted"" to be sitting ""erect"" on floor. The notes do not indicate the location. The notes prior to and the day of the incident revealed that the resident ""propels self in wheelchair"". Review of the resident's Care Plan indicated that he was at risk for falls. The Care Plan was not updated to include the resident's incident nor interventions to prevent reoccurrence. The October 2011 POF contained no safety devices other than a DPM (Defined perimeter Mattress). On 10/25/2011 at 2:40 PM, review of the incident report did not indicate any safety measures in place. At 3:00 PM, during an interview with LPN#4, she stated that no interventions to prevent reoccurrence were necessary as the resident was unable to propel self around facility. Nurses' Notes dated 7/15, 7/22 and 7/23/2011 were reviewed with the LPN which documented the resident was propelling self in wheelchair. At that time LPN#4 stated that she remembered the resident not being able to propel self and she was not aware of what the nurses had documented. In an interview with the Minimum Data Set (MDS) Coordinator on 10/25/2011 at 4:15 PM, she stated that the facility does not update Care Plans for each incident. She verified that there was no Care Plan [MEDICAL CONDITION], she stated that she had "" missed that laboratory result.""",2015-05-01
9328,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,285,D,0,1,VY3711,"**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 ensure that a PASARR (Pre-Admission Screening and Resident Review) was completed prior to the Resident #21 admission into the facility. (1 of 3 closed records reviewed for PASARR completion) The findings included: The facility admitted Resident #21 on 6/17/11 with [DIAGNOSES REDACTED]. Record review on 10/25/11 revealed the resident was admitted on [DATE] and a PASARR was completed on 6/20/11. There was no documentation to indicate a PASARR was completed prior to the resident's admission into the facility. An interview on 10/25/11 at approximately 3:40 PM with the facility consultant and Social Services Director confirmed the findings.",2015-05-01
9329,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,309,E,0,1,VY3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of the facility's ""Recommended Procedure for the Care of the [MEDICAL TREATMENT] Resident"" policy, the facility failed to obtain a physician's order to provide the necessary care and services for 1 of 1 sampled residents reviewed for [MEDICAL TREATMENT]. Resident #14 had no physician's order related to receiving [MEDICAL TREATMENT] and no physician's order regarding a fluid restriction. Resident #9 pacemaker was not monitored by the facility. (1 of 2 sampled residents reviewed with a Pacemaker.) The findings included: The facility admitted Resident #14 on 9/07/11 with [DIAGNOSES REDACTED]. Record review of the resident's History and Physical revealed the resident was receiving [MEDICAL TREATMENT]. Further record review revealed the facility did not have a physician's order related to care and services of the [MEDICAL TREATMENT] resident. Review of the resident's care plan indicated Resident #14 was on a fluid restriction and could not have a water pitcher at the bedside. Review of the facility's ""[MEDICAL TREATMENT] Shunt Record"" form revealed inconsistent monitoring of the resident's access site. The facility's policy related to [MEDICAL TREATMENT] indicated nursing was to ""monitor for bleeding each shift and document."" An interview on 10/25/11 at approximately 4:45 PM with the DON revealed there was no physician order related the monitoring the access site and there was no physician's order related to the resident being on a fluid restriction. There was no documentation of the resident's fluid intake being monitored. An interview on 10/26/11 at approximately 8:35 AM with RN (Registered Nurse) #1 confirmed there was no physician's order for fluid restriction as indicated on the care plan. RN #1 further stated the resident had a Perma cath related to [MEDICAL TREATMENT] and no thrill and bruit would be monitored. However, there was inconsistent documentation of monitoring for thrill and bruit. The RN stated ""we were told by [MEDICAL TREATMENT] not to touch it."" RN#1 further stated there was no in intrajugular line. An interview on 10/26/11 at approximately 8:45 AM with LPN (Licensed Practical Nurse) #1 revealed the Dietary Department just told her to take the water pitcher out of the resident room and confirmed there was no fluid restriction physician's order. An interview on 10/26/11 at approximately 9:45 AM with the Dietary Consultant revealed there was no physician's order related to fluid restriction. The Dietary Consultant stated the facility communicated with [MEDICAL TREATMENT] and just took the water pitcher out of the resident's room. The facility admitted Resident #9 on 5/24/2011 and readmitted her on 10/14/2011 with [DIAGNOSES REDACTED]. Review of Resident #9's History and Physicals (H&P) and discharge summary's on 10/25/2011 at 12:20 PM, from hospital visits, dated 1/25/2011 and 10/6/11 indicated that Resident #9 had a Pacemaker. The resident's physician's documentation at the facility dated 5/27/2011 and 10/17/2011 noted the resident as having Pacemaker. The Nursing Admission assessment dated [DATE] had a Pacemaker site documented on the skin history and observations section as well as the in the history statement. Review of the admission Nurses' Notes also noted a Pacemaker site. Nurses' Notes dated 5/24/2011 stated ""has Pacemaker."" A copy of the Grace Cottage Pacemaker Schedule was reviewed on 10/25/2011. Resident #9 did not appear on the schedule. In an interview with the resident on 10/25/2011 at 4:15 PM, she stated that the Pacemaker had been checked at the physician's office but had not been checked since she came to the facility. She also stated that she ""thinks it is time for a check and that it is checked every 3 months."" At 4:25 PM on 10/25/2011, Licensed Practical Nurse (LPN) #3 (the evening shift Unit Manager) stated that she did not know the resident had a Pacemaker. LPN #3 also verified that the resident was not on the Pacemaker Schedule. The resident did have a Care Plan for a Pacemaker. No other information related to the resident's Pacemaker was provided until 10/25/2011 at 10:55 AM. A hand written document was provided by the Consultant. The document contained the resident's name, the clinic which managed the Pacemaker and appointments. The document indicated that on 6/8 the resident was a ""no-show"" for an appointment. The last pacemaker check was documented as 3/9/2011. In an interview with the facility Consultant,. she stated that the facility was not aware of the appointments .",2015-05-01
9330,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,371,F,0,1,VY3711,"On the days of the survey, based on observations, interviews and review of the facility's policy and procedure for Calibration Of Thermometers and Handling Food, the facility failed to Store, prepare, distribute and serve food under sanitary conditions. The facility's emergency food supply contained expired items. The freezer contained undated items and the sugar bin was left uncovered. Dietary Staff were unable to calibrate a thermometer; food items were handled with soiled gloves and staff meals were served while resident meals were being served. The findings included: During initial tour of the facility's kitchen area on 10/25/2011 at 10:40 AM, (24) -1.48 ounce containers of instant grits were noted to have expired on 10/21/2011 and were on a shelf in the emergency food area. The walk in freezer contained 4 large bags of fried green beans which were not in the original container and were not dated. At 10:50 AM, the sugar bin was observed to have the lid open. These items were verified by the Certified Dietary Manager/Registered Dietitian (RD/CDM) at the time they were observed by the surveyor. On 10/25/2011, during observation of the meal service in the facility's kitchen, the cook was unable to calibrate a thermometer. She attempted 2 different thermometers by putting them in ice water, they both reached a temperature of 40 degrees. The RD/CDM stated that they knew how to calibrate but did not have the tool needed to do this. The CDM/RD then provided a new/in the package digital thermometer to check the temperature of the food. A Cook in the kitchen was observed to touch oven door handles with gloved hands then remove a ""riblet"" from the warmer with the same gloved hands and placed it on a resident's plate. The riblet was not served and again the Cook picked up the riblet with soiled gloves and placed it back in the warmer. During the resident meal service, another kitchen staff member was observed to plate staff lunches with gloved hands, carry them to the door, open the door with the same gloves and then plate more staff meals multiple times touching the same serving utensils that were being used to serve the residents. In an interview with the staff member she did not dispute the surveyors observations. In an interview with the Corporate Consultant, she stated they used to have set times for staff meal service and that they needed to re-visit that issue. Review of the facility's policy entitled Calibration of Thermometers stated ""...Procedure: 1. Remove thermometer from sheath and immerse stem a minimum of 2 inches into an ice water bath. 2. Adjust calibration nut until the indicator reads 32 degrees...at sea level...A facility provided policy related to Food Handling stated...""Procedure: 1. When picking up food...use tongs, plastic gloves, or other suitable utensils. 2. Avoid cross contamination: Hands shall be washed or clean gloves/utensils used ...""",2015-05-01
9331,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,502,D,0,1,VY3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews the facility failed to provide or obtain laboratory services to meet the needs of its residents. The facility failed to enter and obtain laboratory orders for 1 of 1 residents who had been ordered a [MEDICAL CONDITION] panel. (Resident # 7) The findings included: The facility admitted Resident #7 on 7/7/2010 and readmitted him on 9/28/2011 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 10/25/2011 revealed a 9/21/2011 Physician's Telephone Order for a [MEDICAL CONDITION] Panel and a Liver Function Test to be obtained on 9/22/2011. Review of the Laboratory results for 9/22/2011 did not contain a [MEDICAL CONDITION] Panel. In an interview with Licensed Practical Nurse (LPN) #4,she verified that the [MEDICAL CONDITION] Panel was not drawn and stated that it had not been entered into the computer to be drawn.",2015-05-01
9332,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2011-10-26,274,D,0,1,VY3711,"**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 identify and complete a comprehensive assessment for significant changes in the resident's physical condition, mood, and activities of daily living (ADL) for 1 of 13 sampled residents reviewed for significant change. Resident # 8 had noted declines in ADL function and was readmitted with a catheter. No significant change assessment was completed. The findings included: The facility admitted Resident #8 on 6/28/10 and readmitted him on 7/25/11 with [DIAGNOSES REDACTED]. Record Review on 10/24/11 at approximately 3:30 PM revealed the Quarterly Minimum Data Set (MDS) with the Assessment Reference date (ARD) of 8/23/11 showed that a significant change assessment should have been completed rather than a quarterly. When compared to the Annual MDS assessment completed on 6/3/11 significant changes (declines) were noted in the mood severity score which went from minimum ""02"" to moderate ""11"". In Section G of the document which describes the ADL Performance and Support, the 6/3/11 annual coded Resident #8 ""3"" for extensive assistance and ""2"" 1 person assist with walking in corridor. The 8/23/11 quarterly assessment compared with the 6/3/11 annual coded ""8' for did not occur for walking in the corridor. In Section H of the MDS the 6/3/11 annual coded Resident #8 to not have any appliances such as a catheter. The 8/23/11 quarterly MDS coded Resident #8 as an A, which means he now has an indwelling catheter. Section K of the 6/3/11 annual MDS noted the resident to weight 202 pounds with no weight loss. Review of the 8/23/11 quarterly MDS revealed Resident #8 to weight 182 and was coded as a ""2"", not a physician prescribed weight loss. During an interview on 10/25/11 at approximately 12 PM, the MDS Coordinator reviewed the MDS assessment records for 6/3/11 and 8/23/11. The MDS Coordinator stated Resident #8 was showing improvement and ""as a team we were considering if a significant change should have been done"". After reviewing the MDS, the MDS Coordinator verified that significant changes had occured and stated it should have been done.",2015-05-01
9333,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,253,E,0,1,UJW911,"On the days of the survey, based on observations and interviews, the facility failed to provide effective housekeeping and maintenance services for the bathrooms on one of two resident care units. Multiple rooms/bathrooms on the 200 Hall had soiled walls and baseboards, as well as stained floors, toilet bowls, and sinks. In addition, the 100 Hall Spa #2 had excessive soiled build-up on the baseboards. The findings included: During the Initial Tour on 200 Hall with Licensed Practical Nurse #4 on 5-31-11 beginning at approximately 11:30 AM, and during the environmental tour with the Maintenance Supervisor and Administrator on 6-2-11 at 9 AM, the following housekeeping/maintenance concerns were identified and confirmed: -Room 202 bathroom had pink-orange build-up on the baseboards. -Toilets had rust-colored stains inside the bowls in the bathrooms for Rooms 203, 205, 206, 207, 208, 209, 211, and 215. -Bathroom floor covering was stained (rust-colored) behind toilets and/or in corners around the toilet and sink areas in Rooms 205, 206, 207, 208, 209, 211, 212, 213, 214, and 215. -Bathroom baseboards had heavy pink-orange build-up in Rooms 202, 206, 208, 209, 210, 214, and 215. -Rooms 207 and 209 bathrooms had cracked toilet bowls and the grout at the bases was soiled dark brown/black. -Bathroom sinks were in poor repair in Rooms 208, 209,211, 213, 214, and 215. They appeared as if unsuccessful attempts had been made with either porcelain repair or some type of paint, resulting in a chalky appearing porous-type substance on the surfaces. -Dried spills were noted on the walls in the bathrooms in Rooms 205 and 207. During the initial tour of the facility on 05/31/11 at approximately 12 noon, an observation was made of the Spa Room on the 100 unit. The shower in the Spa Room was observed to be soiled with a filmy build-up around the bottom of the shower walls. Multiple observations were made during the survey and the condition of the shower stall remained unchanged.",2015-05-01
9334,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,425,D,0,1,UJW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of the facility policy entitled ""MEDICATION STORAGE IN THE HEALTHCARE CENTERS (11/07), "" the facility failed to follow a procedure to ensure proper storage and disposal of single use medication. The findings included: During the Initial Tour on 06/01/2011 at 10:30 AM, in room [ROOM NUMBER], one open 100 ml (milliliter) single use bottle of Normal Saline with a date of 04/26 on the lid was noted on the bedside table. Also, in a zip-lock bag, there was an open/ undated bottle of the same solution. In room [ROOM NUMBER], two 100 ml single use bottles of Normal Saline were noted on the bedside table. During observation and interview on 06/01/2011 at 1:20 PM, Registered Nurse (RN) #2 verified the above observations and stated that, once open, the bottles of Normal Saline were only good for 24 hours. Upon request, a copy of the facility's policy entitled ""MEDICATION STORAGE IN THE HEALTHCARE CENTERS (11/07)"" was obtained from the Director of Nursing on 06/01/2011. However, the policy failed to address the use and storage of this product.",2015-05-01
9335,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,314,D,0,1,UJW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to provide care and services to promote the prevention of pressure ulcer development for two of ten sampled residents reviewed for care and services. The facility failed to turn and position Residents #4 and #6 as ordered by the physician. Both resident's had a history of [REDACTED]. The findings included: The facility admitted Resident #4 on 10/16/2006 with [DIAGNOSES REDACTED]. limited to Altered Mental Status, Spinal Cord Disease, Spondylosis, Multiple Joint Contractures, Failure to Thrive, Diabetes Mellitus, and History of Pressure Ulcer. During multiple observations (on 06/01/2011 at 10:40 AM, 11:10 AM, 12:08 PM, and 6:00 PM), Resident #4 was noted laying on her back in bed. On 06/01/2011 at 2:40 PM and 3:40 PM the resident was observed in the geri- chair. Record Review on 06/01/2011 at 10:45 AM revealed a physician's orders [REDACTED]. ""TURN Q2HR (every two hours)."" Review of the ""ADL (activities of daily living) CARE PLAN RECORD"" revealed that staff was to turn and position "" the resident every two hours"". Further review revealed that the resident was care planned for ""Potential for pressure ulcer/skin breakdown due to impaired mobility and incontinence of bowel and bladder"". Approaches included ""Turn and position frequently"". Record review also revealed a 11/23/2010 ""BRADEN SCALE-FOR PREDICTING PRESSURE SORE RISK"" score of 11. (A score of 12 or less represented high risk.) During an interview on 06/01/2011 at 3:30 PM, the physician's orders [REDACTED]. and positioning every two hours was confirmed by Licensed Practical Nurse (LPN) #2. The facility admitted Resident #6 on 4/7/10 with [DIAGNOSES REDACTED]. Record review on 5/31/11 at 4:30 PM revealed current physician's orders [REDACTED]. Avoid direct pressure over wound site while limiting side lying position to 30 degree tilt and/or HOB (Head of Bed) elevation to 30 degrees in bed."" Review of the Care Plan revealed the Problem: ""Actual pressure ulcer/Skin breakdown due to impaired mobility."" Under the Approaches was listed: ""Assist and encourage frequent position changes."" It was observed on 5/31/11 at 4:10 PM, and 6:20 PM that Resident #6 was flat on her back with the head of the bed at a 30 degree angle of elevation. No position change was noted during these times. It was observed on 6/1/11 at 8:30 AM, 10:15 AM, 12:15 PM, and 1:10 PM, that Resident #6 was flat on her back with the head of the bed at a 30 degree angle. No change of position was noted during these times. During an interview on 6/1/11 at 4:20 PM, Certified Nursing Assistant (CNA) #1 admitted that Resident #6 had only been turned at 3:00 PM that day and she could not remember turning her the day before. Record review revealed that CNA #1 was the assigned care giver for Resident #6 on 5/31/11 and 6/1/11. During an interview on 6/1/11 at 5:25 PM, the Director of Nursing stated that her expectations for care of a resident that was at risk for skin break down or that had a pressure ulcer was to ""Turn every two hours.""",2015-05-01
9336,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,281,D,0,1,UJW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview and review of the Advisory Board Opinion ""Nursing Management Of Invasive Devices (Catheter, Lines and Tubes)"", the facility failed to provide services that met professional standards for one of one sampled residents reviewed with a suprapubic catheter. A suprapubic catheter change was performed on Resident #7 by a Licensed Practical Nurse (LPN) who had not received training or education to perform this task. The findings included: The facility admitted Resident #7 on 3-14-07 with [DIAGNOSES REDACTED]. Record review on 6-1-11 at approximately 12:30 PM revealed a physician's orders [REDACTED]."" Review of the Nurses Notes revealed Licensed Practical Nurse (LPN) #1 performed a suprapubic catheter change on 5-26-11 at 4:45 PM. Review of the facility's policy and procedure on suprapubic catheter change on 6-2-11 at approximately 1:00 PM revealed that it did not stipulate what qualified or licensed staff should perform this task or what the professional qualifications were. Review of the ""Nursing Management of Invasive Devices (Catheter, Lines and Tubes)"" from the South Carolina Board of Nursing confirmed that an LPN could perform a suprapubic catheter change with specialized education and training, which the facility failed to provide for LPN #1. . During an interview with the Director of Nursing (DON) on 6-2-11 at approximately 10:45 am, she confirmed the identity of LPN #1 by verifying her signature on the facility's ""Bamberg County Nursing Center Licensed Staff Signature Sheet"", and that LPN #1 was an LPN. The DON confirmed there was no inservice or specialized training provided to nursing staff regarding suprapubic catheter change, and she verified that after speaking with LPN #1, she had not received any prior training or competency.",2015-05-01
9337,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,164,D,0,1,UJW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the South Carolina Nurse Aide Candidate Handbook the facility failed to provide full visual privacy for two of eight residents observed for treatments. During observation of wound care, Resident # 1 was overly exposed, the privacy curtain was not pulled entirely, and a Certified Nursing Assistant (CNA) entered the room several times to attend to the roommate. Resident #6 was overly exposed during Foley catheter care. The findings included: The facility admitted Resident #1 on 8-10-07 with [DIAGNOSES REDACTED]. During observation by two surveyors of sacral wound care to Resident #1 on 6-1-11 at 12:35 PM, Registered Nurse (RN) #2 failed to close the privacy curtain entirely. It was pulled from the wall to the end of the bed on both sides, leaving the entire end of the bed exposed. Resident #1 was in a semi-private room in the bed nearest the door. Certified Nursing Assistant (CNA) #2 knocked and, without waiting for someone to give permission, entered and walked past Resident #1's bed to deliver a lunch tray to the roommate. The CNA then walked past the bed again to exit the room. Several minutes later CNA #2 knocked and entered the room, even though RN #2 stated she was ""doing a dressing."" She walked past the foot of the bed to deliver an overbed tray table, and then walked past the bed again to enter the bathroom to wash her hands. She returned to the roommate to set up the lunch tray, and then walked past to exit the room. During this time, Resident #1 was lying on her right side with her entire back side of her body exposed. During an interview on 6-1-11 at approximately 1:00 PM with RN #2 and CNA #1, when asked if they had observed CNA #2 enter the room without knocking on her third entrance, they both said they ""were not paying attention."" The facility admitted Resident #6 on 4-7-10 with [DIAGNOSES REDACTED]. During observation of Foley catheter care to Resident # 6 on 6-1-11 at 11:15 am, CNA # 3 removed the sheet off Resident # 6 and pulled her gown up to her chest and began the procedure. The Resident remained exposed from the chest to the toes during the entire procedure. The CNA failed to cover the areas of the body that were not necessary to be exposed. The South Carolina Nurse Aide Candidate Handbook under Catheter Care page 28, state: ...""Provides for client's privacy during procedure with curtain, screen or door....Exposes only area surrounding catheter.""",2015-05-01
9338,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,323,E,0,1,UJW911,"On the days of the survey, based on observations, interviews, and record reviews, the facility failed to provide residents with safe water temperatures on one of two nursing care units. Water temperatures above 120 degrees Fahrenheit were recorded in residents' bathrooms and the shower room on the 200 Hall. The findings included: During the Initial Tour beginning at 12:05 PM on 5/31/11, the water in Room 205 bathroom felt exceedingly warm. The water temperature was taken with the surveyor's digital thermometer which recorded a temperature of 131.3 degrees Fahrenheit (F). In Room 208 bathroom, a reading of 134.6 degrees was noted. At 12:15 PM, in the residents' shower room (north 200 wing), the water temperature was 134.5 degrees. During an interview on 5/31/11 at 2:10 PM, the Maintenance Supervisor stated that the water temperatures were ""monitored everyday with a thermometer."" At 2:10 PM in Room 223, the Maintenance Supervisor and Environmental Consultant recorded a water temperature reading of 128.3 F. Across the hall, in Room 224, a water temperature of 129.6 degrees was noted. The residents' shower room near Room 209, on the other end of the 200 Hall, registered 133.9 degrees. The Maintenance Supervisor stated, ""The water temperatures were too high. They should not be over 120 degrees."" The Maintenance Supervisor then stated that he had had ""problems with the water heater"" in the past, but ""had not been contacted by the (Maintenance) Assistant in a couple of weeks for high temperatures."" During an interview on 6/1/11 at 2:00 PM, the Administrator stated that the water temperatures were to be monitored every day and that he was kept informed of trends. He stated, ""I review water temperatures every month"", and was ""aware of the possibilities"" of potential outcome to the residents. Following the Initial Tour, surveyors checked and recorded water temperatures in resident rooms throughout the facility. The 100 Hall had temperatures within the acceptable range. Water temperatures were recorded on the 200 Hall as follows: Room 223 = 125 F, Room 224 = 126.5, Room 222 = 127.9, Room 225 = 128, Room 221 = 128.5, Room 226 = 128.3, Room 227 = 128.8, Room 220 = 130.3, Room 228 = 132.1, Room 218 = 133.5, Room 219 = 132.7. During an interview on 5-31-11 at approximately 2:20 PM, the Maintenance Supervisor stated that the Maintenance Assistant was responsible for taking water temperatures and did so with a laser-type (point and shoot) thermometer. When asked about the operation of the device as he stood back from the sink to determine the water temperature, he stated that the temperature was measured when the laser ""comes in contact with water"". The Environmental Consultant stated that the thermometer had to be within 2 feet of the water source and retook the temperatures using a digital device. The digital device measured the temperatures 2.3 to 3.6 degrees higher than the laser. During an interview on 5-31 11 at 4 PM, the Maintenance Supervisor stated that his assistant usually let him know about temperature concerns but had not done so recently. He stated that water temperatures were rechecked and water heaters adjusted when outliers were brought to his attention. However, he estimated that no concerns had been brought to his attention since ""prior to April"". When asked if an outside contractor serviced the boilers/hot water heaters, he stated that this was not done routinely. The contractor had come in approximately three months previously to service a unit because of ""no hot water"". Review of the Water Temperature Daily Logs on 5-31-11 revealed that during the month of 5-2011 to the date of the survey, water temperatures for the 200 Hall were recorded at greater than 120 and up to 130 degrees on 12 days. Water temperatures for the 200 Hall were recorded at greater than 120 and up to 140 degrees for 21 of 30 days in 4-2011. Water temperatures for the 200 Hall were recorded at greater than 120 and up to 135 degrees for 29 of 31 days in 3-2011. During an interview (with the Administrator present) at 4:40 PM on 5-31-11, the Maintenance Assistant stated that he reported to work at 7 AM and ""CNA's come at me"" because the water ""is not hot enough"". He stated that if the water was too hot, he would report it to the supervisor who would then adjust the water heater. He stated that he had had no recent problems with the water being too hot. When asked at what water temperature he would let his supervisor know, he stated, ""If over 125-127."" Later in the interview, the Assistant stated, ""Water temps shouldn't go over 120. 125 to 130 is too hot."" During an interview on 6-1-11 at 11:30 AM, the contractor who did repair service for the facility stated that he had not been aware of any concerns about water temperatures being too hot in the resident care areas until notified on 5-31-11. Receipts for service calls were reviewed and he confirmed that in 2-2011, he had been contacted for ""no hot water"". In 3-2011, he had serviced the water heater supplying the kitchen and laundry areas. The contractor noted that the mixing valve had been replaced several years ago. He reviewed the logs and stated he had not been advised that the water temperatures were running high or that the facility was unable to maintain consistent temperatures within the acceptable range. On 6-1-11 at 2 PM, when asked if he checked the water temperature log, the Administrator stated he ""usually checked them once a month and should have caught it"". He stated he expected the water temperatures to be monitored daily and would expect immediate notification and intervention if results were outside acceptable parameters. The Administrator stated that he would also expect the temperatures to be rechecked and the results of any intervention documented. Review of the facility policy provided by the Administrator on 6-1-11 noted: ""Plumbing fixtures that require hot water and that are accessible to residents shall be supplied with water that is thermostatically controlled to a temperature.....not to exceed one-hundred and twenty (120) degrees Fahrenheit at the fixture."" During group interview, two of five residents complained that the water was too cold; and three of five resident's stated the water fluctuated between hot and cold. There were no documented negative resident incidents related to elevated water temperatures",2015-05-01
9339,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,407,D,0,1,UJW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to provide Physical and/or Occupational Therapy services as ordered in a timely manner for 2 of 4 sampled residents reviewed for rehabilitation services. A Physical Therapy consultation ordered on 4-13-11 for Resident #6 was not done until 4/20/11. Resident #7 had a 4-14-11 order for Occupational Therapy and Physical Therapy consultations which were not done until 4-27-11 and 4-28-11. The findings included: The facility admitted Resident #6 on 4/7/10 with [DIAGNOSES REDACTED]. Record review on 6/2/11 at 8:30 AM revealed Nurses Notes written on 4/13/11 at 11:00 PM which indicated that a new order had been received from the Physician for a ""PT (Physical Therapy) Consult."" Review of Physician's Interim Orders on 4/13/11 at 11:00 PM revealed ""Consult PT for ROM (Range of Motion) exercises."" Further documentation revealed that Resident #6 was not seen until 4/20/11 for loss of ROM. During an interview on 6/2/11 at 10:20 AM, the Rehabilitation Director stated, ""We are notified within 24 hours of the order written.'' At 10:40 AM she stated, ""We were short of staff that week and PT came in on the twentieth for evaluations."" She indicated that the Registered Therapist only came to the facility on a weekly basis to conduct the therapy evaluations. The Rehabilitation Director then provided a note that stated, ""PT came in on 4/20 for evals (evaluations)/sups (supervision)."" The Facility admitted Resident #7 on 3-14-07 with [DIAGNOSES REDACTED]. Record Review on 6-1-11 at 12:30 pm revealed a physician's orders [REDACTED]."" A xeroxed copy of this order was attached to the original with a note to the physician of the facility dated 4-20-11 stating ""Need u (you) to write an order if you want him to have PT/OT."" One week later on 4-27-11 a physician's orders [REDACTED].-28-11 a physician's orders [REDACTED]."" Further review of the Physical Therapy record on 6-1-11 at 12:30 pm revealed Resident #7 did not receive a Physical Therapy consultation until fourteen days later on 4-28-11. During an interview with the Director of Nursing on 6-2-11 at approximately 10:05 am, she confirmed that Resident #7 did have a PT/OT order written on 4-14-11 and after she spoke with the physical therapy department, she ""does not know why"" the order was not implemented until 4-28-11. She said that she remembers discussing that the resident had an order for [REDACTED].",2015-05-01
9340,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,441,E,0,1,UJW911,"On the days of the survey, based on observation, interviews, review of laundry temperature logs, and review of the facility policy entitled ""Temperature Control"", the facility failed to implement procedures to ensure that personal laundry was being hygienically cleansed. The findings included: During observation of the laundry process on 6-1-11 at 9:30 AM, the Housekeeping/Laundry Supervisor and Laundry Aide stated that the personal laundry was being sanitized by maintenance of the hot water temperatures over 160 degrees. The bleach dispenser had a red light flashing on it, which the Aide indicated meant ""It's empty."" Both staff noted that bleach was not used. The Supervisor stated that she thought there was bleach in the detergent, (Solid Super Star) but review of the manufacturer's information did not support this. The Supervisor stated that water temperatures were taken every morning and were recorded consistently at greater than 160. She provided logs which corroborated this. However, upon direct observation, both washers were in use and set on ""warm"" instead of ""hot"". The surveyor asked the Laundry Aide to check the water temperature entering one of the washers with the facility's routinely-used digital thermometer. The temperature of the water was 80.2 degrees. During an interview on 6-1-11 at approximately 10 AM, after the Administrator was advised of the washer settings, he confirmed that the water temperatures in the washers should have been maintained at over 160 degrees. He provided for review the facility policy which stated: ""Hot water provided for washing linen and clothing shall not be less than one-hundred and sixty (160) degrees Fahrenheit...""",2015-05-01
9341,PRUITTHEALTH BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2011-06-02,463,E,0,1,UJW911,"On the days of the survey, based on observation and interviews, the facility failed to ensure that all portions of the call systems were fully functional. Random observations revealed that the call system in the 200 Hall Shower Room did not have a visual signal outside the door. Also, the 100 Hall audible system was observed to be turned off at the nursing station on 6-2-11. The findings included: During the Initial Tour on 200 Hall with Licensed Practical Nurse (LPN) #4 on 5-31-11 beginning at approximately 11:30 AM, and during the environmental tour with the Maintenance Supervisor and Administrator on 6-2-11 at 9 AM, the facility staff verified that the three call lights in the Shower Room did not have a visual signal outside the door. LPN #4 stated that the call lights had not worked properly for ""some time"" (unspecified). The Maintenance Supervisor stated that he was unaware of the needed repair. The surveyor requested preventive maintenance records for the call system, but none were provided for review. Prior to a treatment observation on the 100 Hall on 6-2-11 at 11:20 AM, and immediately after completion of the treatment, a call light was ""on"" in the corridor outside of Room 127. No audible signal was heard at the nursing station. There were four staff members in the immediate area. When the surveyor brought this to the staff's attention in the presence of the Unit Manager, one of the staff reached over the counter of the nursing station and turned the audible portion of the call system panel ""on"".",2015-05-01
9342,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,241,D,0,1,4KMU11,"On the days of the survey, based on random observations and interviews, the facility failed to promote care for residents in a manner that enhanced their dignity and respect related to dining for 1 of the 3 Units observed and random observation of staff member pulling a resident backward in Geri chair. The findings included: A random observation on 6/21/11 at 3:25 PM on the 600 Unit revealed a CNA #3 pulling a resident backward from the day area near the nursing station to his room down the hall. The resident was heard asking the CNA ""Why are you pulling me. I do not want to go"". Registered Nurse (RN) #5 was observed trying to calm resident down in front of his room. An interview on 6/21/11 at approximately 3:30 PM with CNA #3 revealed she had difficulties in pushing the Geri chair forward so resident was pulled backward. CNA #3 further stated ""I know I should not have pulled the resident backward but it was more comfortable to pull him backward."" An interview on 6/21/11 at approximately 3:35 PM with RN #5 confirmed the resident was pulled backward and staff was aware not to pull residents backward. On 6/20/11 at 12:30 PM, observation of lunch meal service was conducted on the 600 Unit dining room. It was observed that staff served only 1 and sometimes 2 residents per table before moving to the next table, resulting in all residents seated at the same table not being served at the same time. Staff was observed placing clothing protectors on residents without asking if they wanted to wear one or not.",2015-05-01
9343,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,250,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interviews, record review, and review of the dacility admission packet, the facility failed to provide medically related social services for 1 of 1 resident with known dental problems. Resident #7 with history of dental problems on admission and care planned on 5/16/11 for a dental referral due to ""evidence of dental caries and broken tooth/teeth"" and no referral was made by Social Services. The findings included: The facility admitted Resident #7 on 12/15/10 with [DIAGNOSES REDACTED]. During an individual interview on 6/20/11 at approximately 3:20 PM Resident #7 was asked ""Can you get to see a dentist, podiatrist or other specialist if you need to?"" Resident #7 stated he had asked to see a dentist because he had a tooth that needed to be pulled. The resident further stated he told facility staff that he had a tooth ache related to dental concerns. Record review revealed a care plan updated 5/16/11 that indicated resident had dental or oral cavity health problems as evidenced by dental caries and broken tooth/teeth. The recommended intervention was to refer resident to dentist/hygienist for evaluation related to teeth to be pulled or repaired. During an interview on 6/21/11 at approximately 3:50 PM with the Social Services Director (SSD), the SSD stated ""I made a referral a while back related to the dental care."" The SSD confirmed there was no documentation in the chart to indicate a referral was made to the dentist. The SSD further stated he was aware the resident had dental concerns since admission but there was some confusion with the facility dental provider related to an unpaid account. The SSD confirmed the resident had no appointment to see the dentist. On 6/22/11 the SSD provided documentation that the resident had a dental appointment set for 6/23/11. Review of the facility's admission packet page 3 under ""Social Workers"" indicated a social worker ""can help ......refer you to community resources, provide support regarding your health care needs.""",2015-05-01
9344,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,251,E,0,1,4KMU11,"On the days of the survey, based on interviews, the facility failed to employ a qualified social worker in a facility with more than 120 beds on a full time basis. Based on South Carolina Code of Laws, Title 40, Section 40-63-30 a qualified social worker must be licensed in the State of South Carolina to practice social work in the state. The findings included: An interview on 6/23/11 at approximately 1:15 PM with the facility Administrator confirmed the facility did not have a Social Worker in the facility and that they have 2 staff members who provide social services. The Administrator stated the facility Social Service Director (SSD) was not a licensed social worker and the other staff member that provide social services was not licensed. The Administrator was referred to the South Carolina State Laws web page related to social workers must be licensed in the State of South Carolina in order to be identified as a qualified social worker. The Administrator was also referred to the federal guidelines that indicated some State or local laws are more stringent than the Federal requirement on the same issue. Review of the facility's admission packet page 3 under ""Social Workers"" indicated a social worker ""can help you plan for discharge, identify sources of financial assistance, refer you to community resources, provide support regarding your health care needs.""",2015-05-01
9345,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,309,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to implement a physician's order for vital signs for one of twelve sampled residents receiving antihypertensive medication. Resident #8 had a physician's order to hold her AM dose of antihypertensive medication and monitor vital signs every two hours for the next eight hours. The medication was held but the vital signs were not monitored as ordered. The findings included: The facility admitted Resident #8 on 6-28-06 with [DIAGNOSES REDACTED]. Record review on 6-22-11 at 10:30 AM revealed a physician's order for ""Do not give [MEDICATION NAME] CD 240 mg (milligrams) cap (capsule) po (by mouth) AM (morning ) dose 3-31-11 only. Do not give [MEDICATION NAME] 50 mg tablet po AM dose 3-31-11 only. VS (Vital Signs) every two hours for 8 hrs (hours)."" Review of the Nurses Notes and the Blood Pressure Summary revealed that the blood pressure was only taken on 3-31-11 and at 13:37, 1600, and 1610. There was no documentation that a complete set of vital signs were not monitored every two hours for 8 hours as ordered by the physician. During an interview with the Unit Manager on 6-22-11 at approximately 10:50 AM, she stated that Vital signs were recorded in the Medication Administration Record [REDACTED]. She confirmed that the vital signs as ordered by the physician were not documented on the Blood Pressure Summary, the Medication Administration Record [REDACTED]",2015-05-01
9346,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,364,E,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interviews and observations, the facility failed to provide foods (grits) that was at the proper temperature for 1 sampled residents (Resident #7), 5 random rooms on the 400 Unit and 7 of 8 group members expressed concerns related to food served cold and staff will not reheat. The findings included: The facility admitted Resident #7 on 12/15/10 with [DIAGNOSES REDACTED]. During an individual interview on 6/20/11 at approximately 3:20 PM Resident #7 expressed concerns that his breakfast meal was not served hot. The resident indicated his grits were cold and stiff. The resident further indicated he has asked staff to reheat foods but they are too busy passing out trays. During observation of breakfast on 6/21/11 at approximately 8:02 AM, the resident received grits for breakfast. The resident placed a soft butter spread on the grits and the butter did not melt and no steam was noted coming from the grits. On 6/21/11 at 8:05 AM Registered Nurse (RN) #4 confirmed the findings that the butter did not melt. RN #4 stated she would not want cold grits served to her. Random observation in rooms 405 at 8:07 AM, Room 403 at 8:10 AM, Room 407 at 8:13, Room 400 at 8:15 AM and Room 408 at 8:16 AM noted residents with grits with soft butter that did not melt on the grits. During an interview on 6/21/11 at approximately 8:17 AM with Certified Nursing Assistant (CNA) #1, when asked ""what does it mean when soft butter does not melt on grits?"" CNA #1 stated she did not know why the butter was not melting and ""she just puts it in and stirs it up"". During an interview on 6/21/11 at approximately 8:40 AM with CNA #2, when asked ""what does it mean when soft butter does not melt on grits?"" CNA #2 stated ""The grits were not hot"". During group interview on 6/21/11 at approximately 10 AM , 7 of 8 group member identified by the facility as being interviewable, stated they received cold grits and that sometimes lunch and dinner meals were served cold "" if you eat in your room"". The group members further stated they have shared the concerns related to cold meals and no changes have been made. During the days of the survey, food service carts were noted placed on the units for long periods of time before meals were served.",2015-05-01
9347,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,492,D,0,1,4KMU11,"On days of the survey based on interview and record reviews, the facility failed to ensure that the required 48 hours ""Notice of Medicare Provider Non-Coverage"" was submitted timely for 2 of 3 sampled residents reviewed. The CMS (Centers for Medicare and Medicaid Services) form was not completed with the effective date the coverage of services would end. The findings included: An interview and observation on 6/21/11 at approximately 2:45 PM with the Business Office Manager revealed 2 of three ""Notice of Medicare Provider Non-Coverage"" notices were not completed with effective date the medicare coverage would end and there was no documentation that a notice was given to a resident. There was no documentation to ensure the residents and/or responsible parties were informed timely (required 48 hours) to request further services. An interview on 6/21/11 at approximately 2:55 PM with the Social Services Director (SSD) confirmed they could not locate a notice for one resident and there was no end of service date on the CMS for for another resident.",2015-05-01
9348,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,281,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of the ""Saunders Nursing Drug Handbook 2008,"" the facility failed to provide professional standards of care by not monitoring blood pressures (B/P) for one of twelve sampled residents reviewed receiving antihypertensive medication. The nursing staff was administering two antihypertensive medications every morning to Resident #8 without monitoring her B/P or heart rate prior to administration. One of the medications had a significant decrease in dosage without appropriate monitoring of the B/P or heart rate. The findings included: The facility admitted Resident #8 on 6-28-06 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Record review on 6-21-11 at 9:45 AM revealed that the resident was sent to the emergency roiagnom on [DATE] for evaluation of a laceration to her left leg received during a transfer. The Nurses Notes stated that the ""MD (medical doctor) was on the unit and assessed the resident"" with a B/P of 99/48 and pulse of 60. Review also revealed physician's orders [REDACTED]."" physician's orders [REDACTED]."" Review of the MAR's and the ""Blood Pressure Summary"" sheet confirmed that there was no B/P or heart rate monitoring done during the month of April, 2011, up until the physician wrote the order on 5-6-11 to do a daily B/P. Continued review revealed that nursing staff had been administering two antihypertensive medications since at least 4-1-11 without regularly monitoring the B/P and heart rate until the physician wrote the order on 5-6-11. During an interview with the Unit Manager on 6-22-11 10:50 AM, she stated that the facility had no policy on monitoring B/P and that she would administer these B/P medications without monitoring the B/P and heart rate unless the physician ordered the B/P and heart rate to be taken. During an interview with Registered Nurse (RN) #6 on 6-22-11 at 10:55 AM, she stated she ""takes the B/P each time just prior to administering the B/P medication."" When asked where she recorded it, she stated, ""If there is not a place for it marked on the MAR, then I don't record it."" Review of the ""Saunders Nursing Drug Handbook 2008,"" page 367, for administration of [MEDICATION NAME] CD, revealed ""Nursing Considerations...to assess B/P, apical pulse immediately before drug is administered."" On page 765, for administration of [MEDICATION NAME], ""Nursing Considerations"" stated ""Assess B/P , apical pulse immediately before drug administration (if pulse is 60/minute or less or systolic B/P is less than 90 mm Hg, withhold medication, contact physician."" Listed under ""Side Effects"" of both of these drugs is ""Dizziness...contact physician if dizziness occurs."" On page 367, under Adverse Effects of [MEDICATION NAME], it stated ""Abrupt withdrawal may increase frequency, duration of [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), second- and third-degree AV (Atrioventricular) block occur rarely.""",2015-05-01
9349,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,314,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and review of Perry and Potter 7th Edition, pages 178-179 Center for Disease Control and Prevention Isolation Guidelines, the facility failed to ensure that Resident # 6, with a Stage IV pressure Ulcer received the necessary care and services to promote healing and prevent infection. (1 of 3 sampled residents observed for Pressure Ulcer treatments.) The findings included: Resident #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review revealed a care plan [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus), a drug resistant infection. On 6/21/11 at 1:10 am, an observation was made of Licensed Practical Nurse ( LPN ) # 2 providing pressure ulcer care to a stage IV Pressure Ulcer treatment to the coccyx and an observation of wound care to the right upper thigh. LPN # 2 removed a soiled dressing to the right thigh and without changing gloves/washing her hands, cleansed the area with wound cleanser. Continuing to wear the same gloves, she opened a dressing, applied it to the wound bed area and applied a foam adhesive dressing. After removing her gloves, she dated and initialed the dressing before washing her hands. The LPN then provided care to the stage IV pressure ulcer on the coccyx. Wearing gloves, she removed the soiled dressing, discarding it into a red bag. Without changing gloves/washing hands, she applied wound cleanser and cleaned the area with a 4 x 4 . Continuing to wear the same gloves, she applied [MEDICATION NAME] powder to the wound bed, covered the area with a dressing, and dated and initialed the dressing. The contaminated gloves were not removed until after positioning the resident. Review of the professional resource of Perry and Potter 7th Edition, pages 178-179 Center for Disease Control and Prevention Isolation Guidelines states: ...""change gloves during patient care if the hands will move from a contaminated body site to a clean body site""; and ""perform hand hygiene in the following situations:...After contact with...wound dressings"".",2015-05-01
9350,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,425,D,0,1,4KMU11,"On the days of the survey, based on observation, interview, and review of the policy provided by the facility entitled ""Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles"", the facility failed to ensure an outdated vial of Sterile Water for Injection and expired lab supplies were removed from 2 of 3 medication rooms. The findings included: Observation of the Medication Room on the 500 Unit on 6/22/11 at 8:30 AM revealed one- 10 milliliter (ml) vial of Sterile Water for Injection that had been dated as having been opened on 10-30-10. This was verified by Registered Nurse (RN) #1. Observation the Medication Room on the 400 Unit on 6/22/11 at 8:55 AM revealed a caddy containing lab supplies which included 8 red topped Vacuettes labeled ""serum clot activator"" and 1 pink 60 milliliter (ml) Vacutainer labeled ""KZedta 10.8 mg"" that had expired in ""2/2011"". This was verified by RN #2. Review of the policy entitled ""Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles"" dated 12/1/07 revealed that ""...13. The Facility should destroy or return all discontinued, outdated/expired, or deteriorated drugs or biologicals in accordance with Pharmacy return/destruction guidelines. 14. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis"".",2015-05-01
9351,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,371,F,0,1,4KMU11,"On the days of the survey, based on observations, interview, and review of facility policy entitled "" Glove Usage "" dated 04/07/06, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Concerns were identified related to cleanliness, sanitation, food storage, equipment condition, and serving of meal trays. The findings included: On 6/20/11 at 10:30 AM, the initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). It was observed that sugar packets (both used and new) were on the floor in the dry storage area. The 3 compartment sink was tested and revealed 0 ppm (parts per million) of sanitizer. Two sanitizer buckets that were being used at the time were tested and revealed 0ppm of sanitizer. A bag of open rolls was observed on top of the flour bin under the prep table, with one roll out of the package, lying on the lid. On 6/20/11 at 10:51 AM, initial tour of the 600 wing was conducted. In the nourishment room three sandwiches were in the refrigerator dated 6/16. The microwave had rust on the door and was visibly dirty inside. The ice scoop was on the counter not bagged. On 6/21/11 at 11:15 AM, observation of the trayline was observed. Dietary Aide #1 was observed exiting the kitchen with a tray cart, she re-entered the kitchen and continued tray set up without changing gloves and washing her hands. She was observed getting ice cream from the walk in freezer and then returning to trayline and continued to set up trays. She took sandwiches out of the reach in refrigerator and then returned to the trayline and continued plating food. A random dietary staff member was observed removing gloves and placing new gloves on her hands without washing her hands in between glove changes. On 6/21/11 at 2:15 PM, a tour of the kitchen was conducted with the CDM. Two open bags of french fries were observed in the Walk in Freezer, not sealed or dated. In the dry storage tea bags were observed on the floor. In the reach in cooler 2 containers of macaroni salad dated 6/17 and one container of chopped onions dated 6/17. Dust was observed hanging off of a pipe above the steam tables and above the oven. The inside door of the steamer was visibly dirty with crusty food around the seal. The CDM verified all findings. On 6/21/11 at 3:00 PM a review of the facility policy entitled "" Glove usage "" dated 04/07/06 was conducted. The policy states "" hands are washed before putting on gloves and when changing into a fresh pair of gloves. Gloves used for handling food and eating surfaces are changed whenever an un-sanitized item or surface is touched, such as refrigerator door handle, when they become soiled or torn and before beginning a different talk "" . Additionally, an observation on 6/21/11 at approximately 12:10 PM revealed staff in the 400 dining room removing a food tray off of the transport cart and placing on a table with three residents waiting to be served. The staff member then removed the tray off the table and placed it back in the food cart with other unserved trays. On 06/21/11 at approximately 6:30 PM a random observation was made during the distribution of the evening meal on Unit 400. A Certified Nursing Assistant (CNA) was observed taking meal trays into resident rooms, then returning with the tray and placing it back on the serving cart with other unserved trays. The same CNA was observed repeating this process three times during the serving of the evening meal.",2015-05-01
9352,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,406,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to implement two physician's orders for Physical Therapy (PT) for one of four sampled residents reviewed for specialized rehabilitation. Resident #8 had physician's orders for Biofreeze and PT for neck pain which were not implemented. The findings included: The facility admitted Resident #8 on 6-28-06 with [DIAGNOSES REDACTED]. On 6-22-11 at 10:00 AM record review revealed a 5-6-11 physician's order for ""Biofreeze to neck in AM for cervical pain."" Physician's Progress Notes on the same date stated, ""Neck pain likely muscular, will have Biofreeze in am."" Physician's Progress Notes on 6-14-11 stated "" Pt (patient) requested I see her re: (regarding) neck pain. After visit 5-6-11 she did not get Biofreeze and continues to have pain. Neck now worse.....Chronic neck pain on [MEDICATION NAME] 50 tid (three times a day) and prn (as needed) Tylenol. Will schedule Tylenol and ask PT (physical therapy) to evaluate."" Record review also revealed a physician's order on 6-14-11 to ""Please ask PT to evaluate and tx (treat) for neck pain."" Further record review revealed there was no evidence that Resident #8 received Biofreeze for neck pain or a PT evaluation. During an interview on 6-22-11 at 10:15 AM, the Unit Manager stated that Biofreeze was administered by the PT department and after an order is written for PT, it is communicated to the PT department in the stand up meeting the following AM. During an interview with the Director of the therapy department on 6-22-11 at 10:45 AM, he stated, ""I did not receive an order for [REDACTED]. On the same day, at 11:50 AM, an interview with Resident #8 revealed that she had spoken with the doctor about her neck pain and stated she was ""still waiting for PT to evaluate me.""",2015-05-01
9353,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,412,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to obtain dental services to meet the needs of 1 of 1 resident reviewed with dental concerns. Resident #7 did not recieve dental sevices for known ""evidence of dental caries and broken tooth/teeth"". The findings included: The facility admitted Resident #7 on 12/15/10 with [DIAGNOSES REDACTED]. Record review revealed documentation dated 5/16/11 that indicated Resident # 7 had dental or oral cavity health problems as evidenced by dental caries and broken tooth/teeth. The recommended intervention on the residents care plan was to refer resident to dentist/hygienist for evaluation related to teeth to be pulled or repaired. During an interview on 6/21/11 at approximately 3:50 PM with the Social Services Director (SSD), the SSD confirmed the resident had no appointment/referral to see the dentist.",2015-05-01
9354,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2011-06-22,279,D,0,1,4KMU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to develop a comprehensive plan of care for Resident # 7, who had a physicians order for a no added salt diet but was known to be non-compliant with the order. During the days of the survey, the resident was observed with a large container of salt during meal times and staff expressed a knowledge of the resident's non-compliance. (1 of 1 residents reviewed with known noncompliance without a careplan developed addressing the concern) Th findings included: The facility admitted Resident #7 on 12/15/10 with [DIAGNOSES REDACTED]. Record review on 6/20/11 revealed a current physician order [REDACTED]. During an interview on 6/21/11 at approximately 8:05 AM with Registered Nurse #4, she confirmed the large container of salt and stated that the resident was non-compliant with his physician ordered diet. During an interview at approximately 3:05 PM with the Dietary Manager (DM), it was verified that the resident was not care planned for being non compliant with his diet order. There no care plan indicating that counseling or alternative choices to adding salt were provided related to the resident being in non compliance with the physician ordered diet. .",2015-05-01
9355,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,221,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review, the facility failed to assess and inform the responsible party for 1 of 3 sampled residents reviewed for the use of a physical restraint. (Resident #3) The findings included: Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. On 3/1/11 at approximately 9:55am Resident #3 approached surveyor. The Resident was seated in a wheelchair wearing a seat belt with a button release latch. The resident asked the surveyor to release the belt as the resident could not release it. The Resident demonstrated the inability to release the belt by repeatedly tugging on the belt. At no time did the resident attempt to press the button to disengage the latch. Continued observation of the resident from 9:55am to 10:30am revealed the resident was unable to release the seat belt even though the resident tugged at the belt for the entire time observed. Record review on 3/1/11 at approximately 10:30am revealed a physician's orders [REDACTED]. Further record review revealed no documentation of an assessment of the need for the belt, no assessment of the resident's ability to remove the belt, and no documentation of communication with the resident's responsible party as to the pros and cons of using the belt or consent from the responsible party to use the belt. Interview on 3/1/11 at approximately 2:45pm with Licensed Practical Nurse #1 and the Director of Nursing (DON) revealed when the belt was first placed the resident could release the belt. Further discussion also revealed that therapy was responsible for screening the use of restraints for appropriateness. Interview on 3/1/11 at approximately 3:30pm with the Director of Therapy indicated that the therapist performs a physical restraint assessment/screening when a resident is admitted and at the quarterly reviews. Otherwise, an assessment is not done in between the quarters unless an incident occurs at which time an assessment is done. The Director of Therapy stated that an assessment was not done for Resident #3's seat belt at the time of implementation as the Therapy department was not notified of the physician's orders [REDACTED]. Interview with the DON indicated that no assessment had been completed at the time the seat belt was implemented. The DON further indicated that the responsible party had not been informed of the use of the seat belt at the time it was implemented.",2015-05-01
9356,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,369,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review, the facility failed to provide adaptive eating equipment as prescribed by the physician for 1 of 2 residents reviewed with orders for adaptive equipment. Resident #8 was not provided with an adaptive spoon per physician's orders [REDACTED]. The findings included: Resident #8 admitted with [DIAGNOSES REDACTED]. Observation on 2/28/11 at approximately 6:20pm revealed the resident was sitting up in bed being fed supper. The staff person feeding the resident was using a regular spoon. There was no 90 degree angled spoon observed to be present. Record review on 3/1/11 at approximately 10:50am revealed a physician's orders [REDACTED]. Observation on 3/1/11 at approximately 12:25pm revealed Resident #8 in the therapy room. The Director of Therapy was positioning the Resident and the Certified Occupational Therapy Aide (COTA) was setting up the lunch tray. The COTA noticed that the angled spoon was not on the tray and stated that adaptive eating equipment was to come on the tray with the meal. Interview on 3/2/11 at approximately 10:30am with the Assistant Director of Nursing indicated that when an order is written for adaptive equipment, the order is transcribed to a dietary communication slip and the slip is sent to dietary. Interview on 3/2/11 at approximately 11:20am with the Dietary Supervisor indicated that the resident's angled spoon was not in the kitchen when the COTA came for it at lunch time on 3/1/11. The angled spoon was then found in the resident's room, brought to the kitchen to be cleaned, then used for the lunch meal. The Dietary Supervisor was unable to state why the spoon was in the resident's room or for how long it had been missing from the kitchen. Further interview indicated that the Dietary Supervisor had been notified that the resident was in need of an angled spoon and that Therapy had supplied the needed spoon at the time the order was written.",2015-05-01
9357,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,315,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the facility policy titled ""Incontinence Care"", and review of the South Carolina Nurse Aide Candidate Handbook January 2010, the facility failed to provide appropriate care and services for 1 of 1 sampled resident reviewed for Incontinent Care. During Resident #4's Incontinent Care, the staff member failed to separate the labia to cleanse the meatus. The findings included: The facility admitted Resident #4 on 12-06-10 with [DIAGNOSES REDACTED]. On 03-01-11 at 11:14 AM, Certified Nursing Assistant (CNA) #1 entered Resident #4's room to provide Incontinent Care. CNA #1 closed the room door, washed her hands, donned clean gloves, and proceeded to provide Incontinent Care. Observation revealed CNA #1 cleansed the middle of the labia downward without separating the labia to cleanse the meatus. During an interview on 03-02-11 at 2:15 PM with CNA #1, she verified she had not spread Resident #4's labia to cleanse the meatus and had not turned the resident to cleanse the rectal area although she had known to do this. CNA #1 stated, ""I've seen one of those books before and we need them here"", (referring to the South Carolina Nurse Aide Candidate Handbook January 2010). Review of the facility policy titled ""Incontinent Care"" revealed Procedure 6. stated ""Wash/use cleansing agent to all soiled skin areas, washing from front to back, rinse and dry very well, especially between skin folds"". Review of the South Carolina Nurse Aide Candidate Handbook January 2010, page 39, section titled ""Provides Perineal Care (Peri-Care) for Female"" revealed #11. stated ""After washing genital area, turns to side, then washes and rinses rectal area moving from front to back using a clean area of washcloth for each stroke. Dries with towel"".",2015-05-01
9358,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,323,D,0,1,KJXO11,"On the days of the survey, based on observation, interview, and facility policy titled ""Security of Medication Cart"", the facility failed to ensure that the medication cart was secured to prevent resident access to medications on 1 of 3 units. The findings included: During a random observation of Unit 3 (Building 3) on 3/2/11 at 3:20 PM, the medication cart was observed unlocked in the nurse's station. Registered Nurse (RN)#1, after securing the latch to the small swing door at the entrance of the nurse's station, left the unit. During the time that RN #1 was absent from the unit, two residents and one staff member passed by the nurse's station, but did not try to enter into the station. Eleven minutes passed before RN #1 returned to Unit 3. RN #1 was asked to open the medication cart and at that time asked which drawer to open. RN #1 was asked to open the long drawer in which she reached and pulled open the first drawer. RN #1 was then informed that she had left the unit while the medication cart was not secured. RN #1 at that time confirmed that she had left the unit and not secured the medication cart. Review of the facility's policy titled ""Security of Medication Cart"", revealed the following: 4. - Medication carts must be securely locked at all times when out of the nurse's view. 5. - When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.",2015-05-01
9359,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,367,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, and interview, the facility failed to provide a therapeutic diet as prescribed for 1 of 12 resident diets reviewed. Resident #1 was not served a Two Gram Sodium diet as prescribed by the physician. The findings included: The facility admitted Resident #1 on 5/16/06 with [DIAGNOSES REDACTED]. Review of the medical record on 2/28/11 revealed a current physician's orders [REDACTED]."" Further review of the medical record revealed a previous telephone order dated 10/02/10 to ""Change Diet to 2 gram Sodium diet."" Observation of the dinner meal on 2/28/11 at approximately 6:00 PM revealed Resident #1 eating dinner in his/her room. Observation of the dinner tray revealed one packet of unopened salt on the tray. In addition, observation of the meal/tray card revealed ""Mechanical, Whole Meat"" printed on the card. The meal/tray card did not indicate Resident #1 was to receive a Sodium Restricted diet. Review of the facility's ""Liberalized Diet Change Guide"" revealed a 2 Gram Sodium Diet would be ordered as ""NAS"" (No Added Salt packet). Observation on 3/02/11 at approximately 9:00 AM revealed Resident #1's breakfast tray on a cart in the hallway outside the resident's room. Observation revealed Resident #1 had eaten breakfast, and one unopened packet of salt was observed on the tray. At that time, the Assistant Director of Nursing (ADON) was asked to observe the salt packet on the tray and to confirm that the tray card indicated ""Mechanical, Whole Meat"" and did not indicate Resident #1 was to receive a Sodium Restricted diet. On 3/02/11 at approximately 9:30 AM, the ADON stated that the tray card was incorrect, and that the correct diet was a 2 Gram Sodium Restricted diet. The ADON stated that he/she would write a clarification order for the NAS Diet. The ADON stated that a Diet Order Form was used to send diet changes/orders to the Dietary Department.",2015-05-01
9360,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,441,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies titled ""Dressing Change, Clean"", ""Infection Control, Standard Precautions"", and ""Departmental (Environmental Services) - Laundry and Linen"", the facility failed to provide a safe and sanitary environment to prevent the development and transmission of disease for 1 of 2 sampled residents observed for wound care. The facility further failed to ensure the laundry staff wore appropriate personal protective equipment (PPE) during handling of linen. During Resident #8's wound care, the staff member failed to cleanse scissors prior to and after use, failed to remove gloves upon exiting room and re-entering, and allowed linen to come into contact with his uniform. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 03-01-11 at 4:25 PM, Licensed Practical Nurse (LPN) #2 entered Resident #8's room to perform wound care to the right heel. LPN #2 washed his hands, donned clean gloves, and proceeded to provide wound care. After LPN #2 applied Santyl Ointment to the wound bed, he removed his gloves, washed his hands, and donned clean gloves. LPN #2 proceeded to retrieve a pair of scissors form his uniform pants pocket with his gloved hand, failed to cleanse the scissors prior to cutting a small piece of gause which was placed over the wound bed, and placed the pair of scissors back into his uniform pants pocket without cleansing them. LPN #2 continued with the wound care, wrapped the right heel with Kling, and taped into place. LPN #2 then exited the room without removing his gloves and obtained additional tape. Upon re-entering the room, LPN #2 again retrieved the pair of scissors from his uniform pants pocket with his gloved hand and failed to cleanse the scissors prior to cutting additional tape to place on the Kling. After completion of the wound care of Resident #8's right heel, LPN #2 removed his gloves, washed his hands, proceeded down the hallway with the equipment barrier towel, and allowed it to come into contact with the front of his uniform shirt prior to disposal into the appropriate container in the Soiled Utility Room. During an interview on 03-02-11 at 2:40 PM with LPN #2, he verified he had retrieved the scissors from his pants pocket while wearing gloves and had failed to cleanse them prior to and after use. LPN #2 further verified he had worn his gloves into the hall to retrieve additional tape but had not realized the equipment barrier towel had come into contact with the front of his uniform shirt. Review of the facility policy titled ""Dressing Change, Clean"" revealed section Purpose stated ""To prevent infection and/or spread infection"" and ""To prevent contamination while changing a wound or surgical incision dressing"". Review of the facility policy titled ""Infection Control, Standard Precautions"" revealed Policy Interpretation and Implementation #2 stated ""Gloves: d. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environments"". The Policy Interpretation and Implementation #5 stated ""Resident-Care equipment: b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded"". Review of the facility policy titled ""Departmental (Environmental Services) - Laundry and Linen"" revealed Steps in the Procedure: In Resident Rooms: #1. stated ""Do not allow linen, clean or soiled, to touch clothing or uniform"". Observation of the laundry on 3/1/11 revealed laundry staff wearing aprons. During an interview with Laundry staff #1 on 3/1/11, she stated that when sorting soiled linen an apron and gloves were used. Observation of the gloves revealed that they did not go high on the arm. Laundry staff #1 confirmed that the sleeve of the arm could become soiled when reaching into the soiled laundry barrel. Review of the facility policy titled ""Laundry and Bedding, Soiled"" revealed the following: 4. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment(e.g., gowns if soiling of clothing is likely).",2015-05-01
9361,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,467,D,0,1,KJXO11,"On the days of the survey, based on observation and interview, and review of the facility's Maintenance Checklist, the facility failed to provide adequate outside ventilation in showers for 1 of 3 units(buildings). The findings included: Observation on 2/28/11 at 2:55 PM of unit 3 revealed two shower rooms without ventilation. During rounds with the Administrator and Maintenance Director on 3/2/11 at 4:30 PM, the Maintenance Director confirmed that shower #1 had no ventilation system and shower #2's ventilation system was non-functional. The Maintenance Director confirmed that the shower rooms were not routinely checked. Review of the Maintenance Checklist revealed ventilation in shower rooms were not listed. Unit 3 (Building 3) was noted with an odor on all days of the survey.",2015-05-01
9362,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2011-03-02,514,D,0,1,KJXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 13 residents reviewed. The facility failed to accurately and completely document Resident #1's medical record related to two incidents. The findings included: The facility admitted Resident #1 on 5/16/06 with [DIAGNOSES REDACTED]. Review of the medical record on 3/02/11 revealed the Nurses' Notes dated 1/08/11 at 10:25 AM indicated, ""No noted sexual behavior towards other residents."" The notation on 1/08/11 3-11 noted, ""No sexual behavior noted this shift."" The notation dated 1/09/11 11-7 indicated, ""No inappropriate sexual behavior noted this shift."" The notation dated 1/09/11 at 9:45 AM indicated, ""No noted inappropriate behavior this AM."" The notation dated 1/09/11 indicated, ""No inappropriate sexual behavior noted this shift..."" There was no documentation in the Nurse's Notes during the time of 1/08/11 through 1/09/11 that specified what type of behavior staff referred to in the notations. In addition, record review revealed there were no prior Nurse's Notes or Social Services Notes before or after this time frame related to this type of behavior. Licensed Practical Nurse (LPN) #3 documented the first Nurse's Notes referring to ""sexual behaviors towards other residents"" dated 1/08/11 at 10:25 AM and the notation dated 1/09/11 at 9:45 AM. During an interview on 3/02/11 at approximately 2:45 PM, LPN #3 was asked to clarify the notation and to explain the specific behavior referred to in the documentation. LPN #3 reviewed the Nurse's Notes and confirmed that he/she documented the Nurse's Notes on 1/08/11 and 1/09/11. When asked to explain/clarify the notation as to the specific behavior referred to in the documentation, LPN #3 stated that he/she did not remember. LPN #3 stated that Resident #1 had never displayed this type of behavior and could not recall any specific behavior of this type toward other residents. The surveyor asked LPN #3 to review the medical record and to inform the surveyor if he/she found any other documentation that would clarify the notations. On 3/02/11 at approximately 3:15 PM, LPN #3 stated that no additional documentation could be found in the record to explain the notation ""No noted sexual behavior towards other residents."" During the interview, LPN #3 stated that the only documentation related to behaviors was documented on the ""acute charting"" records. Review of the Alert/Follow Through Charting form revealed documentation dated 12/18/10 which indicated, Resident #1 ""Smoking in dayroom."" Further review of the document revealed instructions at the top of the form indicated staff was to chart ""Unusual behavior - 3 days or as long as unusual behavior is exhibited."" Review of the Nurse's Notes revealed no documentation from 12/01/10 until 1/01/11. There was no documentation related to ""smoking in dayroom"" in the Nurse's Notes or Social Services notes. Review of the Incident Log for Resident #1 from 12/01/09 through 3/02/11 revealed an incident noted 12/18/10 in the ""Living room"" at 2:40 PM. On 3/02/11 at approximately 4:15 PM, the surveyor asked staff for documentation and/or any Incident Report related to the behavior on 12/18/10 and any documentation related to interventions put in place. No documentation and/or Incident Report related to the 12/18/10 notation referring to ""smoking in dayroom"" was provided upon exit from the facility. During an interview on 3/02/11 at approximately 5:15 PM, the Social Services Director stated that he/she ""heard"" that family brought cigarettes to the resident. The Social Services Director stated that he/she spoke with the family about ""not doing that."" On 3/02/11 at approximately 5:20 PM, the Administrator stated that family ""brought cigarettes in"" for the resident on that date. The Administrator stated that the ADON was aware of the incident. In a written statement provided to the surveyor, staff indicated that Resident #1 was ""noted to have cigarettes and lighter given by family and noted in day room with them...Family was counseled to not bring cigarettes/lighter to resident but to give to nurse for safety to be placed in box...No further incidents have occurred since that time.""",2015-05-01
9363,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,314,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Recertification Survey and Extended Survey, based on record reviews, interviews, observations, and facility policy review, the facility failed to ensure that residents with pressure ulcers were assessed timely and adequately, and were re-evaluated for necessary change in treatment or provision of treatment as ordered per physician for 6 of 10 residents reviewed for pressure ulcers (Residents #1, #2, #3, # 4, #7, and # 9.) The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was aphasic with left side mobility impairment. She required total care from the staff for her activities of daily living. The resident received all nutrition and hydration via gastrostomy feeding tube. Review of the medical record revealed the resident arrived at the facility with no pressure ulcers. On 9/10/10, the nurse's note documented small open areas observed on the resident's right (sic) ear and right (sic) buttock. ""... family notified - they were aware of ear wound since beginning of week. ..."" Review of the Treatment Record showed the facility began treating the left ear ulcer daily with triple antibiotic ointment on 9/10/10 and the left buttock ulcer with [MEDICATION NAME] every three days and as needed on 9/11/10. Review of the Skin Notes showed an entry on 9/14/10, at 9 AM, describing the left buttock ulcer as a Stage II pressure ulcer measuring 5.5 by 2 by 0 centimeters (cm) with no bleeding or drainage. This was the first descriptive note concerning the ulcer. Review of the medical record, including the Skin Notes, Daily Skilled Nurses' Notes, Treatment Records, and Alteration In Skin Integrity Addendum To TAR (Treatment Administration Record) showed the right ear ulcer was deemed healed on 9/24/10. The records failed to show any additional assessment of the left buttock ulcer for September 2010. Review of the October 2010 records showed two documented assessments of the ulcer. On 10/8/10, it was noted to be a Stage II measuring 1.9 by 1 by 0 cm with a small amount of bloody drainage. On 10/12/10, the documentation showed the ulcer as a Stage II measuring 2.5 by 1 by 0 cm with a small amount of bleeding. Although the Treatment Record showed continued treatment to the left buttock ulcer until the resident's discharge, no further assessment of the ulcer was noted in the records. Review of the Nutritional Progress Notes showed an entry on 10/15/10 noting the right ear ulcer and left buttock ulcer were healed. Review of the Daily Skilled Nurses Notes on 11/4/10 revealed an entry at 6:30 PM stating an indwelling catheter was inserted secondary to ""stage IV decub (decubitus ulcer) on sacrum that open today per Tx (treatment) nurse ..."" The November 2010 Treatment Record showed the sacral ulcer received treatment with calcium alginate covered with [MEDICATION NAME] every three days and as needed beginning on 11/4/10. The Treatment Record also showed the continued treatment to the left buttock ulcer, indicating the sacral ulcer was a new site. Review of the medical record showed only one description of the new sacral ulcer. The Skin Notes on 11/16/10 showed measurements of 3.5 by 2 by 1.5 cm with a small amount of bleeding and drainage. There was no Alteration In Skin Integrity Addendum to TAR form for November 2010. A nurse's note on 11/16/10 stated: ""... Tx continues to buttocks and (R) (right) heel. ..."" Review of the medical record showed no other documentation concerning a pressure ulcer on the right heel except for two entries on the Skin Assessment forms. On 10/2/10, a red area on the right heel was noted, and on 10/30/10 thick brown skin on the right heel was noted. No information concerning a pressure ulcer to the right heel was noted in the Skin Notes or on the Treatment Record for November 2010. The resident was discharged to the hospital on [DATE] and did not return to the facility. Resident #2 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Nurse's Notes revealed staff identified an open area on the resident's coccyx on 8/11/10. Review of the Treatment Record showed treatment to the site began on 8/13/10 with acrylic [MEDICATION NAME] to be change every five days. The first descriptive note related to the ulcer was noted in the Skin Notes and the Alteration In Skin Integrity Addendum To TAR form dated 8/13/10 showing it measured 1 by 0.4 by 0 cm with no drainage and a pink wound bed. The medical record showed weekly assessments of the pressure ulcer for the rest of August 2010. On 8/31/10, the ulcer was deemed healed. On 8/31/10, the nurse's note at 1:35 PM stated the resident had breakdown to the upper right buttock. It stated the wound nurse was notified and treatment was in place. This was the first documented evidence of this new ulcer. Documentation in the Skin Notes and on the Alteration in Skin Integrity form showed a Stage III ulcer measuring 3.2 by 2.0 by 0.1 cm with light drainage and pink surrounding skin. Acrylic [MEDICATION NAME] treatment with changes every five days was started. Facility staff was asked to produce pressure ulcer tracking and assessment information on the Skin Notes and Alteration in Skin Integrity forms for February 2011. They were unable to produce the documents. Review of the Treatment Record for February 2011 showed the upper right buttock ulcer treatment was changed to ""siversorb sheet"" covered with [MEDICATION NAME] and a ""medfix"" dressing secured with [MEDICATION NAME] film every other day and as needed. Review of the February telephone/verbal orders and the March 2011 cumulative orders failed to show a physician's order for this treatment change. Resident #3 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Treatment Record for December 2010 showed the resident was being treated for [REDACTED]. On 12/21/10, a new pressure ulcer was noted on the right buttock. Documentation on the Treatment Record and in the Skin Notes revealed the ulcer measured 1.0 by 3.0 by 1.3 cm with yellowish tissue in the wound bed and pink surrounding skin. Documentation in the medical record and interview with the treatment nurses failed to provide a rationale showing why the wound was not identified before reaching a depth of 1.3 cm and developing yellow slough. Review of the skin documentation in January 2011 showed measurements on 1/4 and 1/12/11. On 1/12/11, the coccyx ulcer, deemed a Stage II at that time, measured 4 by 1.5 by 0.1 cm with scant drainage and a pink wound bed. The right buttock ulcer, deemed a Stage III ulcer, measured 2.5 by 4.0 by 3.5 cm with some slough in a pink wound bed. Review of the January 2011 Treatment Record showed the current treatments to both sites was discontinued on 1/20/11. Continuing treatment records for January 2011 were not available on request and it could not be determined if treatment was provided to the ulcers for the remainder of the month. Review of the available documentation for February 2011 showed no Skin Notes or Alteration in Skin Integrity notes. The Treatment Record revealed that the right buttock ulcer was treated with packed gauze soaked in basic Dakin ' s solution covered with a dry dressing twice a day and as needed. There was no record of treatment to the coccyx. A nurse's note on 2/5/11 stated the resident's buttock ulcer was a Stage IV. There was no other documentation in February 2011 to support or contradict this entry. Review of the Pressure Ulcer Report of 3/24/11 showed the resident's right buttock ulcer was a Stage II measuring 1 by 1 by 0.2 cm. Resident #4 with [DIAGNOSES REDACTED]. Review of the admission nurse's note showed the resident had ""an area"" on his sacrum. Review of the Skin Assessment sheet of 2/22/11 revealed a diaper rash with a red spot. The spot was drawn onto the body figure at the approximate site of the coccyx. Review of the Skin Notes showed that on 2/22/11, the resident was assessed as having a red inflamed perineal area. Review of the Treatment Record revealed an order to cleanse the sacral area then apply [MEDICATION NAME], to be changed every three days and as needed. Review of the medical record showed no assessment or descriptive note concerning the resident's sacral ""area."" The 3/2/11 Skin Note stated: ""Completed assessment to resident sacral area & [MEDICATION NAME] applied ..."" Zinc cream was applied to the red areas. The remainder of the note described that the resident refused to dress and refused to allow the bed linens to be changed. None of the documentation in the medical record described an open pressure ulcer but review of the Pressure Ulcer Report of 3/24/11 showed the resident's pressure ulcer as a Stage II measuring 1.5 by 2 by 2 cm. The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. The resident was admitted to the 400 unit for rehab and transferred to the 200 unit on 3/11/11. Review of the medical record on 4/18/11 showed the facility Admission Nursing Evaluation Form was completed on 12/10/10. This form showed that the resident had both long and short term memory problems, had swallowing problems, was a total assist with toileting and was incontinent of both bowel and bladder. She also had a bruise to the right elbow and a dressing on the left hip, her sacrum was normal and her feet and heel were normal. The Braden Scale was 11, which showed that the resident was at risk for skin breakdown. There were no other Braden Scales in the record. Review of the treatment records showed that the resident was receiving treatment to both heels starting 12/24/10 which was ""Clean right heel and apply skin prep and tegafoam adhesive q (every) day"" and ""Clean left heel and apply skin prep and [MEDICATION NAME] foam adhesive q day and prn (as needed)."" There was no physician order for [REDACTED]. There were no treatment records found for the month of February. A skin note dated 1/7/11 stated ""both heels remain blanchable at this time."" There were no other notations for January concerning the heels except for dressing changes. The next notation regarding the heels was noted on 3/24/11 and stated, ""During assessment today measurements are 3.4 x 2.5 x 0.2. Wound bed is black eschar with some blanching around wound bed noted. No drainage at this time. Surrounding skin is pink dry and intact. Treatment continues as ordered."" During an interview with Licensed Practical Nurse (LPN) #5 on 4/19/11, she stated that she started the treatment to the heels on 12/24/10 as a preventative measure and to protect the heels. She further stated that she did not look at the heels on a weekly basis. Random observations of the resident on 4/19/11 at 8:45 AM, 10:50 AM and 11:05 AM showed the resident to be flat on her back; she was not repositioned every two hours per protocol. While observing wound care on 4/19/11 at 11:20 AM, it was noted that the resident had blue booties to both feet and an area of eschar was noted to the residents left heel by this surveyor. The area was pointed out to both LPN #5 and LPN #6. Both stated that they had not seen the area before this time and they were doing the dressings daily. Both nurses had the eschar areas staged at a IV. The package insert for the [MEDICATION NAME] foam adhesive stated, ""[MEDICATION NAME] foam adhesive dressing is not intended for use in pressure reduction."" A skin note dated 1/28/11 stated, ""Resident has a red area to her left buttock/ blanchable after pressure is applied. Area cleansed with ns (normal saline)and [MEDICATION NAME] placed as a preventive measure."" There were no treatment records found for the month of February 2011, it is unknown if the treatment continued. There were no other skin notes or facility Skin Integrity Documentation Forms in the chart until March 2011. Review of the nurse's notes revealed that the resident was found to have an open area to the left buttock on 2/21/11. The note stated, ""Called to room by CNA (certified nurses aide) earlier this shift to see a wound to resident's left buttock. Writer observed a wound 3 cm (centimeters) by 2 cm and 1/2 cm deep with possible tunneling under initial wound and also with possible surrounding area at risk for breakdown."" There was no further documentation on the wound until March 2011. For the months of March and April the same treatment continued with little to no improvement. The first measurement on the forms was for 3/3/11. The wound measured 3.0 x 2.5 x 0.2 with tunneling and undermining, the wound bed was yellow, and there was moderate drainage. The last note dated 4/13/11 and the wound measured 3.0 x 2.5 x .5, with undermining, the wound bed was pink and there was light drainage. Interventions included a special mattress and turn and reposition every two hours. During an interview with the Administrator, LPN #5 and LPN #6 on 4/20/11 at 8:45 AM, both LPN's could not explain why the unstageable areas to the heels were not noted in a timelier manner. They both stated that they use the facility wound protocol to stage the areas and they actually thought that eschar was a stage IV when actually it was unstageable. For treatments they both refer to the treatment protocol. When asked why they did not recommend a change in treatment for [REDACTED]. During an interview with the medical director on 4/20/11 at 4:55 PM, he stated that he sees the wounds usually once a month or ""whenever they tell me to look at them"". When asked why there were no notations in the physician progress notes [REDACTED]. When asked if he actually gives the orders for the treatments he stated that the nurses recommend what should be used and he approves the standing wound orders that the facility has. Review of the facility Wound Care Reports (Excluding Pressure Ulcers) dated 12/24/10, 12/31/10, 1/14/11, 1/21/11, 2/3/11, 2/10/11, 2/24/11, 3/3/11, 2/10/11, 3/17/11 and 3/24/11 showed that the wound care nurses were documenting that both the right and left heels were red and the treatment was skin prep/[MEDICATION NAME] foam adhesive dressing. On the facility Pressure Ulcer Report dated 3/31/11, it was noted that on 3/29/11 the right heel was a stage IV pressure ulcer measuring 2.5 x 2.8 x 0. There was no drainage, the treatment was skin prep daily and it was a new area. Review of the facility Pressure Ulcer Reports dated 2/24/11 stated that the resident had a new pressure ulcer to the left buttock with an acquired date of 2/21/11. It was noted to be a stage III pressure ulcer measuring 3.0 x 2.5 x 0.2, with moderate drainage and basic Dakins was the treatment. The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/, 6/10/10, and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. On 4/19/11 at 9:55 AM the Pressure Sore care was observed. The wound on the right hip/sacral area appeared as a horizontal split wound over the upper quadrant of the right buttocks extending to the sacral area. The last measurements dated 4/8/11 were recorded as Stage III 1 (one) CM (Centimeter) in length by 3 CM in width by 3 CM in depth. There was scarring extending out to the right of the wound. review of the resident's medical record revealed [REDACTED]. The Plan of care dated 11/05/2010 included the problem of pressure ulcer. The approaches listed for the the Pressure ulcer included: Reassess at least weekly... The Alteration in Skin Integrity Addendum to the TAR (Treatment Administration Record) forms, which contained the weekly measurements of the Pressure Sores were reviewed. There was no documentation as to when the wound originated. The Alteration in Skin form contained measurements and staging of the Pressure Sore from January 12, 2011 through April 8, 2011. There were no Alteration in Skin Integrity Forms located before January 12, 2011. The measurements for the week of 4/15/11 were not documented. Review of the Physician's Progress Notes dated from 4/15/10 through 4/5/11, (one year) revealed no documentation of Pressure sores. There was no mention of progression or deterioration of the resident's pressure sores by the physician. The Medical Doctor (MD) was interviewed on 4/20/11 at 5:00 PM via telephone. The MD stated that he did see the resident's wounds, ""Not everytime, once a month or so if/when they tell me to look at them."" When told that there was nothing in his progress notes pertaining to the pressure sores, he stated, ""Documentation may be an issue, but I see them as needed"". The MD stated that the nurses made the recommendations regarding the treatment of [REDACTED]. ""I do not oversee to the nth degree with wounds."" The medical record was reviewed for Nutritional Assessments/notes in regards to nutritional interventions to promote healing of the wounds. The last Nutritional Assessment completed was dated 11/4/10. The assessment documented recommendations of Prostat 64 (a protein supplement used to promote healing of wounds). The resident's weight at that time was documented at 398 pounds (lbs.). The assessment included abnormal lab results of an [MEDICATION NAME] of 2.1, normal values 3.5-5 (Measures protein levels in the body), low Hemoglobin, 9.9 (normal value 14-18) and Hematocrit, 30.2 (normal values for men 42-52) (measures the Red Blood Cell volume of the blood). There was no further nutritional assessment available for the resident. The last nutritional progress note was dated 12/22/10. There were no nutritional progress notes for 2011 (4 months) in regard to the resident's pressure sore and nutritional requirements. During an interview with the Certified Dietary Manager and the Registered Dietician (RD) on 4/20/11 at 9:25 AM, when asked how often the RD did Nutritional Assessments and progress notes on residents with wounds, the RD stated that she did progress notes on wounds monthly. She stated, ""I look monthly, what stage it is (wound)."" She stated she estimated the needs if the weight fluctuates and reviewed the labs. When asked where the progress notes and Nutritional Assessments were since December, the RD stated, ""I got confused and just documented his weights. I should have been documenting on his wounds and nutritional needs as well."" On 4/20/11 at 8:40 AM, an interview was conducted with the Administrator, the two wound nurses, the Corporate Nurse, the DHS (Director of Health Services). LPN (Licensed Practical Nurse) #5, one of the Treatment Nurses, stated that the Braden Scale was done weekly for four weeks following an admission. The resident's medical record contained one Braden Scale that was not dated, with the admission assessments of 9/15/10. The score was 12, which placed the resident at moderate risk for pressure sores. LPN #5 stated that she and the other Treatment Nurse; assessed the residents for wounds, see the risk factors, preventive measures such as cushions, wedges, podus boots ""perform an over all assessment"". When asked if they measure and staged the pressure sores, LPN # 5 agreed that they did. The DHS stated that she, as a RN (Registered Nurse), would go and look at the wounds when they were admitted or discovered. She admitted that she did not follow-up on the wounds. LPN #5 stated that they had a Certified Ostomy nurse that gave them direction on treatment of [REDACTED]. LPN #5 stated that she had never met the Ostomy Nurse, but talked with her over the telephone. Resident #9 was admitted with pressure wounds. There was no documentation available on the medical record of when the current pressure sore had developed. There was no documentation of weekly measurements or staging of the pressure sore before January 12, 2011. There were no nutritional assessments or progress notes related to nutritional intervention for 4 months, since December. The physician had no documentation over the past year of having seen or assessed the resident's pressure sores. The resident's pressure sore had been staged at a Stage IV in January and February 2011. A Stage IV is the highest staging of a pressure sore which indicated the pressure sore was severe. No Registered Nurse, had followed or assessed the pressure sore on a routine basis. The Wound Manual was reviewed on 4/20/11. The manual contained a form, ""Pressure Ulcer Report"". The report included the following information: Date Acquired, Date admitted , Site Location, Initial Stage, Highest Stage, Stage Now, Amount of Drainage, Odor, Treatment, Response to Treatment, and Pressure Relief Devices. During an interview with the Administrator on 4/20/11, the surveyor asked if the facility used the Pressure Ulcer Report. The Administrator stated, ""Yes, all residents with pressure sores are included in the report. The report is done weekly."" When asked where the report was kept, the Administrator stated she had it in her computer. ""The Skin Integrity Nurse completed the information."" The reports were requested from August 2010 to present day. The reports were not provided to the surveyors until approximately 8:00 PM on 4/20/11. The facility was repeatedly asked for information regarding pressure sores during the days of the survey. The information was inconsistent on the resident's medical records. The information of the pressure sore reports was not provided until the end of the survey. Cross refer to F-272 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Immediate Jeopardy and Substandard Quality of Care was identified at F-314 at a scope and severity of ""K"" as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failure to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-314 remained at a scope and severity of ""E"".",2015-05-01
9364,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,332,E,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interview, the facility failed to ensure that it was free of medication errors of five percent or greater. The medication error rate was 10%. There were 4 errors noted out of 40 opportunities for error. The findings included: During the medication pass observation on 4/19/11 at 8:30 AM, Resident A was given [MEDICATION NAME] 10 mg (milligram) and [MEDICATION NAME] 25 mg by mouth. The Medication Administration Record [REDACTED]. When Licensed Practical Nurse # 1 (LPN) was asked about the blood pressure, she stated "" the CNA's (Certified Nursing Assistants) get the vital signs."" When asked how she would know if it needed to be held, she stated, "" Oh, let me go look."" LPN #1 approached a CNA and asked for the vital signs, and was told they had not yet been done. The LPN stated: "" I guess that needs to be put on the MAR indicated [REDACTED]."" During the medication pass observation on 4/19/11 at 9:15 AM, Resident B was given a [MEDICATION NAME] inhaler and within 15 seconds was given an [MEDICATION NAME] HFA 115/21 inhaler. When asked about facility policy related to the administration of inhalers, LPN # 4 stated: "" I know they should be given 5 minutes apart, but when you're being watched (shrugged shoulders) you know"". During the medication pass observation on 4/19/11 at 10:35 AM, Resident D was given [MEDICATION NAME] capsule 40 mg. The Medication Administration Record [REDACTED]. The time listed on the orders and the MAR indicated [REDACTED]"" I don't think we specified any, both have signed the MAR.""",2015-05-01
9365,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,272,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of scope of practice for Licensed Practical Nurses as determined by the South Carolina State Board of Nursing, the facility failed to assure that each resident was adequately and accurately assessed for pressure ulcers and that the appropriate assessments were complete for residents with existing wounds for six of ten resident records reviewed for pressure ulcers. Resident #'s 1, 2, 3, 4, 7, and 9 had either no assessments or inaccurate assessments for pressure ulcers. The findings included Resident #1 with [DIAGNOSES REDACTED]. The resident was aphasic with left side mobility impairment. She required total care from the staff for her activities of daily living. The resident received all nutrition and hydration via gastrostomy feeding tube. Review of the medical record revealed the resident arrived at the facility with no pressure ulcers. On 9/10/10, the nurse's note documented ""small open areas observed on the resident's right (sic) ear and right (sic) buttock. ... "" Review of the Skin Notes showed an entry on 9/14/10, at 9 AM, describing the left buttock ulcer as a Stage II pressure ulcer measuring 5.5 by 2 by 0 centimeters (cm) with no bleeding or drainage. This was the first descriptive note concerning the ulcer. Review of the medical record, including the Skin Notes, Daily Skilled Nurses' Notes, Treatment Records, and Alteration In Skin Integrity Addendum To TAR (Treatment Administration Record) showed the right ear ulcer was deemed healed on 9/24/10. The records failed to show any additional assessment of the left buttock ulcer for September 2010. Review of the October 2010 records showed two documented assessments of the ulcer. An assessment on 10/8/10 and again on 10/12/10. Skilled Nurse's Notes identified the area as Stage IV on 11/4/10. Although the Treatment Record showed continued treatment to the left buttock ulcer until the resident's discharge 11/18/10, no further assessment of the ulcer was noted in the records. Resident #2 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. On 8/31/10, a nurse's note at 1:35 PM stated the resident had breakdown to the upper right buttock. It stated the wound nurse was notified and treatment was in place. This was the first documented evidence of this new ulcer. Documentation in the Skin Notes and on the Alteration in Skin Integrity form showed a Stage III ulcer measuring 3.2 by 2.0 by 0.1 cm with light drainage and pink surrounding skin. Facility staff was asked to produce pressure ulcer tracking and assessment information on the Skin Notes and Alteration in Skin Integrity forms for February 2011. They were unable to produce the documents. Resident #3 with [DIAGNOSES REDACTED]. The resident required total care from the staff for her activities of daily living. Review of the Treatment Record for December 2010 showed the resident was being treated for [REDACTED]. On 12/21/10, a new pressure ulcer was noted on the right buttock. Documentation in the medical record and interview with the treatment nurses failed to provide a rationale showing why the wound was not identified before reaching a depth of 1.3 cm and developing yellow slough. Review of the January 2011 Treatment Record showed the current treatments to both sites was discontinued on 1/20/11. Continuing treatment records for January 2011 were not available on request and it could not be determined if treatment was provided to the ulcers for the remainder of the month. Review of the available documentation for February 2011 showed no Skin Notes or Alteration in Skin Integrity notes. The Treatment Record revealed that the right buttock ulcer was treated with packed gauze soaked in basic Dakin's solution covered with a dry dressing twice a day and as needed. There was no record of treatment to the coccyx. A nurse's note on 2/5/11 stated the resident's buttock ulcer was a Stage IV. There was no other documentation in February 2011 to support or contradict this entry. Review of the Pressure Ulcer Report of 3/24/11 showed the resident's right buttock ulcer was a Stage II measuring 1 by 1 by 0.2 cm. Resident #4 with [DIAGNOSES REDACTED]. Review of the admission nurse's note showed the resident had ""an area"" on his sacrum. Review of the Skin Assessment sheet of 2/22/11 revealed a diaper rash with a red spot. The spot was drawn onto the body figure at the approximate site of the coccyx. Review of the Skin Notes showed that on 2/22/11, the resident was assessed as having a red inflamed perineal area. Review of the Treatment Record revealed an order to cleanse the sacral area then apply [MEDICATION NAME], to be changed every three days and as needed. Review of the medical record showed no assessment or descriptive note concerning the resident's sacral ""area."" None of the documentation in the medical record described an open pressure ulcer but review of the Pressure Ulcer Report of 3/24/11 showed the resident's pressure ulcer as a Stage II measuring 1.5 by 2 by 2 cm. The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. The resident was initially admitted to the 400 Unit for rehab and was transferred to the 200 unit on 3/11/11. Review of the medical record on 4/18/11 showed the facility Admission Nursing Evaluation Form which was completed on 12/10/10. This form showed that the resident had both long and short term memory problems, had swallowing problems, was a total assist with toileting and was incontinent of both bowel and bladder. She also had a bruise to the right elbow and a dressing on the left hip, her sacrum was normal and her feet and heels were normal. The Braden Scale was 11 which showed that the resident was at risk for skin breakdown. There were no other Braden Scales in the record. The following body audits were noted in the record: 2/19/11, 2/26/11, 3/5/11, 3/16/11, 3/29/11, 4/11/11, and one with no date. Review of the treatment records showed that the resident was receiving treatment to both heels starting 12/24/10. The skin notes for December 2010 did not mention treatment to the heels or what the condition of the heels were. A skin note dated 1/7/11 stated ""both heels remain blanchable at this time."" There were no other notations for January concerning the heels except for dressing changes. A skin note dated 1/28/11 stated, ""Resident has a red area to her left buttock/ blanchable after pressure is applied. Area cleansed with ns (normal saline)and [MEDICATION NAME] placed as a preventive measure."" There were no other skin notes or facility Skin Integrity Documentation Forms in the chart until March 2011. Review of the nurse's notes revealed that the resident was found to have an open area to the left buttock on 2/21/11. The note stated, ""Called to room by CNA (certified nurses aide) earlier this shift to see a wound to resident's left buttock. Writer observed a wound 3 cm (centimeters) by 2 cm and 1/2 cm deep with possible tunneling under initial wound and also with possible surrounding area at risk for breakdown."" There was no further documentation on the wound until March 2011. The Alteration in Skin Integrity Addendum To TAR was done with wound measurements and documentation of the site on 3/4, 3/10, 3/17, 3/24, 3/31, 4/5 and 4/13/11 for the area to the left buttock. The notations on the skin notes for the month of March started on 3/24/11 and stated, ""During assessment today measurements are 3.4 x 2.5 x 0.2. Wound bed is black eschar with some blanching around wound bed noted. No drainage at this time. Surrounding skin is pink dry and intact. Treatment continues as ordered."" An interview was conducted with the Administrator, Licensed Practical Nurse (LPN) # 5 and LPN #6 on 4/20/11 at 8:45 AM. When asked which wound LPN #6 was referring to in the 3/24/11 skin note, she stated it was the right heel. When asked why this area was not noted before this time, she could not answer. She further stated that she thought the wound was a stage IV until she was informed on 4/19/11 that it was unstagable. LPN #5 stated she did not look at the heels weekly. When asked about the Braden Scales being completed, the policy states once a week for four weeks and then quarterly, they did not know why there was only the initial one in the record. When asked about the body audits, which are to be done weekly by the floor staff, they could not answer why they were not done and why the dressings were not removed to check the wounds. It was further stated in the interview that both of the LPN's are supervised by the DHS (Director of Health Services). LPN #5 has some wound care training and LPN #6 had no training for wound care. Both LPN's stated that skin assessments included looking at the nails, age spots, scars, tenting, hair, scalp and behind the ears. They assess a wound bed for color, drainage, sloughing and odor. No one in the interview could explain why the documentation and assessments were not completed on this resident. The two wound nurses assigned to these duties were LPNs (Licensed Practical Nurses). The South Carolina Board of Nursing has determined ""the analysis and synthesis of clinical information and the formulation of problem statements, nursing [DIAGNOSES REDACTED]."" The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/, 6/10/10, and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. On 4/19/2011 at 9:55 AM the Pressure Sore care was observed. The wound on the right hip/sacral area appeared as a horizontal split wound over the upper quadrant of the right buttocks extending to the sacral area. The last measurements dated 4/8/11 were recorded as Stage III 1 (one) CM (Centimeter) in length by 3 CM in width by 3 CM in depth. There was scarring extending out to the right of the wound. review of the resident's medical record revealed [REDACTED]. The Plan of care dated 11/05/2010 included the problem of pressure ulcer. The approaches listed for the the Pressure ulcer included: Reassess at least weekly... Resident #9 was admitted with pressure wounds. There was no documentation available on the medical record of when the current pressure sore developed. There was no documentation of weekly measurements or staging of the pressure sore before January 12, 2011. There were no nutritional assessments or progress notes related to nutritional intervention for 4 months, since December. The physician had no documentation over the past year of seeing or assessing the resident's pressure sores. The resident's pressure sore was staged as a Stage IV in January and February 2011. A Stage IV is the highest staging of a pressure sore which indicated the pressure sore was severe. No Registered Nurse, had followed or assessed the pressure sore on a routine basis. Cross Refer to F314 as it relates to the failure of the facility to adequately, accurately, and consistently assess residents at risk for skin breakdown with both developing and existing wounds. Immediate Jeopardy was identified at F-272 at a scope and severity of ""K"" as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. The systemic failure of the facility to identify, accurately assess, and monitor residents with skin impairments and or potential impairments placed those residents at risk for serious injury and/or harm. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-272 remained at a scope and severity of ""E"".",2015-05-01
9366,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,281,J,0,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, review of the facility Cardiopulmonary Resuscitation (CPR) policy and review of the South Carolina State Board of Nursing Advisory Option #9, the facility failed to provide care and services that met professional standards for one of two closed records reviewed for full code status and one of one resident reviewed with a Peripheral Inserted Central Catheter (PICC) Line. CPR was not initiated in a timely manner for Resident #27 with an advanced directive for a full code and Licensed Practical Nurses (LPN) with no proof of advanced training, administered antibiotics and flushes via a PICC Line to Resident #12. The findings include: The facility admitted Resident #27 on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Closed record review on [DATE] revealed the resident sustained [REDACTED]. Also noted in the record review was a facility face sheet, which stated, under code status, that the resident was a full code. A facility Advance Directive/DNR Documentation dated [DATE] and signed by the resident on [DATE] stated, ""Verbalizes understanding of the do not resuscitate authorization as explained that no cardiopulmonary resuscitation (CPR) will be administered in the event of cardiac or respiratory arrest. A check mark beside the resuscitate statement was noted. Further review of the record showed that on [DATE] at 2:25 PM a nurse's note documented by LPN #4 stated, ""Approximately 4:30 a (AM) CNA (certified nurse's aide) came up to me and told me resident wasn't breathing, went to room to check pulse, found no pulse and resident was unresponsive. Got other nurse to come down to check resident. She checked heart and lungs sounds, no lung sounds noted, left room to check code status was full code, ... approximately 4:45 p (PM) DHS (Director of Health Services) notified, approximately 5 p administrator notified. RN (registered nurse) arrived at approximately 5:30 p to assess resident. CPR started and AED (automated external defibrillator) pads administered. CPR continued until EMS (emergency medical services) arrived at approximately 5:50 p. EMS transported resident to ... at approximately 6:20 p."" On [DATE] LPN #11 wrote the following nurses note at 4:45 P, ""Called to residents room by residents nurse. Noted resident to be cold to the touch, unresponsive to her name - color pale yellow- blue - heart sounds checked. None noted, code status checked. Crash cart taken to room O2 (oxygen) started at 6 L (liters) per NK (nasal cannula). Examined by ADHS (Assistant Director of Health Services). CPR started and cont. (continued) until ambulance arrived. EMS took over CPR - resident transferred to ... ER (emergency room )."" The last nursing note entry was done by the ADHS on [DATE] and stated, ""At approx. 5:30 this writer arrived to evaluate res. (resident) no heart sounds, no pulse noted. CPR initiated. 911 called. Family notified. At approx. 5:50 EMS arrived and took over CPR. ......"" During an interview with the Administrator, DHS, ADHS and a corporate consultant on [DATE] at 12:20 PM, the Administrator stated that the resident was pronounced deceased at the hospital. The ADHS stated that LPN #11 found the resident at 4:30 PM, CPR was started at 5:30 PM and EMS arrived at 5:50 PM. The ADHS stated that she arrived at the facility at 5:30 PM, came in and started CPR. She confirmed that the staff found the resident at 4:30 PM unresponsive and without a pulse. She also confirmed that the staff did not start CPR and that the senior nurse on the floor stated that there were no signs or symptoms of life. When asked why the LPN did not call 911, the ADHS could not respond. An interview with LPN #11 on [DATE] at 3:00 PM revealed when asked if she knew what the facility policy said about CPR, she stated that if the resident is not a DNR (do not resuscitate) you should start CPR. LPN #4 and LPN #11 have a current American Heart Association CPR training certificate, which expires ,[DATE]. During an interview with the facility medical director on [DATE] at 5:00 PM, when asked when CPR should be started on a resident who is a full code he stated, ""immediately."" Review of the facility policy on CPR, under the Procedure section, #3 stated, ""Designated staff will immediately call emergency services. #4 All staff members certified in CPR or licensed staff should immediately go to the identified room."" Cross Refer to F309 as it relates to the facility's failure to provide care and services that met professional standards of practice when Resident #27, identified as a Full Code, was not given CPR timely. The facility admitted Resident #12 on [DATE], with a re-admission date of [DATE], with [DIAGNOSES REDACTED]. Record review on [DATE] revealed that the resident was sent out of the facility on [DATE] to have a PICC Line placed. A physician order written [REDACTED]. Review of the Medication Administration Record [REDACTED]. Upon re-admission to the facility on [DATE] the physician ordered ""D5W/0.9% Sod Cl ([MEDICATION NAME] 5 % water/0.9% sodium chloride) 1000 ml with potassium chloride 20 meq (milliequivalents) rate 24 ml/hour run via PICC line; [MEDICATION NAME]/D5W 750 mg/150ml IV (intravenously) Q (every) 24 hours, rate 150 ml/hr continue until ,[DATE] then d/c (discontinue)."" Review of the [DATE] Medication Administration Records (MARS) revealed an order to ""flush each lumen of 18 ga (gauge) PICC with 5 ml of ns (normal saline) every shift 7a-7p and 7p-7a"". Also noted on the MARS was a order for ""Flush each lumen in PICC line with 5 ml ns before and after each IV infusion."" The MAR indicated [REDACTED]. The [MEDICATION NAME] was administered via PICC line on [DATE] by LPN #9, on [DATE] by LPN #10 and on [DATE] by LPN #4. The PICC Line flushes for the 7 AM to 7 PM shift were signed as being completed by LPN #9 on ,[DATE], ,[DATE] and ,[DATE], by LPN #10 on ,[DATE] and by LPN #4 on ,[DATE] and ,[DATE]. The initials and names of the LPN's were verified by the ADHS (Assistant Director of Health Services) on [DATE] at 3:15 PM. On [DATE] at 4:00 PM the DHS stated that LPN #4 was at IV training today, LPN #9 had no advanced IV training and LPN #10 stated that she had the training but had no certificate of training. The South Carolina Department of Labor, Licensing and Regulation, (Advisory Opinion #9 B) states, ""The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/lines that includes didactic and supervised clinical competency training with return demonstration... The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter site (port A cath)"". Immediate Jeopardy was identified at F-281 at a scope and severity of ""J"" as it related to the facility's failure to follow a resident's desire for Full Code and the facility did not attempt resuscitation timely. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on [DATE] accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-281 remained at a scope and severity of ""D"".",2015-05-01
9367,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,309,J,0,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on closed record review, interviews and review of the facility policy titled Cardiopulmonary Resuscitation (CPR) the facility failed to initiate CPR in a timely manner for one of two residents designated as having full code status. The facility did not initiate CPR on Resident #27 until one hour after finding the resident without a pulse. The findings include: The facility admitted Resident #27 on [DATE] with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Closed record review on [DATE] revealed the resident sustained [REDACTED]. An x-ray of the right leg from hip to ankle was ordered on [DATE] and completed on [DATE]. The resident was sent out to the hospital for evaluation and treatment for [REDACTED]. She returned to the facility on [DATE] at 12:15 AM with an immobilizer to the right leg. Further review of the record showed that on [DATE] at 2:25 PM a nurse's note stated, ""Resident vomited this morning and c/o (complaint of) nausea. Order for [MEDICATION NAME] 25 mg. (milligrams) po (by mouth) q (every) 6 hours for 24 hours prn (as needed)"". A nurse's note on [DATE] at 3:15 PM stated, ""Resident sleeping in bed."" The next notation in the nurse's notes written on [DATE] by LPN #4 stated, ""Approximately 4:30 a (AM) CNA (certified nurse's aide) came up to me and told me resident wasn't breathing, went to room to check pulse, found no pulse and resident was unresponsive. Got other nurse to come down to check resident. She checked heart and lungs sounds, no lung sounds noted, left room to check code status was full code, ... approximately 4:45 p (PM) DHS (Director of Health Services) notified, approximately 5 p administrator notified. RN (registered nurse) arrived at approximately 5:30 p to assess resident. CPR started and AED (automated external defibrillator) pads administered. CPR continued until EMS (emergency medical services) arrived at approximately 5:50 p. EMS transported resident to ... at approximately 6:20 p."" On [DATE] LPN #11 wrote the following nurse's note at 4:45 P, ""Called to residents room by residents nurse. Noted resident to be cold to the touch, unresponsive to her name - color pale yellow- blue - heart sounds checked. None noted, code status checked. Crash cart taken to room O2 (oxygen) started at 6 L (liters) per NK (nasal cannula). Examined by ADHS (Assistant Director of Health Services). CPR started and cont. (continued) until ambulance arrived. EMS took over CPR - resident transferred to ... ER (emergency room )."" The last nursing note entry was done by the ADHS on [DATE] and stated, ""At approx. 5:30 this writer arrived to evaluate res. (resident) no heart sounds, no pulse noted. CPR initiated. 911 called. Family notified. At approx. 5:50 EMS arrived and took over CPR. Family arrived also. Res. transported via stretcher to ... at approx 6:20 pm. Family followed."" Also noted in the record review was a facility face sheet, which stated, under code status, that the resident was a full code. A facility Advance Directive/DNR Documentation dated [DATE] and signed by the resident on [DATE] stated, ""Verbalizes understanding of the do not resuscitate authorization as explained that no cardiopulmonary resuscitation (CPR) will be administered in the event of cardiac or respiratory arrest. A check mark beside the resuscitate statement was noted. During an interview with the Administrator, DHS, ADHS and a corporate consultant on [DATE] at 12:20 PM, the Administrator stated that the resident was pronounced deceased at the hospital. The ADHS stated that LPN #11 found the resident at 4:30 PM, CPR was started at 5:30 PM and EMS arrived at 5:50 PM. She further stated that she arrived at the facility at 5:30 PM, came in and started CPR. She confirmed that the staff found the resident at 4:30 PM unresponsive and without a pulse. She also confirmed that the staff did not start CPR and that the senior nurse on the floor stated that there were no signs or symptoms of life. When asked why the LPN did not call 911, the ADHS could not respond. An interview with LPN #11 on [DATE] at 3:00 PM revealed that she was present on the day in question and was assigned to the North Hall. The resident was on the South Hall. She stated that the other nurse asked her to come and check the resident. Her statement was the same as what was charted in the nurse's notes. She stated that after the ADHS was called she went back to work until the ADHS arrived at the facility at 5:30 PM. She also stated that she started CPR after the ADHS arrived and told her to do it. When asked if she knew what the facility policy said about CPR, she stated that if the resident is not a DNR (do not resuscitate) you should start CPR. LPN #11 has a current American Heart Association CPR training certificate, which expires ,[DATE]. An interview with LPN #4 on [DATE] at 3:45 PM revealed that she was informed that the resident was not breathing around 4:30 PM. She further stated that she called the other nurse on the floor; she assessed and we called the RN, we should have started CPR then but we waited for the RN. I know we should have started it sooner but we started CPR until the ambulance came and took over. LPN #4 has a current American Heart Association CPR training certificate, which expires on ,[DATE]. During an interview with the facility medical director on [DATE] at 5:00 PM, when asked when CPR should be started on a resident who is a full code he stated, ""immediately."" Review of the facility policy on CPR, under the Procedure section, #3 stated, ""Designated staff will immediately call emergency services. #4 All staff members certified in CPR or licensed staff should immediately go to the identified room."" Immediate Jeopardy and Substandard Quality of Care was identified at F-309 at a scope and severity of ""J"" as it related to the facility's failure to follow a resident's desire for Full Code and the facility did not attempt resuscitation timely. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on [DATE] accepted the Allegation of Compliance for the Immediate Jeopardy and Substandard Quality of Care before exiting the facility. The Immediate Jeopardy and Substandard Quality of Care was removed but the deficiency at F-309 remained at a scope and severity of ""D"".",2015-05-01
9368,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,325,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that nutritional interventions and assessments were completed in a timely manner in regards to weight loss and pressure ulcers for three of 15 resident's records reviewed. Resident #7 did not have interventions for weight loss and pressure ulcers put in to place in a timely manner, Resident # 9 did not have any nutritional documentation or assessments done since December 2010 and Resident #12 was not assessed in a timely manner for weight loss. The findings included: The facility admitted resident #9 on 9/21/07, readmitted on [DATE]/ 6/10/10 and 9/15/10 with [DIAGNOSES REDACTED]. During an interview with the resident on 4/20/11, he stated that he had wounds for 4 years and had wounds when he was admitted to the facility. The medical record was reviewed for Nutritional Assessments/notes in regards to nutritional interventions to promote healing of the wounds. The last Nutritional Assessment that was completed was dated 11/4/10. The assessment documented recommendations of Prostat 64 (a protein supplement used to promote healing of wounds). The residents weight at that time was documented at 398 pounds (lbs.). The assessment included abnormal lab results of an [MEDICATION NAME] of 2.1, normal values 3.5-5(Measures protein levels in the body), low Hemoglobin, 9.9 (normal value 14-18) and Hematocrit, 30.2, normal values for men 42-52, (measures the Red Blood Cell volume of the blood). There was no further nutritional assessment available for the resident. The last nutritional progress note was dated 12/22/10. There were no nutritional progress notes for 2011 (4 months) in regard to the resident's pressure sore and nutritional requirements. During an interview with the Certified Dietary Manager and the Registered Dietician (RD) on 4/20/11 at 9:25 AM, when asked how often the RD did Nutritional Assessments and progress notes on residents with wounds, the RD stated that she did progress notes on wounds monthly. She stated, ""I look monthly, what stage it is (wound)."" She stated she estimated the needs if the weight fluctuates and reviewed the labs. When asked where the progress notes and Nutritional Assessments were since December, the RD stated, ""I got confused and just documented his weights. I should have been documenting on his wounds and nutritional needs as well."" The facility admitted Resident #7 on 12/10/10 with [DIAGNOSES REDACTED]. Record review showed the resident weighing 124 lbs. on admission to the facility. She was placed on a mechanical soft diet. Further review revealed that the resident was seen by speech therapy for pocketing food and dysphagia was added to her list of diagnoses. Her most recent Minimum Data Set (MDS) stated that she was an assist of one for feeding. The residents care plan, which was updated on 3/11/11, under problems, stated DX (diagnoses) dysphagia - hold food in mouth req (required) verbal cues to swallow. A 12/28/10 problem was noted as stating: ""Wt. (weight) loss noted"". Review of the dietary section of the record showed that the RD completed the Nutritional Screening and Assessment Form on 12/17/10. The first note written by the RD was on 2/27/11 and it stated that the residents weight was 115 lbs on 2/16/11 and her plan was to follow up and monitor weights, labs ... An additional note on 3/27/11 stated the weight for the resident was 116 lbs. Review of the labs showed that the only metabolic profile was done on 12/15/10 with the [MEDICATION NAME] being 2.2 (normal 3.2 - 5.3) and the pre-[MEDICATION NAME] was 94 (normal 160 - 400). Review of the Medication Administration Record [REDACTED]. An interview was conducted with the Administrator, the RD and the CDM on 4/20/11 at 9:00 AM. During the interview the CDM stated that the resident gets snacks between meals and the snacks are things such as puddings. There is no documentation of snacks being given or the percentage that was consumed. The RD stated that if a resident has a wound she would add supplements such as snacks, shakes ice cream and milk. She further stated that someone with a wound would be followed on a monthly basis and they would look at the diet, medications and labs. The RD also stated that she should have ordered follow up labs for the [MEDICATION NAME] level for the resident. The RD could not offer an explanation as to why the supplement was not ordered before 4/7/11 and why the weight loss was not acted upon in a timelier manner. The facility admitted Resident #12 on 2/4/11, with a re-admission date of [DATE] with [DIAGNOSES REDACTED]. The first observation of the resident was on 4/18/11 at 1:15 PM. The resident was in the dining room and she had not eaten any of her noon meal. A CNA (certified nurses aide) stated, ""Miss....you need to eat something. I don't want to see you lose any more weight."" The resident then stated, ""I just don't have any appetite."" Record review on 4/18/11 revealed that the resident's weight on 2/4/11 was 168 pounds (lbs). Her weight on 3/11/11 was 164 lbs. When the resident returned from the hospital her weight on 4/7/11 was 154 lbs. The Diet History/Food Preference List and the Nutritional Screening and Assessment Form were completed on 2/9/11. There were no other dietary notes in the record. An interview with the resident revealed that the resident has not had an appetite since re-admission to the facility. During an interview on 4/19/11 at 2:30 PM with the Assistant Director of Health Services (ADHS), when asked of she thought the resident should have been re-weighed, she stated that the resident should have been weighed on 4/12/11 but the resident refused to be weighed. There was no documentation to confirm this. She also stated that she was not sure if a facility Weight Loss/Gain report was completed. The resident was re-weighed on 4/19/11 and the weight was 150 lbs. An interview was conducted with the Administrator, the Certified Dietary Manager (CDM) and the Registered Dietician (RD) on 4/20/11 at 9:00 AM. The RD stated that she was aware of the fact that the resident refused to be weighed and it was on a sheet of paper but she could not find the paper. When asked why the resident was seen only one time the CDM stated that she sees the resident at least once a week on rounds but does not chart on the resident. Both the RD and the CDM were unaware of the fact that the resident was not eating. The RD stated that weight reports were due on Mondays and that the resident would have been picked up on 4/18/11. The Administrator stated that the resident should have been seen within 72 hours of admission and that every day in the daily meetings they talk about who is being admitted or readmitted to the facility and that the CDM attends those meetings. Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Immediate Jeopardy and Substandard Quality of Care was identified at F-325 at a scope and severity of ""K"" as it related to the facility's failure to ensure nutritional assessment and interventions were in place for residents with pressure ulcers. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy and Substandard Quality of Care before exiting the facility. The Immediate Jeopardy and Substandard Quality of Care was removed but the deficiency at F-325 remained at a scope and severity of ""E"".",2015-05-01
9369,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,490,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on record reviews, interviews, and observations, it was determined that Immediate Jeopardy and Substandard Quality of Care existed related to professional standards of practice and pressure sores. The facility Administration failed to ensure the established policies and procedures were carried out to ensure pressure sores were identified, assessed, and treated to promote healing and prevent development of additional wounds. Additionally, the Administration failed to ensure a resident's desire for full code was handled properly by Licensed nursing staff. The findings included: During the Recertification and Extended Survey, 6 of 10 sampled residents with pressure sores were noted to have concerns that included; assessments missing or not completed, wounds not identified or documented incorrectly, treatments not completed as ordered. Review of a Performance Improvement Plan developed and implemented 4/29/10 revealed these same concerns. From this Plan tools were developed and re-evaluation dates were to be ongoing. The last date to re-evaluate listed 7/22/10 and there was no further evidence of monitoring to ensure the goals were met and maintained. Immediate Jeopardy was identified at F490 related to the failure of the facility's Administration to adequately provide the necessary oversight for residents at risk for and with actual skin impairments which placed those residents at risk for serious harm and injury. Cross refer to F2-72 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refer to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Cross refer to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Cross refer to F-520 as it related to the facility failure to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. Immediate Jeopardy and/or Substandard Quality of Care was identified at F-490 at a scope and severity of ""K"" related to the failure of the facility's Administration to adequately provide the necessary oversight for residents at risk for and with actual skin impairments which placed those residents at risk for serious harm and injury. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-490 remained at a scope and severity of ""E"".",2015-05-01
9370,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,501,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility's Medical Director failed to ensure resident care policies and procedures were implemented related to wound care management. The findings included: In a telephone interview with the survey team on 4/20/11 at 5:00 PM the Medical Director (MD) stated that he did see resident's wounds, ""Not every time, once a month or so if/when they tell me to look at them."" When told that there was nothing in his progress notes pertaining to the pressure sores, he stated, ""Documentation may be an issue, but I see them as needed"". The Medical Director stated that the nurses made the recommendations regarding the treatment of [REDACTED]. ""I do not oversee to the inth degree with wounds. Review of the Physician's Progress Notes dated from 4/15/10 through 4/5/11, (one year) revealed there was no documentation of Pressure sores. There was no mention of progression or deterioration of the resident's pressure sores by the physician. Cross refers to F-272 as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds Cross refers to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and/or injury. Cross refers to F-325 as it related to the facility's failure to provide timely nutritional assessments to monitor and implement recommendations to assist in the healing of pressure ulcers. Cross refer to F-520 as it related to the facility failure to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. Immediate Jeopardy was identified at F-501 at a scope and severity of ""K"" as it related to the failure of the Medical Director to ensure facility policies and procedures related to wound care were implemented. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-501 remained at a scope and severity of ""E"".",2015-05-01
9371,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2011-04-20,520,K,1,1,94T811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, identification, and treatment of [REDACTED]. The findings included: On 3/30/11 a Census and Condition documented the facility had 8 resident's in the facility with pressure ulcers, 3 of which were present on admission. On 3/31/11, the facility became aware of concerns related to the care of pressure ulcers. Record review revealed that on 4/29/10, the facility had begun a Performance Improvement Plan for ""Skin Integrity"" with an ""ongoing"" date for resolution. The plan included the completion 100% body audits, weekly assessments, monitoring treatments, careplans, completing Braden scales, weekly documentation, compliance rounds, inservice's on pressure ulcer dressing technique, and adaptive devices. The last date related to the information submitted with this plan was 7/22/10 although the plan stated it was ""ongoing."" On 3/31/11 a second Performance Improvement Plan was begun titled ""Wound Care Assessments"" with a resolution date of 4/30/11 and on-going. This plan included: Wound care assessments would be completed on all new admissions; nurses were to notify the Director of Health Services of new admissions with skin breakdown; body audits were to have been completed on all residents by 4/11/11; no holes (lack of documentation) were to be noted on the treatment records; skin assessment books were to be brought to clinical meetings daily; the physician was to assess residents with wounds and place notes on charts; and filing of wound care nurses notes are to be started on 3/31/11. Additionally, wound care nurses were to participate in wound care classes; wound care nurses will state all wounds, which was to be signed by an Registered Nurse; monthly wound care notes were to be completed; and Nurses and Aides were to participate in in-service related to turning residents. Despite on-going Performance Improvement Plan(s), continued concerns were identified with six of tens sampled residents reviewed with pressure ulcers related to assessment/tracking, proper staging, treatment and adequate nutritional assessment /intervention related to the care of the resident's with known pressure ulcers. Cross refer to F-272 as it related to the facility's failure to assure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. Cross refer to F-280 as it related to the facility failure to develop. review, and revise care plans of residents at risk of skin impairment or with existing skin impairment. Cross refer to F-314 as it related to the facility's failure to adequately assess residents with skin impairments, appropriately treat residents with wounds, adequately monitor residents with wounds and failed to identify residents with pressure ulcers which placed residents at risk for serious harm and or injury. Cross refer to F-490 as it related to the failure of the facility's Administration to provide the necessary oversight to assure policies and procedures related to wound care were implemented. The Administration with known knowledge of quality deficiencies failed to appropriately act upon those areas which placed residents at risk for serious injury and or harm. Cross refer to F-501 as it related to the failure of the medical director to assure facility policies and procedures related to wound care were implemented. The Medical Director also failed to assure the Quality Assurance Committee promptly acted upon known deficient practices which placed residents at risk for serious injury and or harm. Immediate Jeopardy was identified at F-520 at a scope and severity of ""K"" as it related to the facility's failure to ensure each resident was adequately and accurately assessed for pressure ulcers, and the appropriate assessments were completed for residents with existing wounds. The systemic failure of the facility to identify, accurately assess, and monitor residents with skin impairments and or potential impairments placed those residents at risk for serious injury and/or harm. Based on observations of inservices, staff interviews, and documentation provided by the facility, the Survey Team on 4/20/11 accepted the Allegation of Compliance for the Immediate Jeopardy before exiting the facility. The Immediate Jeopardy was removed but the deficiency at F-520 remained at a scope and severity of ""E"".",2015-05-01
9372,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2012-01-25,152,D,1,0,YR0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, interviews, and review of facility policies, the facility failed to ensure that two physicians examined and certified the resident's inability to formulate advanced directives and/or consent to a Do Not Resuscitate (DNR) order for 1 of 1 cognitively impaired resident reviewed with a DNR order authorized by another person (#11). The findings included: Resident #11 with [DIAGNOSES REDACTED]. On [DATE], the resident's wife authorized a DNR order. On [DATE], the physician gave the DNR order. Review of the medical record failed to show a determination by two physicians, who examined the resident, that he was incompetent to make health care decisions. A document was noted in the medical record dated [DATE], written on notepaper and allegedly signed by the resident, stating he desired no CPR (cardiopulmonary resuscitation). The names of two witnesses were on the form, both printed in the same handwriting. A note at the bottom of the page was dated [DATE] and said the resident appointed his wife as decision maker and his daughter as alternate. The resident's signature for the added notation was not witnessed. Review of the facility's policy and procedure for Advanced Directives revealed the following: ""Incompetent - When a resident is incompetent, he/she is unable to make his or her own decisions. A resident should not be presumed incompetent unless two (2) physicians render an opinion of such ... "" (page ,[DATE]) ""Residents that are not competent may be judged to be without capacity by two (2) physicians that will evaluate the resident and select the Code Status that is in the best interest of the resident. The 'Advanced Directive - Choice of Treatment' form must be signed by both physicians. ..."" (page ,[DATE]) Review of the facility's Admission, Transfer, & Discharge Procedures, Chapter 1, page ,[DATE], stated: ""... The forms to document competency include: ""Resident Capacity, which is determined by the attending physician and then ""Choice of Treatment, which must be signed another (sic) physician as required by SC law which requires two (2) physicians to deem a resident 'without capacity.' ...""",2015-05-01
9373,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2012-01-25,153,G,1,0,YR0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on medical record review, review of facility records, and interviews, the facility failed to ensure that a resident's legal representative was allowed to purchase copies of the resident's medical record with 2 working days advance notice for 2 of 2 requests made by family members (#1 and #2). The facility also failed to release copies of a medical record, requested by the resident, in a timely manner (#A). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was unable to communicate. His parents were deceased . For all his time at the facility, his sister was his responsible party and made all decisions for him. She signed authorization for Do Not Resuscitate (DNR)and for vaccinations. The facility staff notified the sister about any change in condition the resident experienced. The sister attended care plan meetings and actively participated in the ongoing plan of care for her brother. She was the one who signed discharge paperwork at the facility, and it was she who authorized release of information to the resident's new facility. Review of the available medical record revealed that on [DATE], two physicians signed a form titled Authorization of Do Not Resuscitate Incompetent Resident. The physicians certified that the resident did not have the capacity to make decisions and that DNR status was appropriate for him. Resident #1's sister signed consent for the DNR order. Review of the South Carolina Health Care Consent Act revealed that a residents inability to consent must be certified by two physicians. ""... Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. ...6 an adult sibling, grandparent, or adult grandchild of the patient ..."" On [DATE], the resident's sister requested copies of his medical record for the period of [DATE] to [DATE]. On [DATE], the facility sent the requested copies of the medical record to their corporate legal office. On [DATE], the facility sent a letter to the resident's sister stating "" ... (Resident) was deemed as 'Incompetent' as of his admission to our facility back in 2002 according to the documentation we have on file. ..."" The facility continued to say: ""Our legal team has indicated to me you will have to pursue legal 'Guardianship' through the Probate Courts in order to have any documentation related to (resident's) care at our facility released to you. ..."" As of [DATE], the medical record copies still had not been released to Resident #1's sister. Resident #2 lived at the facility from [DATE] to [DATE]. Her [DIAGNOSES REDACTED]. Throughout most of her stay at the facility, the resident made her own decisions. She displayed impaired cognitive status in early 2011 (,[DATE] on the Brief Interview for Mental Status, assessment date of [DATE]) and had a decline in condition which became more pronounced in mid-[DATE]. At that time, the resident was included in the facility's Butterflies Are Free program for end of life comfort care. All diagnostics were discontinued. A physician's orders [REDACTED]. On [DATE], the resident vomited a large amount of brown emesis. Facility staff contacted the physician who instructed them to call the daughter and follow her wishes. The resident expired at the facility on [DATE]. On [DATE], the resident's daughter requested copies of the medical record. The facility sent copies of the record to their corporate legal department on [DATE]. As of [DATE], the copies had not been released to the resident's daughter. Resident #A requested copies of his medical record on [DATE]. The facility sent the copies to their corporate legal department on [DATE]. The copies were released to the resident on [DATE]. During an interview with the Administrator and the Health Care Information Management Director on [DATE] at 1:25 PM, they confirmed the information concerning the three medical records noted above.",2015-05-01
9374,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2012-01-25,155,D,1,0,YR0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, interviews, and review of facility policies and procedures, the facility failed to ensure that residents formulated their own advanced directives for 3 of 5 alert and oriented residents with Do Not Resuscitate (DNR) orders. Residents #4, #12, and #14 had the decision for DNR made by other individuals. The findings included: Resident #4 with [DIAGNOSES REDACTED]. There was no evidence in the medical record showing two physicians had deemed the resident without capacity to make her health care decisions. The initial Resident Assessment Instrument with an assessment date of 1/5/12 showed the resident with a BIMS (Brief Interview for Mental Status) score of 15/15, indicating no cognitive impairment. On 1/24/12, the physician gave an order for [REDACTED]. Resident #12 with [DIAGNOSES REDACTED]. Her son authorized a DNR on 12/30/11. Review of the medical record failed to show evidence that two physicians deemed the resident incompetent to make her own health care decisions. The resident scored 13/15 on a BIMS completed during the initial assessment completed on 1/10/12, and scored 14/15 as noted by the Social Worker on 1/18/12. The BIMS scores did not indicate cognitive impairment. On 1/24/12, the physician gave the order for DNR. Resident #14 with [DIAGNOSES REDACTED]. The resident's husband authorized a DNR on 12/14/11. Review of the medical record failed to show evidence the resident was deemed unable to make her own health care decisions. On 12/15/11, the physician gave the DNR order. Review of the initial resident assessment dated [DATE] revealed a BIMS score of 15/15, indicating the resident was cognitively intact at the time the DNR order was given. Review of the facility's policy and procedure for Advanced Directives revealed the following: ""The resident has a right to execute or refuse to execute an advanced directive, which stipulates how decisions regarding his or her medical care are made. ..."" (page 1-42)",2015-05-01
9375,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2012-01-25,225,D,1,0,YR0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to ensure that all injuries of unknown origin were reported to the State survey and certification agency for 1 of 1 injury of unknown origin reviewed ( #7). The findings included: Resident #7 with [DIAGNOSES REDACTED]. She complained of right arm pain and of not being able to move her right arm. The resident went to the hospital for evaluation where a fractured humerus was diagnosed . Review of the facility's reportable incident file failed to show evidenced this injury of unknown origin was reported to the State survey and certification agency. The Director of Nurses confirmed that he did not report the injury when interviewed on 1/25/12 .",2015-05-01
9376,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2012-01-25,309,E,1,0,YR0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and review of facility policies, the facility failed to ensure that [MEDICAL TREATMENT] residents were adequately assessed and monitored for fistula/graft patency and signs of bleeding and infection at the site for 2 of 2 residents who required [MEDICAL TREATMENT] (#3 and #6). The findings included: Resident #3 with a [DIAGNOSES REDACTED]. He required [MEDICAL TREATMENT] three times of week. His fistula was located in his upper right arm. Review of the medical record showed no physician's order for monitoring of the [MEDICAL TREATMENT] site. Review of the Interim Care Plan dated 1/12/14 (sic) showed under [MEDICAL TREATMENT] Treatments: [MEDICAL TREATMENT] treatments 3 times per week; transportation services ... ; assess shunt site for bruit and thrill; observe for bleeding at site; do not take B/P (blood pressure) right arm; post [MEDICAL TREATMENT] care per facility protocol."" Review of the Nurse's Notes showed an admission nurse's note saying the resident's right upper arm fistula was patent, demonstrating positive bruit and thrill. One other nurse's note addressed the condition of the [MEDICAL TREATMENT] fistula. On 1/21/12 at 7 PM, the nurse's note said ""... fistula patent. ..."" Review of the Medication Administration Record [REDACTED]. Review of the Treatment Chart showed an entry saying: ""fistula (R) upper arm"" with 7A-7P and 7P-7A noted beside it. There was no daily shift documentation showing the fistula was checked for patency, bleeding, or infection. On 1/24/12, at approximately 10:10 AM, LPN #1 was asked where to find documentation concerning checking the resident's [MEDICAL TREATMENT] fistula related to bruit, thrill, bleeding, or infection. She stated that was documented in the Nurses' Notes. However, as noted above, there was little documentation concerning the patency and condition of the resident's fistula in the Nurse's Notes After a discussion with the Director of Nurses about the lack of assessment and monitoring of the [MEDICAL TREATMENT] site, he provided copies of a form titled Pre/Post [MEDICAL TREATMENT] Checklist. He stated he found the checklists waiting to be filed in the medical record. The checklist form asked for vital signs and information on the shunt both before and after [MEDICAL TREATMENT]. Prior to [MEDICAL TREATMENT] the staff was asked to document ""Shunt, i.e., intact, parts capped & clamped, drsg (dressing), pain. Documentation on the forms for 1/16, 1/18, 1/20 and 1/23/12 showed ""intact"" or that the resident was medicated for pain. After [MEDICAL TREATMENT], the staff was asked to document under ""Monitor shunt site q (every) 30 x 2 hr. (thirty minutes for two hours)(notify [MEDICAL TREATMENT] center if problems) ""a. Location c. Ports capped & clamped ""b. Drsg dry & intact d. Any problems"" The documentation showed initials, checkmarks, and an ""intact"" next to dressing dry and intact; and showed zeros, 0 problems, or N/A next to any problems. Resident #6 with a [DIAGNOSES REDACTED]. He went to [MEDICAL TREATMENT] three times a week. Review of the medical record revealed sporadic charting in the Nurse's Note related to the condition of the [MEDICAL TREATMENT] fistula. In November 2011, the MAR indicated [REDACTED]. The December 2011 MAR indicated [REDACTED]. Documentation on the Pre/Post [MEDICAL TREATMENT] Checklist was noted for 12/2, 12/5, 12/7, 12/14, and 12/16/11. The checklists for 12/9 and 12/12/11 were not found in the closed record. Review of the Nurse's Notes revealed the condition of the resident's [MEDICAL TREATMENT] fistula related to bruit and/or thrill was documented 31 times out of 47 opportunities in November. In December 2011, the condition of the resident's fistula was documented 17 times out of 31 opportunities. Review of the facility's policy on [MEDICAL TREATMENT], page 10-39, revealed: ""Policy The [MEDICAL TREATMENT] resident shall receive consistent care pre and post-[MEDICAL TREATMENT]. The shunt site shall be checked on a daily basis with physician notification for any known or suspected problem."" Under the section for Post-[MEDICAL TREATMENT] ""5. Monitor access site every shift. ..."" Under the section General Guidelines: ""4. ... Check for thrill or bruit every shift. If absent notify attending MD and [MEDICAL TREATMENT] center. ... 6. Document in the clinical nursing record: [MEDICAL TREATMENT] treatment completed, order changes, condition of the shunt site, complaints from resident ( if applicable), and whether physician was notified."" Under the section Care Plan: ""b) Care of access site. Observe for signs of bleeding, infection and patency (check for thrill or bruit) every shift. Notify MD and/or [MEDICAL TREATMENT] facility of complications.""",2015-05-01
9377,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,514,D,0,1,HRMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews, the facility failed to accurately document 1 of 14 sampled residents reviewed for medication administration. Resident #11 Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #11 on 11/27/09 with [DIAGNOSES REDACTED]. Record review on 7/26/11 revealed a July 11 monthly cumulative order that indicated resident had a change in medication [MEDICATION NAME] 20 milligrams. Further record review revealed a physician order [REDACTED]. O. (Per Oral) @ (at) HS (Hour of Sleep)"". Review of the June 11 MAR indicated [REDACTED]. The July MAR indicated [REDACTED]. An interview on 7/26/11 at approximately 11:55 PM with LPN (Licensed Practical Nurse) #2 revealed there had been no change in the order for [MEDICATION NAME] at 20 milligrams for Resident #11, and there was no documentation on the Medication Administration Record [REDACTED]. An interview on 7/26/11 at 12:10 PM with LPN #1 confirmed there had been no change in the physician's orders [REDACTED]. LPN #1 and #2 located the medication card for [MEDICATION NAME] for Resident #11 and stated the medication was given but not documented. This surveyor requested the pharmacist on the team to investigate the medication concern further. Review of the resident's medications in the medication cart revealed a medication punch card containing [MEDICATION NAME] 500 mg ER tablets and a separate medication punch card containing [MEDICATION NAME] 20 mg tablets. Review of the Medication Administration Record [REDACTED]. A call to Agape Pharmacy on 7/26/11 at 1:15 PM confirmed that a separate punch card of medications ([MEDICATION NAME] 500 mg ER and [MEDICATION NAME]) was sent to the facility (Agape Rock Hill) in both June and July. During an interview on 7/26/11 at 1:45 PM, the physician who ordered the medication stated that the [MEDICATION NAME]/[MEDICATION NAME] combination is available in a single medication called [MEDICATION NAME] (brand name). He agreed that using two separate medications and combining them on one line on the MAR indicated [REDACTED].",2015-05-01
9378,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,248,D,0,1,HRMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and record review, the facility failed to provide an ongoing activity designed to meet the needs of low functioning residents. Resident #4 and Resident #9 were not provided structured 1:1 activities that met their needs based on 2 of 2 residents observed for 1:1 activities. The findings included: Resident #4 was admitted with End-stage Dementia, [MEDICAL CONDITION], Adult Failure to Thrive, Hypertension, Type II Diabetes, and Dehydration. On 7/25/11 at 12:18 PM, Resident #4 was observed in bed with legs near his chest mumbling to himself and moving in the bed. On 7/25/11 at 2:10 PM until 3:30 PM, the resident was observed in the same position in bed. On 7/25/11 at 5:30 PM, the resident was observed in a gerichair in his room with his wife sitting next to him. On 7/25/11 and 7/26/11 during repeated random observations, the resident was observed having no structured activities. On 7/25/11 at 5:30 PM, an interview with Resident #4's wife was conducted. She stated that in the past the resident was always a very social person. He loved being around children and always sang in church. On 7/25/11 at 1:00 PM, a review of the residents care plan and activity progress notes were conducted. Resident #4's interim care plan dated 4/16/11 stated that the resident lacked social interaction and stays in his room. The goal was to provide ""sensory stim (stimulation) wkly (weekly) as tolerated"". The comprehensive care plan dated 3/24/11 had no activity care plan provided for the resident. Review of the activity progress notes dated 6/20/11 stated ""He prefers to stay in bed in room to receive daily visits from wife. When up OOB (out of bed) in w/c(wheelchair) resident has attended some activities this quarter passively. Life Enrichment will provide in room stim as desired and tolerated well"". Activity Progress Note dated 7/14/11 stated that the residents wife ""visits him almost daily for several hours for sensory stimulus"". Review of the activities provided by the facility for one to one revealed that on 3/29/11 at 7 PM ""visited resident"", on 4/3/11 at 4 PM ""visited talked with his wife at length"", on 4/9/11 at 1:15 PM ""res asleep"", on 4/12/11 at 6:15 PM ""wife visiting"", on 4/16/11 at 3 PM ""wife visiting"", 4/17/11 at 3:30 PM ""visited spoke with wife"", on 4/24/11 at 1:30 PM ""res sleeping"", and on 4/28/11 at 6:20 PM ""res sleeping wife visiting"". Documentation for May 2011 revealed on 5/3/11 at 6:30 PM ""patient care"", on 5/10/11 at 6:35 PM ""sleep"", on 5/14/11 at 2:00 PM ""patient care"", on 5/19/11 at 6:45 PM ""visited with him and his wife"", on 5/21/11 at 2:15 PM ""sleep; wife was there visiting"", and on 5/29/11 at 12:45 PM ""stopped in for a few minutes he was resting"". Documentation for the month of June 2011 revealed four visits were provided for the month and the resident was asleep during two and receiving care during one. Documentation for the month of July 2011 revealed 5 visits had been provided and during two visits the resident was asleep. On 7/26/11 at 1:30 PM, an attempt was made to interview the resident. The resident mumbled but was not able to answer questions. On 7/26/11 at 1:45 PM, an interview with the Activity Director was conducted. He stated that Resident #4 was being provided 1:1 activities 1-2 times per week. He stated that the resident's wife visited the resident daily and that was considered a structured activity. He did state that it was not a facility initiated activity. The Activity Director stated the resident preferred to stay in bed and that is why he did not go to group activities. He further stated that if the resident was asleep when he did a visit, he did not do a follow up visit when the resident was awake. The facility admitted Resident #9 on 6/28/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 revealed the resident was on contact precaution and required in room activities. Observation on 7/25/11 at approximately 2 PM to 3:30 PM revealed no activities in progress. An interview on 7/25/11 at approximately 3:30 PM with LPN #3 revealed the resident received in room therapy and she was not sure about activities. An observation on 7/25/11 at 4 PM revealed the Activity Director reading to the resident. Record review revealed an activity evaluation was completed that indicated the resident's current activity interest included Animals/Pets, Exercise, Music, Religious Services and Sing-Alongs. Further record review revealed activities progress notes dated 7/06/11 that indicated resident will receive sensory stimulation and social interaction. There was no indication as to what kind of sensory stimulation that the resident would receive. An activity note dated 7/07/11 ""4 PM to 4:20 PM staff read scripture and sang song ""Jesus Loves Me"" with resident"". Review of documented one to one revealed - On 7/12/11 at 11:15 AM resident was asleep. On 7/14/11 at 11:30 AM resident was asleep. On 7/18/11 at 3:50 PM staff read to resident and sang song. On 7/20/11 3:50 PM staff read to resident. On 7/22/11 at 1:30 PM resident was asleep. On 7/25/11 at 3:50 PM staff read to resident. During an interview on 7/26/11 at approximately 2:10 PM with the AD (Activity Director) the surveyors findings were confirmed.",2015-05-01
9379,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,279,D,0,1,HRMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to develop a comprehensive care plan to address the psychosocial needs of 2 of 2 sampled residents that were identified as needing in room one to one activities. (Resident #4 and #9) The finding included: The facility admitted Resident #9 on 6/28/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 revealed a comprehensive care plan with a problem date of 7/11/11 that indicated resident had a potential for social isolation due to needed contact precautions and room isolation. The approaches were to provide in room activities and 1 to 1 when requested and as needed. Further record review revealed an activity evaluation that indicated the resident's current activity interest included Animals/Pets, Exercise, Music, Religious Services and Sing-Alongs which was not addressed in the care plan . The care plan did not address how often in room activities would take place. The resident's current activities of interest were not addressed on the care plan. An interview on 7/26/11 at approximately 2:10 PM with the AD (Activity Director) confirmed the findings. Resident #4 was admitted on [DATE] with End-stage Dementia, [MEDICAL CONDITION], Adult Failure to Thrive, Hypertension, Type II Diabetes, and Dehydration. On 7/25/11 at 12:18 PM, Resident #4 was observed in bed with legs near his chest mumbling to himself and moving in the bed. During repeated observations on 7/25 and 7/26 there was no observation nor documentation of the resident recieving structured activities. On 7/25/11 at 1:00 PM, a review of the residents care plan was conducted. Resident #4's interim (Admission) care plan dated was 3/24/11 stated that the resident lacked social interaction and stayed in his room. The goal was to provide ""sensory stim(stimulation) wkly (weekly) as tolerated"". The comprehensive care plan alsodated 3/24/11 and last updated on 6/22/11 had no activity care plan provided for the resident. On 7/26/11 at 1:45 PM, an interview with the Activity Director was conducted. He stated that the facility was providing the resident with one to one activities because the resident prefers to stay in bed. He stated that he did do an interim/admission care plan for the resident but had not done a comprehensive activity care plan at this time.",2015-05-01
9380,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,280,D,0,1,HRMY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, Resident #2, an interviewable resident, was not invited to attend or participate in his planning care and treatment meeting. ( 1 of 4 interviewable residents reviewed r/t care plan meeting attendance.) The findings included: The facility admitted Resident #2 on 5/19/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 of the Minimum Data Set 3.0 dated 6/1/11 revealed under Section C0500 a BIMS Score (Brief Interview for Mental Status) of 14, C0700 Short Term Memory OK, C0800 Long Term Memory OK. A score of 13-15 = Cognition in tact. The facility had deemed this resident competent to make his own decisions and interviewable. Therefore Resident #2 was selected for an individual resident interview. During the interview 7/25/11 at 2:30 PM, the Resident was asked if he had been notified or had attended any care plan meetings where the staff reviewed a plan for meeting his care and treatment needs. The Resident stated he did not attend and knew nothing about it. An interview with Social Worker #1 on 7/26/11 at 2:30 PM revealed that the MDS (Minimum Data Set) Coordinator would schedule , or review the plan by phone if family could not attend. If the resident was competent but did not attend the meeting, then the Coordinator would go to the resident's room to review the care plan. Documentation in the medical record revealed ""done by phone"" on 6/1/11. The Social Worker stated the coordinator called the resident's wife to review the care plan. No documentation could be found to show that the competent resident (able to make his own decisions) was ever invited or informed about his care plan.",2015-05-01
9381,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,333,D,0,1,HRMY11,"**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 ensure that residents remained free from significant medication errors. Resident #3, one of fourteen residents reviewed for medications, did not receive [MEDICATION NAME] as ordered. The findings included: The facility admitted Resident #3 on 6/13/11 and readmitted him on 7/15/11 with [DIAGNOSES REDACTED]. Record review on 7/25/11 revealed cumulative physician's orders [REDACTED]. One entry revealed an order for [REDACTED]. The medication had been scheduled for 9:00 AM only. Review of Physician's Telephone Orders revealed an order dated 7/15/11 which said to ""Hold [MEDICATION NAME] 20 mg"". A subsequent Telephone Order dated 7/20/11 stated ""PT (Patient) may start [MEDICATION NAME]"". Review of the July 2011 Medication Record revealed an entry for ""[MEDICATION NAME] 20 mg (1) PO Q 8 hrs, On hold per Pharmacy"". The medication had been initialed as having been given once daily at 9:00 AM on 7/20, 7/21, 7/22, and 7/25 instead of every 8 hours as ordered. On 7/23 and 7/24, the nurse's initials had been circled for the 9:00 AM dose which indicated the resident had not received any [MEDICATION NAME] for those two days. Documented on the back of the Medication Record were entries for 7/23 and 7/24 which stated ""[MEDICATION NAME] on hold, pharmacy"". During an interview on 7/25/11 at 6:10 PM, Licensed Practical Nurse (LPN) #1 verified the above findings after reviewing the cumulative July physician's orders [REDACTED]. When asked what [MEDICATION NAME] was for, she stated that [MEDICATION NAME] was another name for [MEDICATION NAME] and that the resident used this medication to improve his [MEDICAL CONDITION] function. When asked if the medication had been on hold on 7/23 and 7/24, LPN #1 stated it hadn't, and that the medication had been available and in the medication cart at that time to be given. During an interview on 7/26/11 at approximately 2:00 PM, the resident's Physician stated the resident was taking [MEDICATION NAME] for [MEDICAL CONDITION] Hypertension.",2015-05-01
9382,AGAPE REHABILITATION OF ROCK HILL,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2011-07-26,371,F,0,1,HRMY11,"On the days of the survey, based on observation and interview, the facility failed to store and serve food under sanitary conditions. Multiple resident meal trays had metal exposed around the edges; plate lids were visibly worn; staff food was stored with resident food. A meal plate was removed from the kitchen, returned and placed back on the steam table. The findings included: On 7/26/11 at 11:30 AM trayline observations were conducted. A tray was observed being placed on the first tray cart. The tray cart was taken out of the kitchen and brought to the floor. Ten minutes later a dietary staff member returned with a tray from the tray cart stating that the resident was going to eat in the dining room. The covered plate of food was placed back on the steam table. On 7/26/11 at 1:25 PM, a tour of the kitchen was conducted with the RD (Registered Dietitian). During the tour it was observed that at least 30 trays had metal exposed on the corners of the tray. Plate lids were visibly worn around the edges. Staff food was observed in the hot box next to resident food. On 7/26/11 at 1:40 PM, an interview with the RD was conducted who confirmed the findings.",2015-05-01
9383,FLORENCE REHAB & NURSING CENTER,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2012-01-30,225,E,1,0,U2IK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on review of the facility's investigation of an allegation of neglect, and review of the facility's grievances filed since 1/1/2011, the facility failed to ensure that 1 of 1 allegation of neglect was reported timely to the State survey and certification agency (#1) and failed to report twelve of fifteen allegations of misappropriation of resident property. The findings included: Resident #1 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the Kardex used by Certified Nursing Assistants (CNAs) showed ""Mechanical"" under the heading of Transfers. Review of the facility's policy related to mechanical lifts revealed all mechanical lifts required a two person assist. On 12/3/11, CNA #1 allegedly attempted to transfer the resident from the bed to the shower stretcher by herself. The resident fell to the floor, hitting her head on the nightstand. The resident's fall resulted in a small hematoma over her left eye. The facility reported this allegation of neglect to the State survey and certification agency on 12/6/11, which exceeded the allowed time frame for reporting. Review of the facility's grievance log since January 2011 revealed fifteen complaints were filed with administration related to missing resident property. The facility provided evidence showing that three of these allegations were reported to the State survey and certification agency. However, it was not able to show evidence that the remaining twelve allegations were reported to the State agency as required. Resident #A reported missing money on 7/24/11, 8/24/11, and 1/11/12. (The resident's allegation of a missing wallet and money made on 6/3/11 was reported to the State survey and certification agency.) Resident #B reported missing a television on 8/22/11. Resident #C reported missing money on 8/15/11. Resident #D reported missing locks on 9/8/11. Resident #E reported missing money on 11/17/11. Resident #F reported missing money on 11/17/11. Resident #G reported missing money on 12/11/11. Resident #H reported a missing cell phone on 12/13/11. Resident #I reported a missing ring on 12/15/11. Resident #J reported a missing cell phone on 12/21/11. Resident #K reported a missing engagement ring on 12/26/11. (A missing wedding band was reported on 1/11/12 and it was reported to the State survey and certification agency.) Review of the facility's policy and procedure for Abuse Prevention, Investigation and Monitoring revealed on page 4: "" When an alleged/actual case of mistreatment, neglect, injuries of unknown source, misappropriation of resident's property or abuse is reported, the facility administrator or his/her designee will notify ... DHEC (Department of Health and Environmental Control) Certification within 24 hours of a report ..."" The findings related to the grievances filed by residents were reviewed with the Administrator during an interview at 2:30 PM. She confirmed that the allegations were not reported to the State survey and certification agency.",2015-05-01
9384,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,315,D,0,1,MVRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, interview and review of the facility policy entitled ""Care of Established Suprapubic Catheter"", the facility failed to provide appropriate care and services for 1 of 3 sampled residents with catheters. During Resident #4's suprapubic catheter care, the nurse failed to properly clean the catheter tubing during care. treatment for [REDACTED].# 1. Inappropriate handwashing occurred during catheter care for Resident # 4. The findings included: The facility admitted Resident #4 on 7-21-10 with [DIAGNOSES REDACTED]. On 10-4-11 at 3:15 PM, during suprapubic catheter care, LPN (Licensed Practical Nurse) #2 anchored the catheter tubing distally with his left hand and with his right hand used a cleansing wipe in a back and forth motion from the site of insertion to his left hand 4 times. During an interview on 10-5-11 at 2:15 PM with the Director of Nursing (DON), she provided and verified the facility policy entitled ""Care of Established Suprapubic Catheter"". Review of the facility policy revealed part (a.) which stated to cleanse using a circular motion starting at the exit site, going outward. LPN #2 signed the policy after reviewing the procedure. The facility admitted Resident # 1 on 1/25/11 with the following Diagnosis: [REDACTED]. Record review on 10/4/11 revealed a Physician order dated 7/17/11 for a ""UA (Urinalysis) and C&S ""(Culture and Sensitivity). The nurse note on 7/17/11 stated: U/A C&S. On 7/21/11, a nurse note stated: "" Urine collected for U/A C&S."" The laboratory result was also dated 7/21/11 and showed Bacteria of 4+. The Culture and Sensitivity result was dated 7/22/11. The treatment was not started until 7/27/11 when a Physician order was written for ""[MEDICATION NAME] 875 mg (milligrams) twice a day for 7 days."" The Assistant Director of Nursing stated on 10/5/11 at 1:30 PM that he remembered why it took so long to get the specimen sent. He stated the nurse could not get the specimen and waited until he came in on his next scheduled day to work.. He then stated "" It was too long and it should have been treated quicker; I don't know why it wasn't."" Observation of Resident #4's Suprapubic Catheter Care on 10-04-11 at approximately 3:17 PM revealed Licensed Practical Nurse (LPN) #2 washed his hands prior to beginning the Suprapubic Catheter Care and turned the water off with his hands without a barrier. At the completion of the Suprapubic Catheter Care LPN #2 disposed of the trash, washed his hands, and again turned the water off with his hands without a barrier. Review of the facility policy titled ""Hand Hygiene/Handwashing"" revealed Procedure #3: Method: Hand/Hygiene Technique stated ""When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet"".",2015-05-01
9385,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,241,E,0,1,MVRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality during 2 random meal observations in the Unit 1 Dining Room and for 2 sampled residents during dining. During random meal observations in the Unit 1 Dining Room, the facility staff failed to serve the residents sequentially and seldom spoke to the residents; often speaking among themselves. The facility further failed to provide a table of sufficient height for Resident #15 during dining and failed to replace flatware for Resident #18; resorting in Resident #18 eating with his/her fingers. The findings included: The facility admitted Resident #15 on 07-26-99 with [DIAGNOSES REDACTED]. Record review on 10-05-11 at approximately 12:15 PM of the Monthly Summary dated 09-21-11 revealed Resident #15's height as 57 inches. Record review on 10-05-11 at 12:15 PM of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in Section K 0200: Height and Weight, Resident #15's height as 57 inches. Record review on 10-05-11 at approximately 12:15 PM of the Care Plan dated 11-05-10 with review date of 08-03-11 related to problem of ""Resident at risk for falling related to cognitive issues, limited physical mobility, impaired vision, periods of restlessness, [DIAGNOSES REDACTED]. free from injury and dignity will be maintained until next review"". Section ""Approach"" of the Care Plan revealed ""Anticipate needs, provide prompt assistance"". Observation on 10-05-11 at 1:15 PM of the lunch meal in the Unit 1 Dining Room revealed Resident #15 sitting at a table in a wheelchair with her chin almost at the level of the table top. Observation further revealed Certified Nursing Assistant (CNA) #3 stopped feeding Resident #15 to speak to other residents, gathered used dishes from another dining table and placed them on the meal cart, and then returned to feeding Resident #15. CNA #3 again began feeding Resident #15, stopped to assist another resident across the table, and then once again began feeding Resident #15. Measurements of the table height by the facility staff on 10-05-11 revealed the height of the table to be 30 and 3/8 inches. The top of the wheelchair backrest to the floor measured at 29 and 3/8 inches. Random evening meal observation on 10/04/11 at approximately 6:50 PM in Unit One dining room revealed staff in dining room feeding residents but not engaging in conversation with the resident they were feeding. A random resident was noted eating pancakes, sausage and hash browns with fingers and staff not engaging resident to use tableware. The resident observed eating with their fingers was noted scraping the bottom of plate with no staff response to ask the resident if he/she wanted more food. Random breakfast observation on 10/05/11 at approximately 8:55 AM in Unit One dining room revealed staff not serving all residents seated at the same table before delivering meals to a different table. Staff was observed taking trays from the cart on Unit One dining room and taking the trays to residents in their rooms while residents seated in dining were still not served. An interview on 10/05/11 at approximately 9 AM with CNAs #2 and #3 revealed they deliver meals to the residents based on how they are arranged on the cart. CNA #2 further stated that residents in the dining room that need to be fed are served last. The facility admitted Resident #18 on 6/01/07 with [DIAGNOSES REDACTED]. During lunch observation on 10/06/11 at approximately 1:10 PM, Resident was noted eating from a divided plate using fingers due to the fork being on floor. (The meal that was served was greens, peas and meat). Two staff members noted in Unit One dining room failed to offer resident clean silverware. The fork remained on the floor until staff transported the resident out of the dining room. An interview on 10/05/11 with the MDS (Minimum Data Set) Coordinator revealed the divided plate for resident was not care planned and there was no assessment to determine if divided plate was needed. Random observation of lunch on 10/05/11 at approximately 1:15 PM in the Unit One dining room revealed staff not serving the residents seated at the same table before serving other residents. One resident was noted raising her hand to get staff attention because she still was not served while the other residents were eating. Staff were observed talking loudly to residents seated away from them while feeding other residents. Staff did not engage in conversation with the residents they were feeding. An interview on 10/05/11 at approximately 1:35 PM with the Staff Development Coordinator revealed the facility had not provided in-services related to dignity in dining for ""years."" The Staff Development Coordinator observed CNAs feeding residents and talking to other residents in dining room without engaging in conversation with the resident they were feeding. The Staff Development Coordinator further stated residents seated at the same table should be served before serving residents at a different table.",2015-05-01
9386,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,333,E,0,1,MVRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility staff did not give [MEDICATION NAME] 1600 milligrams three times a day as ordered for Resident # 10. ( 1 of 20 sampled residents reviewed for medications.) The findings included: The facility admitted Resident # 10 on 8/22/11 with [DIAGNOSES REDACTED]. Record review on 10/4/11 revealed an admission physician order [REDACTED]. When the back of the MAR (Medication Administration Record) was examined, it was blank. There was no documentation found in the record to explain why the medication had not been given. An interview with LPN # 3 (Licensed Practical Nurse) revealed that she did not know why the medication had not been given. An authorization -To- Dispense ""MLO"" Form was found dated 8/25/11. No documentation could be found that the physician had been notified that the resident had not been receiving the medication. The nurse confirmed that no further documentation was available and that no order had been obtained to start the medication when it arrived in the facility.",2015-05-01
9387,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,441,E,0,1,MVRU11,"On the days of the survey, based on observations, interviews, and the review of the facility's ""Skills Verification Checklist and Competency Needs Identification-Certified Nursing Assistant (CNA)"", the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of disease and infection in 2 of 3 dining rooms observed and for 1 of 3 residents observed for Catheter Care. During random observations of 2 of 2 dining rooms, facility staff failed to wash their hands in-between residents and after touching residents' food. Facility staff further failed to wash their hands after Foley Catheter Care prior to refastening the resident's brief, adjusting the linen, and checking the Foley Catheter leg strap. The findings included: The facility admitted Resident #5 on 09-17-11 with Post Sacral Vertebroplasty, Coronary Artery Disease, and Diabetic Neuropathy. On 10-04-11 at approximately 2:55 PM, CNA #1 entered Resident #5's room to provide Foley Catheter Care. Observation revealed CNA #1 failed to dispose of her gloves and wash her hands after completion of the Foley Catheter Care prior to refastening Resident #5's brief, adjusting the bed linen, and checking the catheter leg strap. Review of the facility's ""Skills Verification Checklist and Competency Needs Identification-Certified Nursing Assistant #8: Infection Control (A) Handwashing technique, (B) Handling of Linen, and (D) Blood and Body Fluid Precautions"" for CNA #1 revealed CNA #1's Date of Completion had been 05-23-11. During an interview on 10-05-11 with the Director of Nursing due to CNA #1's not being available for interview, she agreed CNA #1 should have removed her gloves after completion of the Foley Catheter Care and washed her hands prior to continuing with resident care. Random observation of lunch on 10/05/11 at approximately 1:15 PM in Unit One dining revealed staff positioning residents closer to dinner room tables by there wheelchair handles, and then the same staff would directly touch the resident's bread/ other foods without washing their hands. Staff were noted wiping their forehead and touching residents, then directly touching residents food without sanitizing their hands. During the days of the survey a random observation of supper in the dining room on 10/4/11 at approximately 5:45 PM revealed, a CNA (Certified Nursing Assistant) wiping her forehead while passing meals from the tray cart. Once the CNA finished passing trays from the meal cart at approximately 6 PM there was an observation of her moving a chair so she could feed a resident without sanitizing her hands,",2015-05-01
9388,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,278,D,0,1,MVRU11,"**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 ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status related to pressure ulcers and falls for Resident # 1. (One of 3 sampled residents reviewed for careplans related to pressure ulcers/falls.) The findings included: The facility admitted Resident # 1 on 1/25/11 with the following Diagnosis: [REDACTED]. Record review on 10/4/11 revealed two MDS's dated 4/5/2011 and 7/15/11 that did not include pressure ulcer information under the M section, and did not include fall information in the J section. The resident was admitted with a Stage III pressure ulcer which was not captured on the admission MDS (section M0210 which asks if the resident has one or more unhealed pressure ulcers) or Section M 0300 which asks how many pressure ulcer at each stage. The resident had three falls dated 1/7/11, 3/11/11 and 9/14/11 which were not captured in the MDS's section J1700, which asks for Fall History, and J 1800 and 1900 which ask for Falls since Admission and Number of Falls since Admission or Prior Assessment. The MDS Coordinator stated during a interview on 10/5/11 at 9:00 AM: "" Yes, the falls and pressure ulcer should be on the careplan."" She confirmed that the information documented on the MDS is what is used to develop/cause the careplan to be initiated and/or updated.",2015-05-01
9389,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,280,D,0,1,MVRU11,"**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 3 of 3 sampled residents reviewed for falls/pressure ulcers careplans and 1 of 5 resident's reviewed with a catheter. Resident # 1, 5 and 12's careplans were not not revised related to falls and Resident # 1's careplan was not revised related to pressure ulcers. Resident # 5's care plan was not updated to reflect the insertion of a catheter. The finding included: The facility admitted Resident # 1 on 1/25/11 with the following Diagnosis: [REDACTED]. The record review on 10/4/11 revealed a careplan for Urinary Incontinence which stated that the resident was at risk for skin breakdown. This careplan was last signed as updated on 7/27/11. At that time, a handwritten note (with lines drawn through it) was written stating ""[MEDICATION NAME] 875 mg (milligrams) twice a day for 7 days for UTI (Urinary Tract Infection)"". Another careplan on the medical record for actual skin breakdown was dated 1/25/11 and stated the stage III pressure ulcer on right buttocks resolved on 2/7/11. There was no additional careplan documentation related to a pressure ulcer which started on 8/11/11 to the right lateral ankle or a pressure ulcer which was found on the sacrum on 9/16/11 except for a careplan dated 1/28/11 related to redness left buttock, groin and abdominal fold which was resolved on 3/7/11. This careplan had a line drawn from one corner of the page to the other. Resident # 1's careplan revealed a care plan for falls related to a previous fall with injury. A hand written entry under the problem list dated 3/11/11 stated ""actual fall."" The care plan was not updated to reflect a fall that occurred on 9/14/11. The MDS (Minimum Data Set) Coordinator stated on 10/5/11 at 9:00 AM "" The careplan is not up to date as it should be."" The facility admitted Resident #5 on 09-17-11 with [DIAGNOSES REDACTED]. Record review on 10-04-11 at 2:10 PM of the Physician/Prescriber Telephone Orders dated 09-23-11 revealed an order ""Insert Foley Catheter 18 French"". Additional record review on 10-04-11 at 2:10 PM of the Physician/Prescriber Telephone Orders dated 09-24-11 revealed an order for [REDACTED].#5 required extensive assistance with transfer and total assistance with locomotion, dressing, toileting, and bathing. Additional record review on 10-04-11 at 2:10 PM of the Interim Plan of Care dated 09-17-11 related to Fall Risk and Toileting revealed it had not been updated to reflect Foley Catheter and Falls. Further record review on 10-04-11 at 3:40 PM of the Daily Skilled Nurse's Note dated 09-21-11 revealed Resident #5 experienced a fall in the bathroom. During an interview on 10-05-11 at 11:25 AM with MDS Coordinator #2, she, after record review, verified the Initial Care Plan dated 09-17-11 had not been updated to reflect Resident #5 had a Foley Catheter and had experienced a fall. The facility admitted resident #12 on 10/14/03 with the [DIAGNOSES REDACTED]. Record review on 10/4/11 at approximately 2:30 PM the Nurse's Notes revealed on 9/15/11 at 2 AM ""heard resident calling for help, went to room observed resident sitting on buttocks on floor next to bed."" Review of the Care plan revealed a problem with an Problem Start Date of 5/24/2010 ""Resident #12 is unsteady with balance tests, placing her at risk for falls."" Review of the Care plan on 10/4/11 at approximately 4 PM revealed that it was not updated to reflect Resident #12's fall on 9/15/11. During an interview on 10/4/11 at approximately 5:15 PM, MDS Coordinator #1 stated Care plans are updated quarterly and as needed. Care plans should be updated to reflect falls, infections, and other changes. The MDS Coordinator verified that the Care plan was not updated to reflect residents fall.",2015-05-01
9390,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2011-10-05,514,D,0,1,MVRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are accurately documented. Residents # 1's medical record contained record related to Code status. The findings included: The facility admitted Resident # 1 on 1/25/11 with the following Diagnosis: [REDACTED]. Record review on 10/4/11 revealed a sticker on the inside cover of the residents record that stated "" Full Code"". The Physicians cumulative orders stated the resident was a ""Full Code"". However, the Medication Administration Record [REDACTED]"" (Do Not Resuscitate). The resident's care plan dated 2/3/11 and reviewed on 7/27/11 documented the resident had a code status of DNR. The Minimum Data Set Coordinator stated on 10/5/11 at 1:30 PM that ""he is a full code"", and "" I don't know why he is down as a DNR."" She also stated the nurse would obtain the information from the MAR indicated [REDACTED]. Licensed Practical Nurse # 1 stated on 10/5/11 at 10:00 AM when asked the residents code status: "" He's a DNR"". There is no Physician written order for a DNR, and the resident had capacity to make his own decisions.",2015-05-01
9391,MAGNOLIA PLACE - SPARTANBURG,425175,8020 WHITE AVENUE,SPARTANBURG,SC,29303,2012-01-30,225,D,1,0,M6X111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the compliant inspection based on record review and interview the facility failed to timely report one of one allegations of misappropriation of resident property to the appropriate state agencies. The facility also failed to protect other residents from an alleged perpetrator. Resident #1's diamond ring was reported missing on 11/16/2011, the facility did not send the 24 hour report until 11/21/2011. The facility was given information on a potential perpetrator on 12/13/2011. The facility failed to suspend the Certified Nursing Assistant (CNA) until 12/20/2011, allowing her to work with residents from 12/13-12/19/2011. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. Review of the Resident Interview Section C Cognitive Patterns revealed the resident's Summary BIMS (brief interview for mental status) score was a 5 out of a possible score of 15. The Admission Minimum Data Set and Comprehensive Care Plan were not due. Review of the Admission Body Audit revealed the resident had three rings on her right hand. Record review revealed the Inventory of Personal Effects had not been completed. Review of the 24 Hour report dated 11/21/2011 revealed the date of the reportable incident was 11/16/2011. The Responsible Party reported the diamond cluster ring was missing. Review of the Missing Items/Concerns Report revealed on 11/16/2011. The grievance was ""received by the administrator or designee"" on 11/17/2011, the Administrator's name was written in. The resolution was: ""Ring not found will notify DHEC."" The Administrator signed the form on 11/21/2011. Review of the 5 Day Follow Up Report dated 11/22/2011 revealed: ""resident's POA, stated that (Resident #1) had a cluster ring that was between the other two rings on at 11 AM (11/16/2011 ) when Resident #1 was gotten up. Her friend came by around 2:30 PM and noticed the ring was missing. When (the POA) came at 3:30 PM she tried to remove the other two rings and was unable to remove the rings over the resident's knuckle. We have searched the facility and our laundry for the ring and cannot find it... I will forward the police report when I receive it."" During an interview on 1/30/2012 at 10 AM, the Responsible Party, stated that the resident had a diamond cluster ring that was approximately 1 karat stolen. She stated that the police told her after the fact that the CNA had stolen the ring on 11/15 and pawned it. The RP stated that on 11/16/2011 a friend had noticed the ring was missing and called her. She stated that she went to the facility and saw the ring was missing and reported it to staff. She stated that the diamond ring was on her right hand and the other two rings were on the resident's left hand. She stated that she tried to remove the other two rings but was unable because the resident's hands were puffy. The RP stated that she made the police report. She also stated that right before Christmas the police returned the stolen ring to the resident. Review of the Follow Up information sent to the State Survey and Certification Agency revealed: ""12/13/2011, 2 PM I received a phone call from a very excited male telling me he was (CNA #1's) boyfriend, that he loved her but she was leaving him. He told me that (CNA #1) found a set of rings wrapped up in a toilet tissue in a resident's room, stole them and pawned them. I could go to the newest pawn shop, he didn't remember the name, and it was either in her name or his. If he was going down she was going with him. He repeated that she stole the rings and pawned them. I then called the local police and gave them the above information. They told me that the responsible party or resident would have to make the complaint. I then called the RP, she informed me that she had made the report. I requested that she call them and have them go to the local pawn shop and investigate. (The Assigned Detective) called me and set up a time to come to (the facility) to meet with (CNA #1). (The Detective) interviewed (CNA #1) on Monday. I interviewed (CNA #1) on 12/20/2011, she admitted to stealing the rings. She was suspended. On Dec. 27, 2011, (CNA #1) was terminated for violation of code of conduct, thief in the workplace."" Review of the Spartanburg County Detention Facility-Inmate History revealed CNA #1 was arrested and posted bond on 12/26/2011 at 9:22 AM for Petty Larceny. CNA #1 was arrested and posted bond again on 1/4/2012 at 3:45 PM for Obtaining property under by false pretenses. Review of the CNA Assignment Sheets revealed CNA #1 was assigned to Resident #1 on 11/15/2011 from 7-3 and on 11/16/2011 from 7-3. Review of the Time Card for CNA #1 revealed she clocked in at 7:05 AM on 11/15/11 and clocked out at 2:56 PM. On 11/16/11 the CNA clocked in at 6:57 AM and clocked out at 2:57 PM. Review of the facility obtained statement from CNA #1 documented on the 5 Day Follow Up, revealed on 11/21/11: ""(CNA #1) stated that (Resident #1) had on rings that morning but they were turned around on her finger so she didn't notice what kind of rings they were."" Documented on the Corrective Action Form for (CNA #1): ""Violation of the code of conduct: accused of stealing a resident's ring."" ""Employee comments: (CNA #1) admitted to the above."" CNA #1 was not available for interview during the survey. Review of the facility obtained statement from Licensed Practical Nurse #1 and documented on the 5 Day Follow Up report revealed: ""(LPN #1) remembers (Resident #1) having 3 rings on admission, but she recalls each ring was flat, not a cluster ring."" During an interview on 1/30/2011 at 10:30 AM, LPN #1 she did the admission assessment for Resident #1 on 11/15/2011 and she documented the three rings on the body audit. She stated that rings were on the left hand but confirmed that she had documented they were on the right. She stated that the rings were only on one hand. LPN #1 stated that she recalled the diamond cluster ring was in the middle of the other two rings. She stated that the next day the diamond ring was reported missing, a search was initiated and the ring was not found. The Administrator was notified. During an interview on 1/30/12 at 10:45 PM, the Administrator stated that CNA #1's boyfriend called her and stated that CNA #1 had stolen the ring and pawned it. She stated that after the phone call she had gone to the nearest pawn shop to see if the ring was there. The Administrator stated that she called the police and they advised her to have the RP call the police and update the report. The Administrator also stated that the CNA was arrested on two separate occasions and charged with two separate misdemeanors. The Administrator was asked about the delay between the phone call from the boyfriend and when the CNA was interviewed and suspended. She stated that the police asked her to not ""tip"" her off, and since the CNA was not working anyway it was not a concern. The Administrator then stated that the police were gathering their evidence against the CNA. The Administrator also confirmed that the 24 hour report was late. She stated that she was within her ""5 day"" window for reporting missing items. Review of the Time Card for CNA #1 revealed she was working with her usual resident assignment on 12/13, 12/15, 12/16, 12/18 and 12/19/2011. During a follow up interview on 1/30/2012 at 11:50 AM, the Administrator confirmed that the CNA was working with residents on the above dates and stated again that the police had asked her to not tip off the CNA so she, the Administrator allowed her to continue to work with residents.",2015-05-01
9392,MAGNOLIA PLACE - SPARTANBURG,425175,8020 WHITE AVENUE,SPARTANBURG,SC,29303,2012-01-30,226,D,1,0,M6X111,"On the day of the complaint inspection based on record review, interview and review of the facility policy on Abuse and Neglect the facility failed to report one of one allegations of misappropriation of resident property to the appropriate state agency and failed to protect other residents from a potential perpetrator. The findings included: Resident #1's diamond ring was reported missing on 11/16/2011, the facility did not send the 24 hour report until 11/21/2011. The facility was given information on a potential perpetrator on 12/13/2011. The facility failed to suspend the Certified Nursing Assistant (CNA) until 12/20/2011, allowing her to work with residents from 12/13-12/19/2011. Review of the facility's policy on Abuse and Neglect revealed: ""Component V: Reporting: 1. All alleged violations concerning abuse, neglect or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency."" ""Component IV: Investigation: 4. The investigation may include but is not limited to the following: A. Identification and removal of alleged perpetrator(s)...5. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process..."" Cross Refer to F 225.",2015-05-01
9393,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2012-01-17,225,E,1,0,51RV11,"On the day of the complaint inspection, based on review of the facility's grievance file and interview with the Administrator, the facility failed to report all allegations of misappropriation of resident property to the State survey and certification agency for 6 of 7 allegations of misappropriation of resident property noted (Resident A, B, C, D, and E). The findings included: Review of the facility's grievance file revealed seven allegations of misappropriation of resident property. One allegation, of a missing ring, was reported to the State survey and certification agency while six other allegations were not reported. The Administrator confirmed this during an interview at 3:25 PM on 1/17/12. Resident A complained on 10/9/11 that she was missing a bag and its contents including clothing, dentures, and other various items. Resident B complained of missing $25.00 on 10/12/11. Resident C complained of missing $30.00 on 10/13/11 and another $30.00 on 10/17/11. Resident D complained of a missing wallet on 10/30/11. Resident E complained of a missing Visa card on 11/14/11. The pre-paid card still had $77.91 available to use.",2015-05-01
9394,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,371,F,0,1,U6UU11,"On the days of the survey, based on observation, interview, and review of the facility policy entitled "" Hand Hygiene"" from Nutrition Policies and Procedures dated 10/09, the facility failed to serve and distribute food under sanitary conditions. The findings included: On 8/9/11 at 12:20 PM, tray line service was observed with the CDM (Certified Dietary Manager)present. Dietary Staff #1 was observed dropping all of the paper tray cards onto the floor in front of the steam table. She picked up the tray cards, placed them back onto the front of the steam table, and began placing the tray cards onto each tray that she set up. Dietary staff #1 was observed picking up the kitchen telephone with her bare hand and the returning to the tray line to set up trays and place plated food onto the trays. This dietary staff member touched the phone on three different occasions during the tray line observation without sanitizing her hands at any time. A dietary staff member dropped 2 empty tea pitchers onto the floor. She picked them up with her bare hands and placed them by the dish machine. Without sanitizing her hands, she then picked up a clean tea pitcher, scooped ice into it and filled with tea. This staff member was also observed going into the dining room to assist with the lunch meal and returning to the kitchen to get items and not washing her hands upon entering the kitchen. On 8/9/11 at 12:35 PM, staff was observed placing dirty tray lids on top of an open cart next to and above trays that had not been served to residents yet. On 8/9/11 at 2:15 PM, a tour of the kitchen was conducted with the CDM. A sanitizer bucket was observed on the prep sink next to sandwiches which were being prepared at the time. On 8/9/11 at 2:46 PM, an interview with the CDM was conducted. She stated that staff normally does not wash their hands after touching the phone because the staff is not directly touching food. She acknowledged that the staff are touching plates, silverware, and lids. On 8/9/11 at 3:30 PM, review of the facility provided Nutrition Policies and Procedures ""Hand Hygiene"" dated 10/09 stated ..."" Wash hands:: after contact with soiled or contaminated articles, such as, dirty dishes"".",2015-05-01
9395,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,166,E,0,1,U6UU11,"On the days of the survey based on interviews the facility failed to resolve grievances related to staff responding to call lights timely to assist residents to the bathroom. (Two individual resident interviews and 7 of 7 group members expressed concerns that staff did not respond timely to call lights). The findings included: An interview on 8/08/11 at approximately 3:55 PM with a resident determined to be alert and interview-able by the facility alleged that it took staff 20 to 45 minutes to respond to an activated call light. The Resident further stated the respond time varied on each shift depending which staff member was on duty. An interview with a resident determined to be alert and interview-able by the facility alleged "" When I turn on the light, staff will come in and turn it off and leave the room. They say they will come back to help me, but they never do."" During a Group interview on 8/09/11 at approximately 11 AM, 7 of 7 group members stated the staff does not respond to call lights timely to assist them to the bathroom. When the group members were asked which shift failed to respond timely, the group members indicated ""all shifts"". When the group members were asked if they had informed the facility staff of the concerns, the group members stated ""yes"". Review of the ""Resident Council Minutes"" for April 2011 to August 2011 revealed residents expressed concerns at the April 2011 Council Meeting that staff was not responding to call lights timely. Review of the May 2011 and June 2011 council minutes revealed there was no documentation to indicate if the facility attempted to interview the group members to determine if the respond time to call lights had improved. Review of July 2011 council minutes revealed the group members expressed concerns about call lights not being answered timely to assist residents to the bathroom. Review of the August 2011 council minutes revealed the group members expressed concerns that staff are not responding timely to take the resident to the bathroom. An interview on 8/10/11 at approximately 9:50 AM with the AD (Activity Director) revealed she documented the council minutes and shared the residents' concerns with the facility department involved. The AD further stated the concerns had been shared with the facility Administrator.",2015-05-01
9396,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,241,E,0,1,U6UU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random observations during the evening meal on 8/8/11 and lunch meal on 8/9/11, residents were not observed to be served sequentially by tables. Residents # 10 and #19 were observed to be served their trays with their table, but their food sat uncovered until all trays were served and staff came to feed them. The other residents at the tables were already being fed or eating while Residents # 10 and # 19 waited. (1 of 1 dining room observed.) The findings included: The facility admitted Resident # 10 on 5/5/04 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During the supper meal observation on 8/8/11 at 5:45 PM, Resident # 10 was seated in a Geri-chair at a table with 2 other residents. One of those residents was feeding herself and the other resident was being fed by a staff member. Resident # 10's tray was sitting to the side of the resident with all foods uncovered. The resident was observed to reach out several times to try to reach her food and the resident's food next to her. The resident continued to reach out until a staff member came to feed her. The other residents had almost finished eating their meal. Other residents were also observed sitting at tables where residents were eating and their trays were open in front of them, but they were not being fed with table mates. The same process was observed at the lunch meal on 8/9/11, where resident's trays were placed on the tables in front of them but were not fed at the same time as their table mates. The facility admitted Resident #19 on 3/9/10 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. During the lunch meal in the main dining room on 8/9/11, Resident # 19 was observed leaned back in a reclined Geri-chair at a table with 3 other residents. All trays were placed in front of each of the residents. One resident was feeding herself. Another resident was being fed by a staff member. The other two residents were sitting at the table waiting to be fed. One staff member approached Resident # 19, called her name and put a bite of food to her mouth. The resident's eyes were closed and did not respond. The staff member got up and went to another resident to feed. A second staff member came to Resident # 19, offered a bite. and left the resident. This occurred two more times. The staff did not try to awaken the resident, change her position, or try to get the resident to eat. The resident was documented as having a 3 pound weight loss in 3 months. During a random dinner observation on 8/08/11 at approximately 5:50 PM residents at the same table in the dining room were not served prior to staff serving residents at a different table. There were tables noted with one or two residents eating while other residents at the same table were waiting to be feed. There were residents able to feed themselves positioned at tables with residents that required staff to feed them. The residents that could feed themselves were provided their meals. At the same time, residents that needed staff assistance had their meals placed (uncovered) on the table in front of the residents until staff was available to feed them. Random lunch observations on 8/09/11 at approximately 12:40 PM revealed residents seated at the same table in the dining room were not served prior to staff serving residents at a different table. There were tables noted with one or two residents eating while other residents at the same table were waiting to be fed.",2015-05-01
9397,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,248,D,0,1,U6UU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to provide Resident # 7 with an ongoing program of activities to meet the physical, mental, and psychosocial needs for this resident . The resident was bedfast and was not receiving an appropriate program of activities. ( 1 of 11 sampled residents reviewed for activities.) The findings included: The facility admitted Resident # 7 on 2/1/02 and readmitted the resident on 2/4/10 with [DIAGNOSES REDACTED]. The Resident was determined by the facility to be interviewable. An individual interview was done on 8/8/11 at 5:10 PM. When the resident was asked if she participated in activities at the facility, she stated. ""No, I have PAD (Peripheral Artery Disease) and I don't walk. It is to much trouble to get me up, so I just lay here and watch TV (Television) or read."" When asked if Activities or staff came in to do 1:1 (one to one) activities with her , she stated ""No."" When asked ""Can you choose how you spend the day?"" She replied, ""Not much of a choice."" An interview was conducted with the Activity Director on 8/9/11 at 12:30 PM. The Director confirmed she did not do 1:1 activities with Resident # 7 nor did she have any plan for activities other than resident watching TV and reading. The Director further stated she did go in each morning to read the menu and tell her what day it was. An Activity Evaluation done 5/12/09 revealed the resident enjoyed these past activities: Animals/pets, arts/crafts, beauty shop, bingo, board games, cards, community outings, cooking/baking, cultural events, education programs, exercise, group discussion, movies, music, religious services, religious studies, resident council, shopping, sing-alongs, social parties, sports, volunteering and writing. Review of the Resident's individual Participation Record revealed no structured activities for this resident. The activity participation included watching TV, reading, occasional family visits,some word puzzles were done. The serving of juice or drink to resident was documented as an activity. On 8/9/11 the Activity Director visited the resident, and the resident stated she would like one to one visits and would like to do some card games during those visits.",2015-05-01
9398,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,425,D,0,1,U6UU11,"On the days of the survey, based on observation, record review and interview, the facility failed to discard expired "" AMLGEL-ATIVAN .5 milligram (MG)/ HALDOL 1 MG/ REGLAN 5 MG "" in one of 2 medication storage rooms. The findings included: On 8/8/11 at approximately 1:29 PM, inspection of station 2 medication storage room revealed one partial and two full "" AMLGEL-ATIVAN .5MG/HALDOL 1MG/REGLAN 5 MG "" with expiration dates of August 1, 2011. During an interview with Licensed Practical Nurse #1 at approximately 1:48 PM on 8.8/11, she verified the expiration date and stated, "" Med (Medication) Nurses on cart #2 are responsible for checking Resident A's syringes for expiration dates, they should check each bag for expiration dates as they are opened for use. Pharmacy comes once a month and checks all expiration dates. "" On 8/8/11 at approximately 2 PM, review of the current Medications Flowsheet for Resident A revealed that the AMLGEL-ATIVAN .5 MG/ HALDOL 1MG/ REGLAN 5 MG had been administered 12 times after the date of expiration",2015-05-01
9399,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,333,E,0,1,U6UU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review and interview, the facility failed to ensure that one resident (Resident A) was free of a significant medication error. Resident A recieved twelve doses of an expired medication. The findings included: On [DATE] at 1:30 PM, observation of the Station 2 Medication Room revealed two bundles of 30 syringes each and one partial bundle containing 20 syringes of AMLGEL ([MEDICATION NAME] 0.5mg/[MEDICATION NAME] 1mg/[MEDICATION NAME] 5 mg) all for Resident A and all with an expiration date of [DATE]. Review of the current Medication Administration Record [REDACTED]. During an interview on [DATE] at 1:48 PM, Licensed Practical Nurse (LPN) #1 stated that the Medication Nurses on Medication Cart 2 are responsible for checking Resident A's syringes for expiration dates. They should check each bundle for expiration dates as they are opened for use.",2015-05-01
9400,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,225,D,1,1,U6UU11,"**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 report one of one fractures of unknown origin to the appropriate agencies. Resident #3 sustained a fracture of unknown origin. The facility failed to investigate or report the fracture to the State Certification Agency. The findings included: The facility admitted Resident #3 on 5/3/2011 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 received a BIMS score of ""4"". Resident #3 was also coded as requiring limited supervision for transfers and locomotion in the room. Resident #3 was coded as independent for toilet needs but required one person limited assist for hygiene. Review of the Nurses Notes on 8/16/2011 revealed an entry dated 8/13/2011 at 12:10 PM that documented: ""CNA called this nurse to residents room, upon arriving noted resident on back c (with) L (left) shoulder against door frame and head through bedroom door. Resident stated I'm OK, help me get up. Resident was moving all extremities s (without) distress no complaints of pain. This nurse and 2 CNAs assisted resident to feet. No external rotation or length discrepancies were seen. Upon lifting resident noted resident dragging left leg so placed resident in wc (wheelchair) and took to bed, full body lifted resident c assistance of 2 CNAs in to bed. @ (at) this time resident said his hip was hurting, requested that resident stay in bed until x-rays were obtained. "" At 4:00 PM, ""received results of hip x-rays. There is a right sub capital fx (fracture) with slight displacement."" Resident #3 was transferred to hospital with a right [MEDICAL CONDITION]. Review of the Incident Report dated 8/13/2011 revealed: ""Res(ident) noted on floor lying on back c shoulder propped up on room door. Res was ambulating to BR (bathroom). Res assisted to wc and then assisted to bed. NP (nurse practitioner) on call notified for R (right) hip xray. "" Step taken to prevent re occurrence were: ""Explained to res to use call light when needing assistance to BR. Res verbalized understanding. "" Review of the reportable incidents revealed no investigation had been initiated and no report had been made to the State Certification Agency. During an interview on 8/16/2011 at 12:15 PM, the Administrator confirmed that no investigation had been initiated and no report had been made to the State Certification Agency. The Administrator stated that she was the Abuse Coordinator and stated that if she was not present then the Director of Nurses would be her designee to investigate and report. The Administrator stated that an injury of unknown origin should be reported to the State Certification Agency if the injury did not have a cause and based on the extent of the injury. During an interview on 8/16/2011 at 2:15 PM, the Director of Nurses stated that she was notified of the fall on Saturday 8/13/2011. She stated that she did not initiate an investigation and stated that she did not ask the nurses if there were any witnesses and no witness statements were obtained. The DON confirmed that she did not rule out abuse or neglect and did not determine through an investigation that the fracture was not of unknown origin. She also confirmed that no report was made to the State Certification Agency.",2015-05-01
9401,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,226,D,1,1,U6UU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility's policy on Abuse/Neglect, the facility failed to implement the Abuse Policy and investigate and report a fracture of unknown origin to the appropriate State Certification Agency for one of one fractures of unknown origin. Resident #3 sustained a [MEDICAL CONDITION] on 8/13/2011. The facility failed to initiate an investigation and failed to report the injury to the State Certification Agency. The findings included: Resident #3 sustained a right [MEDICAL CONDITION] on 8/13/2011. No investigation was initiated and no report was made to the State Certification Agency. Review of the Abuse Policy revealed: Reporting: ""... all alleged violations concerning abuse, neglect or misappropriation of property are reported verbally immediately to the Administrator/Designee and other enforcement agencies according to state law including the State Survey and Certification Agency."" Further review revealed ""Investigation: the facility maintains that all allegations of abuse, neglect and misappropriation of property are thoroughly investigated and appropriate actions are taken... Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions..."" Cross Refer to F 225 as it relates to the facility's failure to investigate and report a fracture of unknown origin.",2015-05-01
9402,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,280,G,1,1,U6UU11,"**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 ensure a resident's care plan was updated with new and appropriate interventions after each fall to prevent falls from occurring again. Resident #3's care plan was not updated with new interventions after a fall to prevent further falls. (One of five sampled residents reviewed for care plan revisions). The findings included: The facility admitted Resident #3 on 5/3/2011 with [DIAGNOSES REDACTED]. Review of the Nurses Notes on 8/16/201 revealed an entry dated 8/12/2011 at 7 AM that documented ""CNA found resident sitting on floor next to bed...spoke with resident re: (regarding) importance of using call light and not walking sock footed or barefooted. Resident not receptive to using call light and does not want to and is then reinforced on the importance of both. "" Further review revealed an entry dated 8/13/2011 at 12:10 PM that documented: ""CNA called this nurse to residents room, upon arriving noted resident on back c (with) L (left) shoulder against door frame and head through bedroom door. Resident stated I'm OK, help me get up. Resident was moving all extremities s (without) distress no complaints of pain. This nurse and 2 CNAs assisted resident to feet. No external rotation or length discrepancies were seen. Upon lifting resident noted resident dragging left leg so placed resident in wc (wheelchair) and took to bed, full body lifted resident c assistance of 2 CNAs in to bed. @ (at) this time resident said his hip was hurting, requested that resident stay in bed until x-rays were obtained."" At 4:00 PM, "" received results of hip x-rays. There is a right sub capital fx (fracture) with slight displacement. "" Resident #3 was transferred to hospital with a right [MEDICAL CONDITION]. Review of the Incident Report dated 8/12/2011 revealed ""CNA was walking on hall and saw resident was sitting on floor next to bed... "" Steps taken to prevent re occurrence were ""educated res(ident) to use call light. "" Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 received a BIMS (Brief Interview for Mental Staus) score of ""4"". Review of the Fall Risk Evaluation revealed on 5/3/2011 Resident #3 scored an ""18"". Review of the evaluation revealed ""a resident who scores a 10 of higher is at risk. If resident scored a 10 or above interventions should be initiated."" Interventions added were ""top ? of side rails up when in bed for mobility."" Review of the Care Plan revealed a problem area related to falls was identified with approaches including ""assure the floor is free of glare, liquids, foreign objects; encourage me to call for help; keep personal items and frequently used items within reach; make sure my call light is in reach,; orient to changes in environment such as new furniture, room change etc."" On 8/12/2011 the care plan was updated with the fall. An intervention was added for ""reinforced to resident the importance of using call light."" The intervention to reinforce the importance of using the call light was not appropriate for Resident #3 with a BIMS score of 4. No additional interventions were added to prevent further falls. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) confirmed the care plan was not updated with new and appropriate interventions to prevent further falls. The DON confirmed the use of the call light was an intervention that was in place since the resident's admission. The DON stated new interventions were not put in place because the facility did not want to restrict the resident. The DON then stated that other non restrictive interventions could have been put in place such as a toileting program and fall mats. The DON confirmed Resident #3 fell again on 8/13/2011 and sustained a [MEDICAL CONDITION].",2015-05-01
9403,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2011-08-16,323,G,1,1,U6UU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interviews the facility failed to ensure two of five sampled residents received the necessary supervision and interventions necessary to prevent accidents. Resident #1 was transferred using the wrong lift that resulted in a fall with injury on 6/26/2011. Resident #1 was also transferred incorrectly from 6/9/2011 through 6/30/2011. Resident #3 did not have new and appropriate interventions put in place after a fall and Resident #3 fell again resulting in a hip fracture. The facility also failed to assure Therapy recommendations were acted upon and followed. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as requiring total dependence with two person assistance for transfers. Review of the Care Plan dated 1/18/2011 revealed Resident #1 was to be transferred with a Hoyer Lift with a two person assist. Review of the CNAs Care Plan revealed Resident #1 was transferred with a Hoyer lift. Review of the ADL (Activities of Daily Living) Tracking Form for June 2011 first shift revealed the staff was documenting Resident #1 required total one person assistance with transfers from 6/9/2011 through 6/13/2011. Staff then documented that Resident #1 required extensive one person assist with transfers from 6/13 through 6/30/2011. Review of the Nurse's Notes revealed an entry dated 6/26/2011 at 8:15 AM, Certified Nursing Assistant (CNA#1) called for assistance in resident's room; upon entering room noted resident c (lift) pad attached to resident; resident laying on right side on floor and lift laying tilted over to left side resting against bedside table; resident's head and shoulders still suspended in air; disconnected lift from resident c assistance from other staff members...(CNA#1) reported resident was up in wc and while using stand up lift to change resident, resident's left leg started jerking and came off lift causing lift to become unbalanced and tip over...noted pink/purple area 2 inches in diameter round shape on R(ight) mid back... "" Review of the Physical Therapy assessment dated [DATE] revealed Resident #1 was to be transferred with a Hoyer lift and 2 people. During an interview on 8/16/2011 at 11:30 AM, CNA#1 stated that she was assigned to Resident #1 on 6/26/2011. She stated that third shift usually got Resident #1 up in the mornings. CNA#1 stated that she had been caring for the resident for over a year and never checked the CNAs Care Plan. CNA#1 stated that she always used a stand up lift for the resident and was never informed that he was a total lift for transfers. CNA#1 stated that Resident #1 did not have a total lift sling that was required for use with the Hoyer lift. CNA#1 stated again that Resident #1 transferred with a stand up lift or with two people and a gait belt. CNA#1 stated that she was going to change Resident #1 and he was standing up in the stand up lift when his leg gave way and the lift tipped over. CNA#1 stated that CNA#2 had left the room to get a towel and was not in the room when the resident tipped over. Multiple attempts were made to contact CNA#5 (third shift Nursing Assistant routinely assigned to Resident #1) without success. During an interview on 8/16/2011 at 11:45 AM, CNA#2 stated that she was in another resident's room feeding him breakfast when she heard a loud boom. She walked down the hall and heard CNA#1 screaming. CNA#2 entered Resident #1's room and saw Resident #1 still suspended in the stand up lift that had fallen over. CNA#2 stated that she called for more assistance. CNA#2 stated that she was not in Resident #1's room and did not assist CNA#1 during a transfer on 6/26/2011. CNA#2 stated that she had assisted CNA#1 on previous occasions with the stand up lift for Resident #1. CNA#2 stated that she was aware all lifts required two staff members to assist. CNA#2 also stated that if a resident required a Hoyer lift then the sling would be under the resident. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) and Administrator confirmed Resident #1 was transferred with a stand up lift on 6/26/2011. Both stated that the Resident was a two person transfer with a Hoyer Lift. The Administrator stated that CNA#1 transferred the resident by herself with the wrong lift. The Administrator also stated that CNA#1 did not check the care plan. Both confirmed that CNA#1 was terminated. The Administrator stated an in-service was conducted on 6/29/2011 related to Abuse and Neglect and the importance of the CNAs Care Plan. The Administrator confirmed CNAs documentation was identified as a concern in May 2011. She stated that an in-service was conducted on 6/22/2011 related to the proper coding for documentation. The Administrator stated that no action plan was put in place. She also stated that no other audits or follow up was completed related to the documentation errors. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 received a BIMS score of ""4"". Resident #3 was also coded as requiring limited supervision for transfers and locomotion in the room. Resident #3 was coded as independent for toilet needs but required one person limited assist for hygiene. Review of the Nurses Notes on 8/16/2011 revealed an entry dated 8/12/2011 at 7 AM that documented ""CNA found resident sitting on floor next to bed... spoke with resident re: (regarding) importance of using call light and not walking sock footed or barefooted. Resident not receptive to using call light and does not want to and is then reinforced on the importance of both."" Further review revealed an entry dated 8/13/2011 at 12:10 PM that documented ""CNA called this nurse to residents room, upon arriving noted resident on back c (with) L (left) shoulder against door frame and head through bedroom door. Resident stated I'm OK, help me get up. Resident was moving all extremities s (without) distress no complaints of pain. This nurse and 2 CNAs assisted resident to feet. No external rotation or length discrepancies were seen. Upon lifting resident noted resident dragging left leg so placed resident in wc (wheelchair) and took to bed, full body lifted resident c assistance of 2 CNAs in to bed. @ (at) this time resident said his hip was hurting, requested that resident stay in bed until x-rays were obtained. "" At 4:00 PM, "" received results of hip x-rays. There is a right sub capital fx (fracture) with slight displacement. "" Resident #3 was transferred to hospital with a right hip fracture. Review of the Incident Report dated 8/12/2011 revealed ""CNA was walking on hall and saw resident was sitting on floor next to bed..."" Steps taken to prevent re occurrence were ""educated res(ident) to use call light."" Review of the Incident Report dated 8/13/2011 revealed ""Res(ident) noted on floor lying on back c shoulder propped up on room door. Res was ambulating to BR (bathroom). Res assisted to wc and then assisted to bed. NP (nurse practitioner) on call notified for R (right) hip xray."" Step taken to prevent re occurrence were ""Explained to res to use call light when needing assistance to BR. Res verbalized understanding. "" Review of the Fall Risk Evaluation revealed on 5/3/2011 Resident #3 scored an ""18"". Review of the evaluation revealed ""a resident who scores a 10 of higher is at risk. If resident scored a 10 or above interventions should be initiated."" Interventions added were ""top ? of side rails up when in bed for mobility."" Review of the Care Plan revealed a problem area related to falls was identified with approaches including ""assure the floor is free of glare, liquids, foreign objects, encourage me to call for help, keep personal items and frequently used items within reach, make sure my call light is in reach, orient to changes in environment such as new furniture, room change etc."" On 8/12/2011 the care plan was updated with the fall. An intervention was added for ""reinforced to resident the importance of using call light."" To reinforce to the resident the importance of using the call light was no an appropriate intervention for a resident with a BIMS score of 4. Review of the Certified Nursing Assistant Care Plan revealed the resident was ""Independent"" with transfers. Review of the Therapy Discharge Note dated 7/3/2011 revealed Resident #3 upon discharge could only recall 3/5 steps related to safety awareness. Resident #3 required hand held assist with ambulation and required supervision with transfers. The note indicated that the staff was provided education related to the residents needs. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) and Administrator confirmed the use of the call light was an intervention that was in place since the resident's admission. The DON stated new interventions were not put in place because the facility did not want to restrict the resident. The DON then stated that other non restrictive interventions could have been put in place such as a toileting program and fall mats. The DON confirmed Resident #3's poor safety awareness and confirmed the therapy discharge note that documented the resident's transfer requirements as well as ambulation requirements. The DON confirmed that the Physical Therapist did not recommend that Resident #3 was independent in transfers or ambulation. The Administrator also confirmed that Resident #3 did not have decisional capacity per the Psychiatrist and confirmed that the resident was not alert and oriented per the BIMS score. During a telephone interview on 8/16/2011 at 2 PM, the Physical Therapist stated that all modes of transfers were assessed by the Therapy Department at least quarterly or when there was a change. He stated that all recommendations should be followed. The PT stated that he gives the RAC (Resident Assessment Coordinator) Nurse the transfer screen. The PT then stated that there was no follow up on the recommendations to assure that they were followed. He stated that he would provide education for the staff if requested. The PT stated that after he gives the Screens to the RAC nurse it was then nursing's responsibility to disperse the information to the staff. During an interview on 8/16/2011 at 2:10 PM, the RAC Nurse stated that she did not receive the screens from Therapy and that they were put into the residents' charts. She stated that the Rehab Manager would discuss the resident needs in the morning stand up meetings. She stated that the Unit Managers attended the morning meeting and would take the information and then update the CNAs' care plans, inform the charge nurse and place the resident in the ""hot box"" charting. The RAC nurse stated that it was the Unit Manager's or the Charge Nurses' responsibility to assure the recommendations were followed. During an interview on 8/16/2011 at 3:35 PM, the Unit Manager stated that she did not actually see the therapy screens but was aware they were in the resident's charts. She also stated that during the morning meetings she would be informed by the Rehab Manager of the recommendations. The Unit Manager stated that she would then update the CNAs' care plans and would verbally tell the CNAs if she saw them. The Unit Manager also stated that she would ""sometimes"" place the residents in the hot box charting. The Unit Manager stated that she did not check to make sure the CNAs were following the recommendations assessed by the Physical Therapist. Five CNAs were interviewed during the Complaint Survey, three of the five CNAs stated that they did not check the care plan daily. All five stated that the resident care needs were located on the care plan. CNA#1 stated that she did not check the care plan at all. CNA#2 stated that she would only check the care plan if there was a change in the resident's condition. CNA#3 stated that she would check the care plan once or twice a week. CNA#4 and CNA#6 stated that they checked the care plan daily. The DON and Administrator confirmed there was no written policy regarding how Therapy recommendations were dispersed and how the recommendations were to be followed accordingly.",2015-05-01
9404,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,281,K,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled ""Glucometer"" and ""Cleansing and Disinfecting Diagnostic Equipment"", facility nursing staff failed to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Concerns were identified with ten of ten sampled residents with ordered blood glucose monitoring, Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 received Finger Stick Blood Sugars (FSBS) from 5/1/11 through 9/13/11. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed expired Gluco-Chlor (Sodium Hypochlorite) towelettes in boxes and in 2 red caddies that had ""D20EXP0411"" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dates. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what ""exp date 0411"" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what ""exp date 0411"" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 stated she had ordered more Gluco-Chlor wipes and they were on their way to the facility. RN #1 provided the facility policy entitled ""Glucometer"" which included information that the ""Glucometer would be maintained per manufacturers' recommendation"". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there were 2 glucometers that were used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometers had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometers available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a ""Fingerstick blood sugar once a week on Wednesday"". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometers had expired. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record [REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The order was changed to FSBS daily on 9/13/11. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.20 F-281 was identified at a scope and severity of ""K"". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean Glucometer's used for multiple residents with an appropriate cleansing agent. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2015-05-01
9405,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,441,K,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled ""Glucometer"" and ""Cleansing and Disinfecting Diagnostic Equipment"", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from 5/1/2011 through 9/13/11. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed two red caddies on the counter each with a handful of Gluco-Chlor (Sodium Hypochlorite) towelettes that had ""D20EXP0411"" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. There was one unopened box of 100 Gluco-Chlor towelettes along with a partial box of 57 towelettes in an upper cabinet in the medroom. Printing on the boxes revealed ""exp date 0411"". Imprinted on the individual towelettes in the boxes was ""D20EXP0411"". During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dated. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what ""exp date 0411"" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what ""exp date 0411"" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 was brought to the medication room and verified the expiration dates on the boxes of Gluco-Chlor wipes as 4/11. She stated that Central Supply was usually responsible for checking medical supplies for expiration dates but since this was not her building she would need to find out. RN #1 asked the Administrator who stated they did not have a Central Supply. The Administrator did not know if there were any other Glucometer cleaning wipes in the building but stated she would find out. According to RN #1, she had ordered more Gluco-Chlor wipes and they were on their way to the facility. When asked if there were any Gluco-Chlor wipes in the DON's office, the Administrator stated she did not know. RN #1 provided the facility policy entitled ""Glucometer"" which included information that the ""Glucometer would be maintained per manufacturers' recommendation"". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During a phone interview on 9/13/11 at 10:22 AM, the DON stated she did not think she had any Gluco-Chlor wipes in her office. She stated there were some Caveat wipes in the storage closet in the small Day Room. When asked if the nursing staff used the Caveat wipes to clean glucometers she stated that they could, but usually did not. When asked who was responsible for checking for expired medical supplies she stated that either she or her Assistant Director of Nursing (ADON)was responsible. She stated that her ADON was presently on leave but had been checking the medicine rooms for expired supplies. She stated that the 3rd shift night nurse was also responsible for checking for expired things. When asked if the night shift nurse would check the glucometer cleaning wipes, she stated she should. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there are 2 glucometers that are used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. When asked if she knew what Caveat wipes were, LPN #1 shook her head ""no"". LPN #1 and LPN #2 both shook their heads ""no"" when asked if they used Caveat wipes to clean the glucometers. LPN #1 was asked to accompany the surveyor to the small Day Room. Observation of the storage closet there revealed 10 containers of Micro-Kill Deodorizing Cleaning Wipes. LPN #1 shook her head ""no"" when asked if she knew that the wipes were there or what they were used for. During an interview on 9/14/11 at 2:42 PM, the Physical Therapist in the small Day Room stated the wipes in the storage cabinet were used to clean therapy equipment after each resident use. During a phone interview on 9/13/11 at 11:30 AM, a representative form Medtrol (the company that manufactured the Gluco-Chlor towelettes) was asked about the expiration date imprinted on the wrapper of the Gluco-Chlor towelette""D20EXP0411"". She stated that the ""D20"" meant the product was packaged April 20th. She stated that by EPA (Environmental Protection Agency) standards, the product expired 12 months from the package date which would be 4/11. She stated the ""EXP0411"" meant the product expired in April 2011 and should not be used after that date. According to information provided by Medtrol and reviewed on 9/15/11 entitled ""Lot Number (Batch Record) and Expiration Date"", the expiration date on the Gluco-Chlor disinfecting wipes ""...is determined by shelf life studies documented for each EPA Registered product. EPA Registered products expire when the strength of the active ingredient (i.e. sodium hypochlorite-bleach) drops below the strength stated on the product label. Therefore, the Expiration Date on the Gluco-Chlor and Super-Chlor packets means ""do not use"" after the Expiration Date"". Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During a phone interview on 9/13/11 at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on 9/13/11 at 12:50 PM, the Pharmacy Consultant stated she comes once a month to check the narcotic box and do the residents' chart reviews. She stated they used to check the medroom quarterly for expired medications, but since they are under new ownership the full medroom check had not been done recently. She stated they usually did not check medical supplies for expiration dates, only medications. Review of the the Consultant Pharmacist's Medication Regimen Review on 9/14/11 revealed no concerns related to expired medical supplies. Review of the ""BWNC Night Nurse Assignment Sheet"" on 9/14/11 revealed the night nurse (11-7 shift) was responsible for cleaning and checking the glucometer nightly and checking all refrigerated medications for expiration and date of opening weekly. There was nothing to indicate the night nurse was responsible for checking for expired medical supplies. Review of the ""Consulting Services Overview"" provided by the facility listed the responsibilities of the consultant pharmacy revealed the pharmacy was responsible for random sampling of medication storage/carts and emergency kit audits. There was nothing to indicate the pharmacy was responsible for checking for expired medical supplies. The facility provided a copy of the ""User's Guide"" for the ""[MEDICATION NAME]"" glucometer which revealed on page 41 information related to ""Caring For Your Monitor"". Under ""Cleaning Your Monitor"", it stated ""...Healthcare professionals: Acceptable cleaning solutions include 10% bleach, 70% alcohol, or 10% Ammonia"". On 9/14/11 the Nurse Consultant provided a policy entitled ""Cleaning and Disinfecting Diagnostic Equipment"" which detailed the procedure used to clean resident care equipment such as glucometers. It stated that ""Diagnostic equipment such as blood glucose meters and PT/INR machines are designed and developed to prevent blood specimens from entering the machine. Therefore, any gross blood found on a machine should be disinfected immediately with a bleach wipe"". According to the policy, the procedure for cleaning and disinfecting the glucometer should be repeated between each resident usage and at the end of each shift. The surveyor had requested an invoice of when the Gluco-Chlor wipes had been delivered, however, per the Nurse Consultant they could not obtain this information since the supply company they had used to get the wipes no longer had this information. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Inservice information provided by the facility on 9/13/11 and reviewed by surveyor(s) on 9/13/11 and 9/14/11 revealed an ""Inservice Attendance sheet"" which listed nursing staff who had attended the inservice given by the DON on 9/13/11. According to the documentation provided, some of the nursing staff who were not present were educated by phone or left messages. Included in the inservice was the policy for ""Cleansing and Disinfecting Diagnostic Equipment"" which detailed the steps to cleaning the glucometer. As stated above, the steps did not include checking the disinfectant wipes for an expiration date. Also included in the inservice was information from the Centers for Disease Control (CDC) related to ""Recommended Infection Control and Safe Injection Practices to Prevent Patient-To-Patient Transmission of Bloodborne Pathogens"". Under ""Diabetes Care Procedures & Techniques"" information stated that ""Environmental surfaces such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluids occurs or is suspected...If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected..."" On 9/14/11 interviews were conducted with nursing staff working the 3-11 shift. At 6:20 PM, LPN #4 was asked to explain the process used to obtain a FSBS. She stated she would take a bleach wipe and clean the glucometer before using it. She did not mention that she would check the expiration date on the wipe. When asked if she had received an inservice on the glucometers, she stated she had an inservice last week on cleaning the glucometers. When asked specifically if she had been inserviced that day or the day before on cleaning the glucometers, she stated she had not been inserviced that day or the day before. On 9/14/11 at 6:25 PM, LPN #3 was asked what she would do to check a FSBS. She stated she would get a meter and strip, wipe the finger with alcohol and prick the resident's finger. She did not mention that she would clean the meter first with a disinfectant wipe or check for an expiration date on a wipe. She was asked what she should do with the glucometer before she even started to prick the resident's finger and was even prompted by the surveyor asking if the glucometer should be cleaned to which she responded that she did not clean the glucometer prior to resident use since the nurse who used it last should have cleaned it. She stated she cleaned the glucometer after she did the FSBS. When questioned by the surveyor as to how she knew that the nurse before her really cleaned the glucometer after a FSBS she stated ""So I need to wipe it before I start"". When asked what she did before she opened the chlorine sanitizer wipe, she did not know to check the expiration date on the wipe. When asked if she had received an inservice today or yesterday she stated she had been inserviced yesterday on the proper cleaning of the glucometer. When asked if she was told to check the expiration date on the wipe she stated she did not remember that. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometers had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometers available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a ""Fingerstick blood sugar once a week on Wednesday"". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometers had expired. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated fingerstick blood sugar (FSBS) readings were done Monday, Wednesday, and Friday. In addition, further record review of the Medication Administration Records and/or Diabetes Monitoring Records indicated FSBS readings were done three times per week during May, June, and August 2011. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated FSBS readings were done daily at 6 AM, 11:30 AM, 4:30 PM, and 8 PM. Further record review of the Diabetes Monitoring Records and/or Medication Administration Records indicated FSBS readings were done four times daily during May, June, July, and August 2011. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record indicated FSBS readings were done four times per day at 6 AM, 11:30 AM, 4:30 PM, and 9 PM with Insulin administered per sliding scale. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for July 2011 and August 2011 indicated FSBS readings were done four times daily, and the September 2011 Diabetes Monitoring Record revealed FSBS readings were done twice daily during September. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for May, June, July, August, and September 2011 indicated FSBS were done three times per week. The order was changed to FSBS daily on 9/13/11. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of ""K"". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that Glucometer's used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. The cleansing agent used by the facility had an manufacturer expiration date of April 2011. On 9/13/2011 at 11:30 AM it was verified with the Manufacturer that the product was not to be used after 4/30/2011. There were 10 of 37 residents residing in the facility who required ongoing blood glucose testing with the use of the Glucometer. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2015-05-01
9406,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,490,K,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled ""Glucometer"" and ""Cleansing and Disinfecting Diagnostic Equipment"", the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers with a disinfectant wipe that had not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: 1. Cross refer to F441. Based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled ""Glucometer"" and ""Cleansing and Disinfecting Diagnostic Equipment"", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. 2. The facility did not have a policy or procedure in place related to expired medical supplies or to identify who was responsible to ensure that medical supplies were not expired. During a phone interview on [DATE] at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on [DATE] at 4:55 PM, the Director of Nursing (DON) stated she was responsible for ordering medical supplies. She stated that her Assistant Director of Nursing(ADON) who was presently on leave had been responsible for checking the medrooms for expired medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Immediate Jeopardy was determined to exist on [DATE] at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on [DATE]. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. 483.75 Administration F-490 was identified at a scope and severity level of ""K"". The facility Administration failed to assure that appropriate polices and procedures were in place and implemented related to the cleaning of Glucometer's used for multiple residents. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.",2015-05-01
9407,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,371,F,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and per review of the facilities recipe book from [MEDICATION NAME] Nutrition Corporation dated 2002 entitled ""Pureed Cake/Cookie Slurry"", the facility failed to store, prepare, and serve food under sanitary conditions. The findings included: On 9/13/11 at 6:58 AM, an initial tour of the kitchen was conducted. A tray cart was observed outside of the kitchen with a tray left over from dinner from the night before. Food was still on the tray and residents can access the room at any time. A container of thickener was observed on the counter with a scoop inside with the handle touching the product. On 9/13/11 at 5:05 PM, observation of the tray line was conducted. The cook was observed changing her gloves while taking food temperatures but she did not wash her hands between glove changes. A cell phone belonging to staff was observed plugged up next to the tea machine throughout trayline. The lid for the thickener was off of the thickener for 20 minutes during tray line service. Staff was not using the thickener at that time. The Certified Dietary Manager (CDM) was observed making a slurred cookie for the Dysphagia 3 diet. The CDM poured milk over the cookie without measuring the milk or adding thickener. When asked if there was a recipe for the slurred cookie the Regional Manager stated that there was a recipe. Per the facilities recipe book from [MEDICATION NAME] Nutrition Corporation dated 2002 entitled ""Pureed Cake/Cookie Slurry"", it states that the recipe is 1 cookie, 1/3 cup of milk or juice, and 3/4 tsp of ThickenUp. On 9/14/11 at 2:30 PM, a tour of the kitchen was conducted with the Regional Manager. An open package of powdered pudding was observed in the dry storage. A pipe under the 3 compartment sink contained a black grease-like substance covering one side of the pipe. The Regional Manager confirmed findings.",2015-05-01
9408,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,323,D,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to provide adequate supervision for a resident at risk for elopement. Resident #1, one of two residents reviewed with a secure alarm, did not have his secure alarm monitored for proper placement and functioning on return from the hospital from 8/29/10 through 9/14/11. The findings included: The facility admitted Resident #1 on 4/5/04 with [DIAGNOSES REDACTED]. Review of the Care Plan on 9/13/11 at 3:05 PM revealed an entry dated 6/17/11 (reviewed 8/29) which stated ""At risk for exit seeking behavior AEB (As Evidenced By) Trying to exit building unattended Elopement Risk Medium"". The Goal stated that the ""Resident will not leave building unattended through the next review date"" and included Approaches to ""Check functioning of secure alarm per policy"" and ""Check placement of secure alarm per protocol"". Review of Nurses Notes on 9/13/11 at 6:15 PM revealed Resident #1 had been sent out to the hospital on [DATE] and returned to the facility on [DATE]. On 9/14/11 at 10:32 AM, the surveyor accompanied Licensed Practical Nurse (LPN) #2 to check the functioning of the secure alarm on the resident's right ankle which was functioning properly. Review of the September 2011 Medication Administration Record with LPN #2 revealed there had been no checks of the secure care alarm for placement or functioning in September. Review of the August 2011 MAR revealed an entry for ""Nurse to check Wanderguard placement and function q (every) shift using device tester. If missing or inoperable, replace bracelet as soon as available..."". The entry had been initialed every shift from August 1st through the 11-7 shift on 8/20/11. Review of the MAR dated 8/29/11 revealed no mention of a Wanderguard or secure care alarm. During an interview on 9/14/11 at 11:00 AM, the Director of Nursing (DON) stated that the nurse is expected to check the placement of the Wanderguard every shift and is expected to document on the Medication Administration Record that the check was done. During an interview on 9/14/11 at 3:15 PM, LPN #2 stated that the resident left the facility, went to the hospital, and returned with the Wanderguard in place. She stated she was the nurse who readmitted the resident on 8/29/11 and it had been her responsibility to add it to the MAR to check the functioning and placement of the Wanderguard every shift. She verified she had not done this. She stated since the resident returned from the hospital, he has gone up to the door but hasn't tried to open it. Review of the policy provided by the facility entitled ""Elopement Risk Reduction Plan"" revealed under ""Plan"" that ""...Staff will check each shift to see that each at risk for elopement resident had the Wanderguard in place"".",2015-05-01
9409,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,332,E,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 9.7%. There were 4 errors out of 41 opportunities for error. The findings included: Error #1: On 9/13/11 at 11:54 AM, during observation of the medication pass, Licensed Practical Nurse (LPN) #1 checked a Finger Stick Blood Sugar (FSBS) which was 336 and drew up and administered 18 units of [MEDICATION NAME] R to Resident #7. Review of the September 2011 cumulative Physicians Orders revealed the resident was to receive ""[MEDICATION NAME] R Insulin 10 units Sub-Q (Subcutaneously) 3 times a day before breakfast lunch and dinner"". A second order stated ""Insulin- [MEDICATION NAME] R Sliding Scale=...301-350=6uR. According to the order, the resident was to receive 16 units (10 units + 6 units per Sliding Scale) of insulin and not 18 (10 units + 8 units Sliding Scale). On 9/13/11 at 4:55 PM, LPN #4 verified the Medication Record showed 8 units of Sliding Scale insulin had been documented as having been given instead of the 6 units ordered for a Blood Sugar of 336. On 9/14/11 at 11:45 AM, LPN #1 verified she had given the wrong amount of Sliding Scale Insulin. Error #2: On 9/13/11 at 4:02 PM, during observation of the medication pass, LPN #3 was observed to administer two puffs from a [MEDICATION NAME] HFA metered dose oral inhaler to Resident A, with 6 seconds between puffs. The Drug Facts and Comparisons book (updated monthly), page 669B, stated (in reference to administration technique for aerosol inhalers): ""Allow greater than or equal to 1 minute between inhalations (puffs)"". On 9/13/1, LPN #3 did not dispute the above findings and stated she was nervous and usually waited 1 minute between puffs. Error #3: On 9/13/11 at 5:03 PM, during observation of the medication pass, LPN #3 was observed to administer [MEDICATION NAME] 500 milligrams (mg) (2) tablets to Resident B. Review of Physician's cumulative orders for September 2011 revealed an order for [REDACTED]. On 9/13/11, LPN #3 verified she gave (2) tablets instead of the (1) tablet that had been ordered. Error #4: On 9/14/11 at 8:25 AM, during observation of the medication pass, LPN #1 was observed to administer [MEDICATION NAME] 25 mg capsules (2) to Resident C. Review of Physician's Telephone Orders dated 8/31/11 revealed an order for [REDACTED]. Review of the Respiratory Administration Record (included with the Medication Administration Record) for September 2011 revealed that Resident A should have received [MEDICATION NAME] 25 mg instead of [MEDICATION NAME] 50 mg. On 9/14/11 at 12:05 PM LPN #1 verified she gave the wrong dose.",2015-05-01
9410,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,425,D,0,1,DV6X11,"On the days of the survey, based on observation and interviews, the facility failed to ensure that expired syringes prefilled with Sodium Chloride were removed from the current stock of medications. Ten Monoject Prefilled Advance syringes filled with 5 milliliters (ml) of .9 NACL with expiration dates of June 2011 on the packaging were observed in the medication room cabinet over the sink. The findings included: Observation of the medication room on 9/13/11 at approximately 7:55 AM revealed Ten Monoject Prefilled Advance syringes filled with 5 milliliters (ml) of .9 NACL with expiration dates of June 2011 on the packaging. These were found in the cabinet above the sink next to the stock medications. This was verified by Licensed Practical Nurse #2 on 9/13/11 at 8:10 AM. During a phone interview on 9/13/11 at 12:50 AM, the Consultant Pharmacist stated that a nurse who worked for the company had been coming and checking the medication room for expired medications. She stated that since they have come under new management a couple months ago, a full medication room check had not been done. She stated she was not aware the facility had loose prefilled syringes of Normal Saline. During an interview on 9/14/11, the Director of Nursing stated the syringes belonged to a resident that had come to the facility from the hospital. She could not remember the name of the resident or what the syringes were to be used for.",2015-05-01
9411,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,502,D,0,1,DV6X11,"**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 remove expired lab supplies from the medication room. The findings included: Observation of the medication room on [DATE] at approximately 8:00 AM revealed 44 Hemoccult Sensa Single Slides that had expired in [DATE]. Forty slides were found in a box in the cabinet, and 4 slides were found in a clear plastic container in the cabinet next to the stock medications. This was verified by Licensed Practical Nurse #2 on [DATE] at 8:10 AM.",2015-05-01
9412,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,280,D,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation, and interview, the facility failed to review and revise a plan of care for 1 of 6 residents reviewed for care plan updates. The care plan for Resident #3 was not updated related to elopement risk following the most recent Resident Risk Assessments. The findings included: The facility admitted Resident #3 on 12/31/08 with [DIAGNOSES REDACTED]. Review of the current care plan revealed ""Behavior - Elopement: at Moderate risk for elopement"" was identified as a problem area with interventions which included ""Securecare bracelet as ordered."" Review of the September 2011 physician's orders [REDACTED]. Observation on 9/14/11 with Licensed Practical Nurse (LPN) #2 at approximately 10:30 AM revealed Resident #3 had a Securecare bracelet in place on the right ankle. LPN #2 stated that documentation of the Securecare bracelet placement and function checks per shift would be documented on the Medication Administration Record (MAR). Review of the September 2011 MAR revealed no documentation related to a Securecare bracelet. Review of the most recent Resident Risk Assessments completed 8/19/11 indicated Resident #3 was assessed as a ""low"" elopement risk with no exit seeking behaviors or history of elopement noted on the assessments. Review of the care plan revealed the care plan was reviewed by the interdisciplinary team on 8/31/11. During an interview with the MDS Coordinator on 9/14/11 at approximately 5:30 PM, the MDS Coordinator confirmed that the most recent elopement assessment indicated Resident #3 was at low risk for elopement. The MDS Coordinator confirmed that the Resident Risk Assessments are used to update/revise care plans and stated that Resident #3's care plan should have been updated to reflect the low elopement risk following the 8/19/11 assessment. The MDS Coordinator stated that this was overlooked.",2015-05-01
9413,PATEWOOD REHABILIATION & HEALTHCARE CENTER,425305,2 GRIFFITH ROAD,GREENVILLE,SC,29607,2011-09-14,309,D,0,1,DV6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide necessary care and services for 1 of 6 residents reviewed for physician's orders [REDACTED].#6 according to physician's orders [REDACTED]. The findings included: The facility admitted Resident #6 on 12/16/10 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the August and September 2011 Medication Administration Records (MAR) revealed staff did not document the resident's pulse prior to administering the [MEDICATION NAME] and did not document the resident's blood pressure prior to administering the [MEDICATION NAME]. Review of the July 2011 MAR indicated [REDACTED]. During an interview on 9/14/11 at approximately 4:30 PM, the Director of Nursing (DON) reviewed the physician's orders [REDACTED]. The DON stated that staff should have been checking and documenting the pulse or blood pressure prior to administering these medications.",2015-05-01
9414,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2012-01-26,157,D,1,0,OHFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Survey based on record review and interview the facility staff failed to notify a resident's physician upon readmission of the resident and failed to clarify medication orders. Licensed Practical Nurse #6 did not notify Resident #1's physician of his readmission and failed to clarify the resident's medication orders. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 reviewed a BIMS score of ""3."" Resident #1 was admitted to the hospital on [DATE] for unresponsiveness and vomiting green emesis. Resident #1 was re-admitted to the facility on [DATE] at 2:45 PM. Review of the Nurse's Notes revealed on 12/10/2011 at 2:45 PM, Licensed Practical Nurse #6 documented ""Res(ident) returned to facility, dropped off at the front door, ambulated with steady gait to room, turned money in to this nurse in the amt (amount) of $120.00- locked in med cart. VS (vital signs) 97.7, 84, 16, 140/80, A&O x3 (alert and oriented to person, place and time), no c/o (no complaints) at present."" There was no documentation a body audit was completed or that the physician was notified of the resident's return. Review of the Medication Reconciliation Form (Med Rec) revealed it had been faxed to the facility on [DATE] at 2:15 PM. The Med Rec was signed by the physician and noted which medications the resident was to continue or discontinue. Further review revealed Resident #1's [MEDICATION NAME] dose was decreased from 80 mg to 20 mg, the [MEDICATION NAME] was decreased from 50 mcg/mcg/hr to 25 mcg/hr, the [MEDICATION NAME] dosing time was increased to every 4 hours from every 6 hours, Fingerstick blood sugars were changed to three times daily with new sliding scale orders and the [MEDICATION NAME], Klonopin, [MEDICATION NAME] and Trazadone were discontinued. Upon the resident's readmission, a new physician order [REDACTED]. A new physician's orders [REDACTED].#1. Review of the facility obtained statement from LPN #1 revealed LPN #6 failed to document a nurse's note verifying the medication changes, failed to write new physician's orders [REDACTED]. LPN #1 was unavailable for interview. Review of a facility obtained statement by Registered Nurse (RN) #1 revealed: ""Resident was brought back to facility around 3:15 PM. No papers/orders were received. Res was let out and brought to the front door. To my knowledge nobody signed or received anything. (Hospital) later faxed medication reconciliation report. I asked (LPN #6) if she needed help with anything before I left and she said no. From now on, I will be sure to check over any admissions while acting as supervisor."" During an interview on 1/19/2012 at 10:15 AM, RN #1 confirmed her statement and stated that the resident was dropped off at the front door and walked to his room. She stated that it was routine for the facility staff to sign for the resident and receive new orders and a discharge summary. The hospital later faxed the medication reconciliation form but no discharge summary. RN #1 told LPN #6 to perform a body audit and asked if she needed help with the new physician order [REDACTED].#1 stated that she left the facility at 5 PM. RN #1 stated that she did not check to assure the medication changes were done and did not check for re-admission documentation. RN #1 stated that the medication errors were caught on Monday 12/12/2011 by LPN #1. Review of the facility obtained statement by LPN #6 revealed: ""I thought that because the resident had not been out of the facility 72 hours no admission was necessary-as had been the case in the past. So the admission packet was not completed."" During an interview on 1/19/2012 at 9:50 AM, LPN #6 stated that she was assigned to Resident #1 on 12/10/2011, when he was readmitted to the facility. She stated that the resident arrived and was dropped off at the front door, he did not have any paperwork. LPN #6 stated she contacted the hospital and they faxed over 2-3 pages of medications ""administered at the hospital."" LPN #6 reported to RN #1 that she was not going to do a new POF because she did not have any new orders. LPN #6 admitted to not completing any new admission paperwork and not following facility policy on resident admissions. During an interview on 1/19/2012 at 3:20 PM, LPN #4 stated that she worked the night shift of 12/10/2011 (the day the resident was readmitted ). She stated that there was not a new physician order [REDACTED]. LPN #4 stated that she reviewed all the paperwork received from the hospital and there was a ""sheet signed by the doctor to resume all meds."" Review of the closed medical record revealed no order to resume all meds. She stated that she did not call the physician to clarify any medications. Review of the Admission Assessment Policy revealed: ""The licensed nurse will complete the Admission Nursing Evaluation Form on admission. The Comprehensive Care Plan will be based in part on this assessment."" The Procedure: ""Complete Nursing Admission Assessment. In most cases, the patient's current status will be described, unless otherwise indicated. A head-to-toe assessment and history should include: general information, diagnoses, current medications..."" Review of the Admission Nursing Evaluation Form revealed: ""admitted : Time:, Admitting Physician and MD Notified and Time."" Included on the form was a complete body systems assessment, body audit, medication review, Braden Scale and Care Plan.",2015-05-01
9415,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2012-01-26,224,L,1,0,OHFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, the facility failed to ensure each resident was provided the necessary goods and services to avoid neglect. Residents #2, #3, #4 and #5 were identified during the facility investigation process as having physician's orders [REDACTED]. All residents currently residing in the facility had the potential of incurring harm related to an allegation that Licensed Practical Nurse (LPN) #1's disposed of resident medical record information. On 01/10/2012 physician's orders [REDACTED].#3, #4 and #5 were found in a shred bin. The physician orders [REDACTED]. During the facility investigation statements from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #2 documented she received Hospice Services. On 12/27/2011, Resident #2 finished a prescribed course of antibiotics for a Urinary Tract Infection. On 12/29/2011, the Hospice Nurse assessed the resident and ordered ""Bactrim 400 mg daily x 10 days for urinary tract infection"". The 400 mg had been crossed out and 20 mg was written above. (It was unknown who crossed out the 400 mg). On 1/10/2012 the order was found in the shred bin located under the nurses station desk. Further review of Resident #2's closed medical record revealed the order was not transcribed or implemented. Review of the Nurse's Notes revealed on 12/29/2011 at 10:30 AM, the resident was ""rubbing lower abdomen, voided incontinently though still some lower abdominal distension, NO (nurses order) received #18 Foley Catheter inserted with immediate return of yellow urine..."" On 12/30/2011 at 2:05 AM, ""Res(ident) c (with) confusion and decreased sensation on right side of body."" At 6 PM, ""Medicated (one time) this shift c [MEDICATION NAME] r/t (related to) c/o (complaints of) pain..."" On 1/2/2012 at 4:10 PM, LPN #1 documented, ""MD c NO r/t re-treat UTI (urinary tract infection)/ no c/s (culture and sensitivity)..."" Review of the physician's orders [REDACTED]. Review of the Hospice notes revealed on 12/29/2011 ""Pt (patient) presented confused. Crying and unable to explain why. Soon she c/o pain but was unable to provide any details. R(ight) sided weakness, L(eft) sided facial paralysis. Pain med provided. Assessment and palpation concludes distended abdomen and spasms. Foley cath 18 F(rench) inserted with immediate release. Pt produced 300 cc of dark amber urine. Pt was left resting comfortably, resting with no c/o pain or discomfort. Urine has strong odor. (LPN #1 to) monitor pt and call nurse c any pt status change."" ""Order for Bactrim 20 mg daily for possible UTI requested from (Medical Director)."" The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #3 indicated he received Hospice Services. The closed medical record revealed a chart control copy with an order written [REDACTED]. The order was transcribed to the Medication Administration Record [REDACTED]. The signed physician's copy of the [MEDICATION NAME] drops 1% two drops every 4 hours order as needed sublingually for excess secretions was found in the shred bin by the Director of Nurses on 1/10/2012. Review of the Medication Administration Records for 12/2011 and 1/2012 revealed Resident #3 received the [MEDICATION NAME] drops every two hours instead of the ordered every 4. He received 12 doses of the [MEDICATION NAME] drops between 12/25/11 and 1/5/2012. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the facility investigative file revealed an order written [REDACTED]. During an interview on 1/19/2012, the Administrator confirmed the original order written on 1/2/2012 for the PT/INR was found on 1/10/2012 in the shred bin and was placed back in the resident's chart after the investigation started. She also confirmed LPN #1 wrote a PT/INR order on another telephone order after the investigation started. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Resident #5 received Hospice services. Review of the Investigative file revealed an order written [REDACTED]."" The order was found in the shred bin. Record review revealed an order written [REDACTED].#1 for ""Self Release belt to w/c..."" A physician's orders [REDACTED].#5's medical record. The Director of Nurses found the restraint order written by the MDS Nurse in the shred bin on 1/10/2012. In a facility obtained statement the Minimum Data Set (MDS) Nurse revealed: ""On Monday, January 9, 2012 I wrote an order for [REDACTED]. I saw that another order written for the same resident for a different restraint order had been written. I asked did I need to d/c (discontinue) the order I had previously written on January 9, 2012 and was told no that it was taken care of. Later that day I asked the DHS (DON) to check to make sure I didn't need to write a d/c order for the restraint I had written. On her observation she did not find my order dated the 9th but did see my note dated the date and time. At her request I gave her the interdepartmental copy of the physician's orders [REDACTED]. The original was faxed to the pharmacy and the 2nd copy was put in the MD folder to be signed. I had saved the interdepartmental copy because I am the one who inputs these anyway. That is the extent of my knowledge on this area in question."" During an interview with the state surveyor on 1/19/12 at 1:20 PM, the MDS Nurse confirmed her statement. She stated that she had noted Resident #5 had a soft belt restraint in place on 1/9/2012. She stated that she wrote the order in the chart on 1/9/2012 and documented in the nurse's notes. A copy of the order was placed in the physician's folder. On 1/10/2012, LPN #1 brought the orders to her. The MDS nurse stated that the order she received was for a self release belt and it was not the order she had written. She asked LPN #1 if she needed to d/c the previous order and he told her no, he had taken care of it. She stated that LPN #1 ""looked at my trash can"" and the interaction made her feel ""weird."" She stated that she asked the DON to look in the resident's chart to see if she needed to d/c the order she had written. The DON stated that she could not find the order for the soft belt. The DON took the copy of the order from the MDS nurse. The MDS Nurse stated that she ""guessed"" the DON found the original in the recycle bin."" During an interview on 1/18/2012 at 4:10 PM, the Administrator and Director of Nurses confirmed that the DON found orders for Residents #2, #3, #4, and #5 in the shred bin. Review of the facility investigation regarding the information found in the shred bin revealed the following staff statements: Review of the facility obtained statement from LPN #2 dated 9/1/2011 revealed: ""On Wednesday 8/31/2011, (LPN #1) told this nurse not to write any new orders because it is the last day of the month. This nurse went to (LPN #1) regarding a resident and a skin tear site/deep tissue injury. (LPN #1) rolled his eyes and later that day came to this nurse and called me a fruitcake and told me he needed the med cart keys. This nurse gave him the keys and went on to pass medicines to (a resident). (LPN #1) was standing at the end of A/B hall next to the locked cabinets and this nurse was standing in the TV area when (LPN #1) threw the med cart keys...when they slammed into (resident's) wheelchair. This nurse stated to (LPN #1) you are going to injure a resident and cause me to do another incident report. (LPN#1) said nothing and laughed and walked away. (LPN#1) is constantly telling this nurse please do not write any more incident reports and what the hell kind of orders am I going to have to fix for you today."" During a face-to-face interview on 1/19/2012 at 4:10 PM, LPN #2 confirmed her statement as written and stated that she submitted her statement to the Director of Nursing. LPN #2 stated that the DON spoke with LPN #2 and had followed up with her daily. LPN #2 stated that she was afraid she ""would get fired"" and that LPN #1 ""ran the place."" Review of the facility obtained statement from LPN #5 revealed: ""I have in the time I have worked here seen LPN #1 remove personal info. R/T (related to) Residents from this building numerous times. I have witnessed him sign the MD's name to orders that LPN #1 wrote himself. I have witnessed LPN #1 go back in a chart and alter documentation. I have witnessed LPN #1 instructing other LPN's not to document different info. that we all know needs to be documented. I have experienced being called a [***] by LPN #1 in the workplace. I have also witnessed him name call other staff members. All of the above information I had reported to prior DHS's and Prior Administrators without any follow up R/T concerns."" During a telephone interview on 1/26/2012 at 8:35 AM LPN #5 confirmed her statement and added that she had seen LPN #1 on numerous time over the past few years leave (the facility) with a stack of assessments he was working on. She confirmed that he would take the assessments home and work on them. ""During a DHEC survey, he asked medical records to stall so he could go home and get information they asked for. It was this past year or the year before at survey."" She stated she told the previous Administrator and Director of Nurses. In regards to the signing the physician's initials she stated that LPN #1 would sign the MD's initials, this was also reported. She stated that when she reported this the previous Administrator told her ""It's not how it seems, everything is ok."" She confirmed LPN #2's statement, she stated that LPN #2 a new nurse, would come to her and ask if she needed to write incident reports, when LPN #1 told her not to. LPN #5 alleged that the physician was not notified timely regarding resident's decline. Review of the facility obtained statement by the Financial Counselor (FC) revealed: ""I (FC) have seen (LPN #1) walk out of the building, getting in his car with manuals and things he had worked on from this facility. I ask him why he was carry stuff home and he said he had to work on it."" During a face-to-face interview on 1/19/2012 at 2:10 PM, the FC confirmed her statement as written. She also stated that a family member complained to her about LPN #1's rudeness. The FC also stated that a previous administrator would let him get away with a lot and that when she complained about LPN #1 the administrator asked her, ""You want your job?"" She stated that LPN #1 threw keys and shouted. She stated that LPN #1 would take manuals and documents home; that during the past DHEC survey or the one before, the surveyors asked for information and LPN #1 told the staff to ""stall DHEC"" because it was at home. Review of the facility obtained statement from the Medical Record Clerk dated 1/13/2012 revealed: ""On last survey, DHEC ask for a book, not sure what it was. I asked (LPN #1) where I could find it, he told me to stall them as long as I could because the book was on his dining room table at home. Also I have been looking for orders to put in the chart, when I couldn't find them the nurse would help. We would ask (LPN #1) he would say toss it."" During a face-to-face interview on 1/19/2012 at 2:55 PM, the Medical Record Clerk stated that she was responsible for placing one of the carbon copies of the telephone orders onto the hard copy located in the chart. She stated that she would have carbon copies but not have the hard copy or have the hard copy of the order and not have any carbon copies. She stated that she would ask LPN #1 and he would tell her to ""toss it."" During an interview on 1/19/2012 at 11 AM, the Administrator stated that LPNs #3 and #4 had quit suddenly without notice on 12/26/2011. She stated that a week later LPN #3 called her and stated that he quit because of LPN #1 and ""couldn't cover for him anymore."" The Administrator met with LPN #3 and #4 on 1/11/2012. LPN #3 stated that LPN #1 altered vital sign and weight records, allowed a pressure reducing mattress to remain flat, and tore up incident reports. LPN #3 also reported seeing resident documents in LPN #1's personal briefcase. The Administrator confirmed her interviews and confirmed her notes. She also stated that she had spoken with the DON and the prior administrator regarding LPN #1 and stated that no employee had reported anything to her about LPN #1 until after 1/11/2012. She stated that the ""general consensus was I got to work."" The Administrator confirmed that the Ombudsman, State Law Enforcement and the Attorney General had not been contacted regarding the allegations. She stated that LPN #1 was terminated on 1/18/2012. The Administrator stated that on 1/11/2012 she told LPN #1 he was suspended for documentation concerns. On 1/18/2012, the Administrator ""laid out the issue"" and LPN #1 repeated ""I'm aware, I'm aware..."" LPN #1 refused to write a statement and stated that ""it is what it is."" During an interview on 1/19/2011 at 12:45 PM, the Area Vice President (AVP) stated that she was first made aware of a concern with LPN #1 improperly disposing of medical records on 1/11/2012 when the facility called to suspend the nurse. She stated that she had not received any prior complaint related to LPN #1. The AVP stated she contacted the nurse consultant to come to the facility to help audit the records. She stated that she had not read the investigation as of 1/19/2012 and that the investigation was ""still ongoing."" The AVP stated that she needed to verify all the statements and felt like some of the nurses were ""throwing (LPN #1) under the bus."" During another interview on 1/19/2012 at 6 PM, the Area Vice President (AVP) stated that she had spoken to the previous administrator who stated that LPN #1 was verbally counseled related to LPN #2's complaint. She also stated that there was no record or documentation of the counseling. She stated that she did not witness LPN #1 remove any documents from the premises. The AVP also spoke with LPN #5 who stated that she witnessed LPN #1 remove binders, fall assessments and elopement assessments from the premises. She stated that she witnessed LPN #1 forge the physician's signature on orders. She stated that she had reported this to a previous administrator. LPN #5 stated that she witnessed LPN #1 alter documentation. She also stated that she had reported these incidents to the previous administration. Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 01/10/2012 related to allegations that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The Immediate Jeopardy (IJ) identified at F-224, F-225, F-226, F-281, F-516, and F-520 at a scope and severity of ""L"" remained ongoing at the time the surveyors exited the facility on 1/19/2012. 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 1/26/2012 at which time the survey ended.",2015-05-01
9416,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2012-01-26,225,L,1,0,OHFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Inspection and Extended Survey the facility failed to ensure that staff members reported allegations of abuse, neglect and suspicions of criminal activity. The facility failed to report and/or thoroughly investigate recurring staff allegations that Licensed Practical Nurse's (LPN) #1's removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: Review of the facility investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/12/2012. The facility Administrator was made aware of the alleged disposal of medical records on 1/10/2011. Further review of the investigation revealed facility obtained statements from the staff that alleged that Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a ""shred"" bin located under a desk at the nurse's station. A large locked shred bin located on facility grounds was removed and emptied by the company contracted to do facility shredding on 1/10/2012 without first being checked as part of the facility investigation of the allegations. In addition to the disposal of resident medical records information, the facility was also made aware of allegations that LPN #1 removing protected health information from the premises. Facility staff failed to report the incidents to the current administration. As of 1/19/2012 the facility had audited 11 records (open and closed). Also at the time of exit, the facility investigation had not been completed. The residents identified as having physician's orders [REDACTED]. Resident #2 had a 4 day delay in treatment for [REDACTED]. Resident #3's [MEDICATION NAME] order was altered from every 4 hours to every 2 hours. Resident #4 had physician signed telephone orders for lab work as part of anticoagulant therapy that was disposed of improperly. Resident #5 had a restraint order disposed of improperly. During an interview on 1/19/2012 at 11 AM, the Administrator stated that on 1/11/2012 LPN #1 was suspended and on 1/12/2012 a 24 hour report was sent to the State Survey and Certification agency. The Administrator stated that as of 1/19/2012, 11 records had been audited. She stated that she planned to be finished with the audits by the end of next week. She also stated that she had spoken with the DON and the prior administrator regarding LPN #1 and stated that no employee had reported anything to her about LPN #1 until after 1/11/2012. She stated that (among the staff) the ""general consensus was I got to work."" The Administrator also confirmed that staff had been trained on reporting incidents to their superiors and should have reported any and all incidents related to resident abuse, neglect or any suspicious criminal activity. The Administrator also confirmed the investigation was not completed and would not be completed within the mandated 5 days. The Administrator confirmed that the Ombudsman, State Law Enforcement and the Attorney General had not been contacted regarding the allegations. She stated that LPN #1 was terminated on 1/18/2012. Cross Refers to the following citations 483.13(c) Staff treatment of [REDACTED]. The facility failed to ensure each resident was provided the necessary goods and services to avoid neglect. Residents #2, #3, #4 and #5 were identified during the facility investigation process as having negative outcomes. All residents currently residing in the facility had the potential of incurring harm related to an allegation that Licensed Practical Nurse (LPN) #1 disposed of medical record information. On 01/10/2012 physician's orders [REDACTED].#3, #4 and #5 were found in a shred bin that had not been acted on appropriately. During the facility investigation, statements from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. 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 ""L"". The facility failed to implement their Abuse Policy related to reporting allegations of abuse, neglect and criminal activity by not conducting a thorough and timely investigation related to an allegation that Licensed Practical Nurse (LPN) #1 disposed of protected health information in a shred bin located under the desk at the nurses station. During the facility investigation statements from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 01/10/2012 related to allegations that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The Immediate Jeopardy (IJ) identified at F-224, F-225, F-226, F-281, F-516, and F-520 at a scope and severity of ""L"" remained ongoing at the time the surveyors exited the facility on 1/19/2012. 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 1/26/2012 at which time the survey ended.",2015-05-01
9417,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2012-01-26,226,L,1,0,OHFM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility failed to implement their Abuse Policy related to reporting allegations of abuse, neglect and criminal activity by not conducting a thorough and timely investigation related to an allegation that Licensed Practical Nurse (LPN) #1 disposed of protected health information in a shred bin located under the desk at the nurses station. During the facility investigation statement from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: Review of the investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/12/2012 alleging the disposal of protected health information by a facility employee. Further review of the investigation revealed facility obtained statements from the staff that alleged that Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a ""shred"" bin located under the desk at the nurses station. In addition to the disposal of medical records, the facility was also made aware of allegations that LPN #1 removing protected health information from the premises, altered and destroyed documentation in the resident's medical records. As of 1/19/2012 the facility had audited 5 of 42 open medical records and 6 closed medical records [REDACTED]. During an interview on 1/19/2012 at 11 AM, the Administrator stated that on 1/11/2012 LPN #1 was suspended and on 1/12/2012 a 24 hour report was sent to the State Survey and Certification agency. The Administrator stated that as of 1/19/2012, 11 records had been audited. She stated that she planned to be finished with the audits by the end of next week. The Administrator also confirmed that staff had been trained on reporting incidents to their superiors and should have reported any and all incidents related to resident abuse, neglect or any suspicious criminal activity. The Administrator also confirmed the investigation was not completed and would not be completed within the mandated 5 days. The Administrator confirmed that the Ombudsman, State Law Enforcement and the Attorney General had not been contacted regarding the allegations. She stated that LPN #1 was terminated on 1/18/2012. Review of the facility policy on Abuse Prohibition revealed: ""Any person observing, hearing of a complaint of, and/or identifying any signs or symptoms of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation or patient/resident property or exploitation must immediately report it to the Administrator within 24 hours of the awareness of the occurrence. The Administrator will inform and designate other staff members to assist in the investigation as indicated."" ""The Administrator or designee will be responsible for completing an accurate and timely investigation. Once a complaint or situation involving alleged mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: Investigation Documentation will include but not be limited to, the following: date and time of alleged occurrence(s), Resident's full name and room number, names of accused and any witnesses, details of the alleged incident and injury, signed statements from pertinent parties...Information gathered from the investigation, Action taken by healthcare agency safeguarding the resident and preventing recurrence. The final action/conclusion made by the healthcare center/agency. Any other police or ombudsman reports or anything else related to the investigation..."" ""Whenever a patient/resident, family member or anyone else makes a complaint on behalf of the patient/resident that alleges abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient/resident property or exploitation has occurred, the procedures listed in this policy will be adhered to. The healthcare agency, nor any person employed, will discriminate or retaliate in any manner against any person for making a report or providing information related to an incident."" Abuse Prohibition Training: ""The Healthcare center/agency will have mandatory ongoing in-service training for all staff related to abuse prohibition at least annually. Topics listed below are some of the areas that could be covered:...how staff should report their knowledge of allegations without fear of reprisal...what constitutes, how to recognize and consequences of patient/resident abuse, neglect and misappropriation of resident/patient property...Patient/Resident Rights."" ""Immediate reporting should not exceed 24 hours after the occurrence."" ""The Administrator or designee will immediately notify the appropriate stated agencies and the legal representative and/or interested family member of the incident and the pending investigation. The Ombudsman and the Police Department will also be notified as indicated."" Cross Refers to the following citations 483.13(c) Staff treatment of [REDACTED]. The facility failed to ensure each resident was provided the necessary goods and services to avoid neglect. Residents #2, #3, #4 and #5 were identified during the facility investigation process as having negative outcomes. All residents currently residing in the facility had the potential of incurring harm related to an allegation that Licensed Practical Nurse (LPN) #1 disposed of medical record information. On 01/10/2012 physician's orders for Resident's #2, #3, #4 and #5 were found in a shred bin that had not been acted on appropriately. During the facility investigation, statements from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. 483.13(c)(1)(i)(ii), (c)(2)-(4) Report/Investigate Individuals, F-225 was identified at Substandard Quality of Care and Immediate Jeopardy at a scope and severity of ""L"". The facility failed to ensure staff members reported allegations of abuse, neglect and suspicions of criminal activity. The facility failed to report and thoroughly investigate staff allegations that Licensed Practical Nurse (LPN) #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. Substandard Quality of Care and/or Immediate Jeopardy existed in the facility as of 01/10/2012 related to allegations that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The Immediate Jeopardy (IJ) identified at F-224, F-225, F-226, F-281, F-516, and F-520 at a scope and severity of ""L"" remained ongoing at the time the surveyors exited the facility on 1/19/2012. 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 1/26/2012 at which time the survey ended.",2015-05-01